Lecture 18: Minor Ailments & Responding to Symptoms in Community Pharmacy | Gastrointestinal Queries

Common GI Queries

• Dyspepsia/Idigestion

• Gastro-Oesephogeal Reflux Disease (GORD)

• Constipation

• Diarrhoea

• Nausea and Vomiting

• Piles

• Irritable Bowel Syndrome (IBS)

Common GI Queries - WWHAM

• Define each condition Symptoms

• Causes

• Referral (red-flags)

• Treatment/management (lifestyle changes)

Dyspepsia/indigestion

Refers to a group of symptoms, that are linked to eating and drinking - associated with excess acid

Symptoms:

• Bloating

• Burping

• Stomach cramps

• Flatulence

Causes:

• Certain foods

• Time of eating

• Caffeine

• Medication

• GI tract problems (ulcer, cancer, infection)

Gastro-oesophageal Reflux Disease (GORD)

Reflux of gastric content into the oesophagus

Symptoms:

• Gstric pain

• Discomfort and wind

• Nausea

• Acidity (back of throat)

• Abdominal pain

Causes:

• Diet and lifestyle (overeating, drinking, obesity)

• Pregnancy

• Incompetence of oesophageal sphincter (hernia, drug induced)

GORD - what is it?

Indigestion/heartburn/acid reflux

• Heartburn (acid reflux) : occurs when the sphincter muscle between the stomach and oesophagus allows the stomach acid to leak back up into the oesophagus

• Indigestion (dyspesia): occurs when acid from the stomach comes into contact with the lining of the digestive system

• GORD is a more chronic severe form of acid reflux

Lifestyle advice

• Diet changes: avoid large meals, fatty/hot spicy food, reducing alcohol consumption and stop smoking

• Avoid aggravating factors

• Raising the head of the bed and not lying down withing 3 hours of taking a meal

• Losing weight if overweight

Antacids

• Raise pH (neutralise excess acid) and provide rapid relief

• Alter absorption of certain drugs and damage encentric coating of tablets

Sodium bicarbonate

• Belching CO2, less suitable in flatulence

• Sodium content

Aluminium and magnesium hydroxide

• Aluminium causes constipation

• Magnesium causes diarrhoea

• Used in combination - counteract both problems

Alginates

• Rafting agents

• Could be mixed with antacids

• Forms a raft/viscous foam

• Protects oesophagus during reflux

Bismuth chelates

• Absorbs pepsin

• Increase prostaglandin production and bicarbonate secretion

• Healing ulcers

• Draken stool and tongue, taken on empty stomach

• Misoprostol: analogue of prostaglandines, not recommended in child bearing age women

H2 receptor antagonist

• Competitive antagonist of H2 receptor

• Inhibit histamine-induced acid secretion

• Effective at night

• OTC: Rantidine (Zantac) no longer available OTC due to international recall - minimal amounts of NMDA (probable carcinogen) found

• Slower acting than antacids

Proton pump inhibitors (PPIs)

• Inhibit a chemical system - hydrogen-potassium adenosine triphosphate enzyme system (proton pump)

• PPIs are converted to active drugs at acid pH

• Regular use to be effective as they have preventative role rather than symptomatic

• Inhibit certain drugs metabolism thus increase their concentration

When to refer?

• Dysphagia

• Hematemesis

• Weight loss

• Vomiting

• Upper abdominal masses

• Repetitive request for OTC supply

• Onset of new symptoms

• Upper epigastric pain

• Hunger pain

• Night pain relieved by eating

• Drug induced

Diarrhoea

• Passing soft or watery stool at an increased frequency

• Common and debilitating condition

• Can be life threatening due to dehydration

Symptoms:

• Crampy stomach pains

• Fever

• Loss of appetite

• Nausea and vomiting

Diarrhoea - causes

• Bacterial or viral infection - food is culprit

• Broad spectrum antibiotics - alter natural gut flora leading to superinfection

• Medication: PPIs, magnesium salts, NSAIDs, metformin, iron salts, excessive use of laxatives

• Change of climate and country - body not used to different water and food

• Anxiety and too much alcohol

Diarrhoea - management

• General advice - drink plenty of fluid, high carbohydrate food

• Drug induced: review medication and counselling

• Oral rehydration therapy

• Antibiotics

• Antimotility drugs

Signs of dehydration

Dry:

• Mouth, lips cracked, eyes

• Loose skin, lack of elasticity

• Sunken features

Urine/GI:

• Low output

• Concentrated

• Low abdominal pain, burning sensation in stomach, loss of apetite

Head:

• Dizziness, light-headedness, tiredness, headaches

• Clammy hands and feet

• Confusion and irritability

Oral rehydration therapy

• Dehydration causes electrolyte disturbance - with certain drugs e.g. diuretics

• Specific mixture of electrolytes and glucose

• Made up to correct osmolality - freshly boiled and cooled water

• Number required depends on number of watery stools

Antimotility agents

• Symptomatic but limited use

• Reduce motility of the gut, allowing reabsorption or water and minerals

• Allow control of diarrhoea - less disturbance to daily activities

• Loperamide widely used - less central side effects

Antibiotics

• Most cases are viral in nature

• If bacterial infection confirmed by stool culture, then correct antibiotc prescribed

• Traveller’s diarrhoea: need to ascertain any recent travel history

When to refer?

