Symptoms in the Pharmacy :Gastrointestinal Tract Problems(8)

Indigestion in practice

Case 1

Mrs Johnson, an elderly woman, complains of indigestion and an
upset stomach. On questioning, you find out she has had the problem
for a few days; the pain is epigastric and does not seem to be related to
food.

She has been feeling slightly nauseated. You ask about her diet;
she has not changed her diet recently and has not been overdoing it.
She tells you that she is taking four lots of tablets; for her heart, her
waterworks and some new ones for her bad hip (diclofenac modified
release 100 mg at night). She has been taking them after meals, as
advised and has not tried any medicines yet to treat her symptoms.

Before the diclofenac she was taking paracetamol for the pain. She
normally uses paracetamol as a general painkiller at home; she tells
you that she cannot take aspirin because it upsets her stomach. 

The pharmacist’s view
It sounds as though this woman is suffering GI symptoms as a result of
her NSAID. Such effects are more common in elderly patients. She has
been taking the medicine after food, which should have minimised any
GI effects, and the best course of action would be to refer her back to
the doctor. It would be worth remindingMrs Johnson always to check
before using home painkillers in addition to those prescribed by the
doctor in future. She might otherwise inadvertently duplicate paracetamol
doses.

The doctor’s view
Referral back to her doctor is the correct course of action. Almost
certainly her symptoms have been caused by the diclofenac. A large
clinical trial showed that risk factors for serious complications with
oral NSAIDs were age 75 or more, history of peptic ulcer, history of
GI bleeding and history of heart disease. If this woman were over 75
and taking tablets for heart problems, she has two significant risk
factors. The model predicts that for patients with none of the four risk
factors, 1-year risk of a complication is 0.8%. For patients with all
four risk factors, the risk is 18%.
She should be advised to stop the diclofenac. A blood test for
H. pylori would be helpful and whilst awaiting the results she could
be started on a PPI such as lansoprazole. If the H. pylori test
came back positive she would also benefit from H. pylori eradication
therapy.

Control of her primary symptom (hip pain) will then be a problem.
NSAIDs should be avoided if possible. It may be possible to change the
paracetamol to a compound preparation containing paracetamol and
codeine or dihydrocodeine. Alternatively the GP may consider a cyclooxygenase
(COX) 2 selective inhibitor such as rofecoxib, which is less
likely to cause GI side-effects.

If an NSAID is necessary to control the pain and there is a documented
history of peptic ulceration, an NSAID can be given with a
PPI. The NSAID can also be given concomitantly with misoprostol.
Misoprostol is a prostaglandin analogue that protects the gastric
mucosa and may limit damage from NSAIDs. Research evidence
shows that omeprazole was more effective than misoprostol in preventing
unwanted effects.
Failure to control hip pain due to osteoarthritis (OA) may require
referral to an orthopaedic surgeon to consider a hip replacement.

Case 2
Ken Jones is a local milkman in his early fifties and he comes in to ask
your advice about his stomach trouble. He tells you that he has been
having the problem for a couple of months but it seems to have got
worse. The pain is in his stomach, quite high up; he had similar pain a
few months ago, but it got better and has now come back again. The
pain seems to get better after a meal; sometimes it wakes him during
the night. He has been taking Rennies to treat his symptoms; they did
the trick, but do not seem to be working now, even though he takes a
lot of them. He has also been taking some OTC ranitidine tablets. He
is not taking any other medicines.

The pharmacist’s view
Mr Jones has a history of epigastric pain, which remitted and has now
returned. At one stage his symptoms responded to an antacid but they
no longer do so, despite his increasing the dose. This long history, the
worsening symptoms and the failure of medication warrants referral
to the doctor.

The doctor’s view
It would be sensible to recommend referral to his doctor as the information
obtained so far does not permit diagnosis. It is possible that
Mr Jones has a stomach ulcer, acid reflux or even a stomach cancer,
but further information is required. An appropriate examination and
investigation will be necessary.

The doctor would need to listen carefully, first by asking open
questions and then by asking more direct, closed questions to find
out more information,

e.g.:

• How does the pain affect him? 
• What is the nature of the pain (burning, sharp, dull, tight, constricting)? 
• Does it radiate (to back or chest, down arms, up to neck/mouth)? 
• Are there any associated symptoms (nausea, difficulty in swallowing, loss of
  appetite, weight loss, shortness of breath? 
• Are there any other problems (constipation, flatulence)? 
• What are the aggravating/relieving factors? 
• How is his general health? 
• What is his diet like? 
• How are things going for him generally (personally/professionally)? 
• Does he smoke? 
• How much alcohol does he drink? 
• What does he think might be wrong with him? 
• What are his expectations for treatment/management?

Further investigation may be necessary to clarify the diagnosis. This
could be achieved by a blood test (full blood count, renal and liver
function, ESR, H. pylori serology), an endoscopy or a barium swallow/
meal. The former is the more accurate method and allows for a
biopsy to be taken. A biopsy is helpful in determining whether an ulcer
is benign or malignant and for identification of the presence of
H. Pylori, which can cause peptic ulcers. This bacterium is present
in nearly all cases of duodenal ulceration and over 80% of those with
gastric ulceration. 

Treatment to eradicate H. pylori is very successful
in healing ulcers and reducing the chances of future ulcer recurrence.
This is particularly significant as the natural history of peptic ulcers is
one of repeated relapse. H. pylori eradication may also be of benefit in
non-ulcer dyspepsia. The most effective treatment to eradicate
H. pylori is set out in the BNF.