Improving diagnosis in reflux and dyspepsia

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Key facts

• Reflux and dyspepsia affect up to one in four people at any one time
• Many self-medicate with OTC treatments and are never properly diagnosed
• Pharmacy teams can help improve diagnosis, treatment and prevention

Learning objectives

After reading this educational feature you should:

• Be familiar with the signs and symptoms of common upper digestive tract disorders
• Understand why patients may be  misdiagnosed or not diagnosed at all
• Be vigilant for when OTC treatments are being used inappropriately.

There is a high likelihood that everyone reading this feature will have experienced symptoms of reflux (heartburn) and dyspepsia (indigestion). Working in a busy pharmacy is certainly enough to cause at least one trigger for symptoms — stress. But there are range of possible reasons why reflux, dyspepsia and other upper GI tract issues may occur.

Statistics show that heartburn and indigestion affect up to one in four people at any one time. Many people with these symptoms self-diagnose and self-medicate, since effective OTC products are readily available for self-selection from pharmacies, supermarkets and grocery stores. 

However, patients may be prompted to seek advice from a pharmacist when their regular symptoms are affecting their daily life, even if these symptoms are not particularly severe. Although indigestion and heartburn can be an occasional nuisance for some people, persistent symptoms can affect sleep, mental health, work productivity, social lives and eating habits. 

Lifestyle changes may prevent or ease mild to moderate indigestion or heartburn symptoms. Nevertheless, many patients seek immediate relief when their symptoms occur, or they will want to take medicines that will prevent a flare-up.

Community pharmacy teams play an important role in assessing symptoms, guiding self-management and knowing when to refer patients to their GP. Severe or persistent symptoms need further investigation as these could be a sign of a more serious health condition. 

“Reflux symptoms affect up to 30 per cent of adults, yet the pathway to diagnosis is often anything but straightforward,” says Professor Anthony Hobson, clinical director of The Functional Gut Clinic, which offers pH testing for acid reflux for NHS and private patients. 

“Many patients bounce between GPs, gastro-enterologists and pharmacists without ever receiving clarity about what is actually driving their symptoms. Pharmacists sit at a crucial point in this journey. They are often the first healthcare professional a patient speaks to and sometimes the only one who sees the full pattern of repeated OTC purchases – long-term PPI use, for example – and unresolved symptoms.”

Symptom check

In a recent survey by The Functional Gut Clinic, only 8 per cent of 250 reflux patients had ever undergone formal diagnostic testing, such as pH monitoring, despite 92 per cent having been prescribed PPIs and a third taking them for more than five years.

“This mismatch between treatment and diagnostic certainty is one of the biggest challenges in reflux care today,” says Professor Hobson. “Pharmacists are uniquely placed to help change that. Good questioning in the pharmacy can reveal when the story doesn’t fit acid-driven disease.”

Dr Adam Staten, NHS GP and resident doctor for One Day Tests (onedaytests.com), says: “The main symptom of indigestion or heartburn is a burning type of pain after eating that is felt in the top of the abdomen or rising up into the chest. This may be accompanied by a bloated feeling, belching or a bad taste in the mouth. People may notice that this is worse if they have eaten spicy or salty food or after a large meal.”

Heartburn is a major symptom of gastro-oesophageal reflux disease (GORD), which is usually easy to manage in primary care. If GORD remains untreated or under-treated, however, it can lead to inflammation of the oesophagus (oesophagitis), and increase the risk of Barrett’s oesophagus and oesophageal cancer. 

“Many patients diagnosed with reflux are not experiencing the classic burning pain in their chest with a ‘sicky’ taste in their mouth,” says Professor Hobson. “Many present to the GP or pharmacist with throat symptoms, chronic cough, hoarseness, a sour taste or a sensation of something stuck in the throat. When symptoms persist despite appropriate medication, or when the pattern is inconsistent with acid reflux, that’s a strong signal that the patient should seek proper diagnostic testing from their GP or a specialist.”

Lifestyle management

Heartburn and indigestion tend to be more common in people over the age of 50 and in pregnant women, but symptoms can be caused or worsened by anything that increases pressure inside the stomach or relaxes the lower oesophageal sphincter, which usually stops acidic contents regurgitating when the stomach contracts. 

Dr Staten recommends that reflux patients avoid or limit spicy, salty or acidic foods, including citrus fruits and tomatoes, as well as caffeine, alcohol and smoking, all of which can make heartburn symptoms worse or more likely. Maintaining a healthy weight usually improves  indigestion and heartburn symptoms, and not eating too late in the evening is important as this can reduce symptoms at night.

Understanding common lifestyle triggers helps patients learn how to manage their symptoms. However, according to Professor Hobson, the recent The Functional Gut Clinic survey showed that 50 per cent of reflux patients are still smoking or vaping, 79 per cent are still drinking alcohol and 69 per cent are still eating trigger foods. 

“These are areas where pharmacists can deliver brief, targeted interventions that genuinely change outcomes,” he says.