• Length of diarrhoea > 3 days

• Blood in stool

• Moderate to severe dehydration - not properly self managed (elderly)

• Drug induced (clindamycin, colchicine)

• Recent travel - check

• Regular purchase of codein based products

Constipation

• Altered bowel habits, reduced frequency and passing hardened faeces

• The Rome IV diagnostic criteria for constipation include spontaneous bowel movements occuring fewer than 3 times a week

• Usually harmless but can indicate underlying serious disorders

• What is important regularity not frequency

Constipation - causes

Lifesyle:

• Diet lacking fibres/fluid lack of exercise

• Hospital admission, depression, anxiety

• Ignoring call to stool

Metabolic/drugs/neurological

• Hypothyroidism, hypercalcemia, hypokalaemia, diabetes

• Opiates, irons, antacids, antidepressants

• Dementia, stroke, multiple sclerosis, parkinsonism

Bowel disorders

• Anal pathology

• Tumour

• Diverticular disease

Constipation - management

Lifestyle changes

• Balanced diet, high in fibre and non-starch polysaccharides

• High fluid intake

• Increased exercise

Laxatives

• Medicines that increases the number of bowel movements

• Osmotic/stimulant/bulk-forming/softeners

When to consider laxatives?

• Straning to pass stool that might affect other conditions like haemorrhoids or angina

• Temporary illness which causes constipations e.g. lack of movement or loss of appetite

• Elderly person develop constipation due to low mobility

• Drugs taken concomitantly

• Before colonoscopy - not related to constipation

Bulf forming agents

• Swell up in gut to increase faecal mass - stimulates peristalsis

• Take a few days to work, should be taken with plenty of water and not immediately before bed - risk of bowel obstruction

• Equivalent to high fibre diet

• Can cause wind/bloating

Stimulant laxatives

• Stimulate nerve endings in gut which causes muscle to contract - speeds up persistalsis

• Taken at bedtime, takes 8-12 hours to work

• Rapid relief of symptoms

• Short term - risk of bowel nerve damage

• Can cause cramps/gripping pain

Osmotic laxatives

• Increase the flow of water into the intestines to produce softer and easier to pass stools

• Variable onset of action: phosphate enema (within 1 hour), lactulose (2-3 days), macrogols (12-24 hours) and magnesium salts (2-4 hours)

• Lactulose is broken down in the gut and increase volume of faeces and water content

• Can cause abdominal ramp and wind

Faecal softeners

• Lubricating and softening faeces making them easier to pass

• Small quantites due to serious side effects

• Include: paraffin seepage from faeces which irritate the anus

• Absorption of paraffin from the gut can cause damage to the gut wall

• Interferes with absorption of fat-soluble vitamins (A, D, E and K)

Causes

• Bacterial or viral infection - food is culprit

• Broad spectrum antibiotics - alter natural gut flora leading to superinfection

• Other drugs: PPIs, magnesium salts, NSAIDs, metformin, iron salts, excessive use of laxatives

• Change of climate and country - body not used to different water and food

• Anxiety and too much alcohol

When to refer

• Drug induced when regular laxatives are needed

• Sudden onset of symptoms with no apparent reason especially in elderly

• Blood in faeces (haemorrhoids and straning)

• Overuse - slimming purposes

• Severe abdominal pain

Nausea and vomiting

• Common occurrence

• Could following exposure to bacterial toxin

• May reflect serious underlying pathology

• Focus on GI related nausea and vomiting for OTC supply

Causes

• Alcohol

• Bacterial and viral infection

• Motion sickness

• Drugs (anticancer, NSAIDs, iron salts, erythromycin, SSRIs)

• Peptic ulceration, migraine, pregnancy, head trauma

• Meniere’s disease, renal failure

When to refer

• Blood in vomit

• Duration > 2 days

• Weight loss

• Severe abdominal pain

Treatment:

• Manage the symptoms

• Oral rehydration therapy

• Preventative measures (diet)

Haemorrhoids (piles)

• Swollen veins in the lining of the anus and rectum

• External at the anus or internal at the rectum

• Occur because of the increased pressure on haemorrhoidal vein

• Made worse by straning and constipation

• Pregnant women are particularly prone

Haemorrhoids - symptoms

• Common bleeing after going to the toilet

• Itching and irritation

• Sense of not fully emptying rectum when going to the toilet

• Sense of fullness around the anus

Haemorrhoids - management

• Eat plenty of fibre - fruit, vegetables, wholemeal bread

• Drink plenty of water - alcoholic drinks can be dehydrating

• Fibre supplements: bulk forming/agents/bran

• Toileting: respond to the call to toilet/not postpone, resist straning

• Treating and managing constipation

• Choice of preparation depends on location

• Creams/ointments more suitale for external use

• Suppositories for internal use

• Topical corsticosteroids to reduce inflammation and itching

Irritable bowel syndrome (IBS)

• Ages 20-30, more common in women

• Abnormal contractions of the muscles in the large intestine and increased sensitivity of bowel to the presence of gas and movement

• Causes are poorly understood - may be related to anxiety and depression or certain food types

IBS symptoms

• Gripy, colicky pain acorss lower abdomen

• Wind and bloating

• Fatigue and disturbed bowel habits

• Diarrhoea and constipation

• OTC supply will be based on whether the patient has confimed IBS

IBS - management

• Diary of diet, activity - define aggravating factors and avoid

• Diarrhoea and constipation management as didiscussed in previous flashcard

Non-medical treatment

• Cognitive behavioural therapy

• Hypnotherapy

• Acupuncture

Antispasmodics

• Work by relaxing the intestine muscle so relieve muscle spasms