Several medicines are known to trigger heartburn as a side-effect. These include anticholinergic drugs (including tricyclic antidepressants), calcium channel blockers, nitrates, theophylline, phosphodiesterase inhibitors used to treat erectile dysfunction, and non-steroidal anti-inflammatories (NSAIDs). GLP-1 injections used for diabetes and weight loss work by slowing down stomach emptying, which makes people feel full more quickly, but can also increase the risk of acid reflux. 

Pharmacist advice, rather than product self-selection, is therefore important if patients are taking medicines regularly for other chronic conditions are experiencing heartburn or indigestion symptoms. “Understanding a patient’s lifestyle, any other medical conditions present or existing medication will determine the advice given,” says Dr Richard Middleton, a registered pharmacist.

Short-term symptom relief

The wide range of OTC products available means some patients struggle with self-selection. Pharmacists can help them choose the best product to suit their needs, guided by several factors, including symptom frequency, duration and severity, potential drug interactions, adverse effects and personal preference, including product cost. 

“Patients want fast relief, minimal side-effects and formats that fit their lifestyle,” says Professor Hobson. “Antacids provide rapid but short-lived relief by neutralising acid. Alginates work differently: they form a protective raft that reduces reflux episodes, which is why many patients find them particularly effective after meals or before bed. I think OTC medicines, in conjunction with lifestyle changes, are currently under-utilised in the care of reflux patients.”

Antacids and alginates are usually taken on an “if required” basis. Different products, even within the same brand range, may contain a different balance of antacid versus alginate, which means their suitability will depend on each patient’s symptoms. Although these products tend to be fairly ‘budget-friendly’ and are widely available, they can cause side-effects such as constipation or diarrhoea, and may interact with other medicines and dietary supplements. 

Products containing sodium bicarbonate should be avoided by people on a low-salt diet, for example, and can cause rebound symptoms, and since peppermint is a known trigger of acid reflux, some patients will need to avoid mint-flavoured products.

“Many people find antacid liquids to be slightly more effective, but these aren’t as convenient to carry around as tablets,” says Dr Staten. “OTC products are very safe, but people should always follow the dosing instructions on the pack. Normally, antacids are used when required, which can lead to people taking them multiple times a day. If they find that symptoms aren’t controlled with those doses, it is time to speak to a doctor.”

Dr Middleton says that an increasing number of heartburn and indigestion patients are looking for sustainable or natural remedies rather than conventional medicines. These include medical devices with a lower risk of side-effects and drug interactions.

“Medical devices have a physical action in the gastrointestinal tract in a similar way to alginates,” he says. “Enterosorbents such as Silicolgel contain natural silicic acid in a colloidal oral gel, to coat the stomach and gastrointestinal tract with a protective lining. This attracts and binds with irritants, toxins and pathogens, which are then passed through the digestive tract when the body empties naturally.”

According to Professor Hobson, some natural approaches, such as alginate-based products derived from seaweed, have strong evidence for reducing reflux episodes. “While prebiotics and probiotics don’t treat reflux directly, they can support overall digestive health, particularly in patients with overlapping symptoms such as bloating or irregular bowel habits,” he says.

Longer-lasting relief

Patients who need a longer-acting or preventative medicine can purchase a low-dose proton pump inhibitor (PPI) from pharmacies. PPIs, which should be taken once a day in the morning, work by suppressing stomach acid production. 

They need to be taken for a few days to work properly, but using OTC PPIs without medical advice is only recommended for up to two weeks. If patients require PPIs for longer than this, or in higher doses, they will need to consult their GP.

“Self-management is a good thing if the symptoms are relatively mild, respond readily to the OTC treatment and settle in a fairly short timespan – about a week,” says Dr Staten. “But people should seek medical attention if their symptoms are worsening despite treatment or aren’t responding to the treatment, or if they find they need to self-manage for longer than a week.”

GPs will often prescribe PPIs for four to eight weeks initially, depending on the severity and cause of the reflux. “PPIs are useful where indigestion seems to be due to excessive gastric acid production. Research shows that they can reduce acid production by up to 65 per cent,” says Dr Middleton.

“However, they can cause severe hypomagnesaemia, as well as other electrolyte imbalances, so it is important that PPIs aren’t taken long-term, except under GP medical supervision. This doesn’t detract from appropriate short-term use, but patients should always be advised to talk to the pharmacist to ensure the medicine is safe for them.”

PPIs should be prescribed for the shortest time possible, at the lowest dose possible, to minimise side-effects and complications. However, these medicines are often overprescribed, taken incorrectly, and continued without a regular review. Long-term use of PPIs has been linked with an increased risk of hip fractures, Clostridioides difficile colitis, vitamin B12 deficiency and, in rare cases, acute interstitial nephritis.

Professor Hobson says that PPIs are often used as a default rather than a targeted therapy. “Pharmacists can play a vital role in reviewing long-term PPI use, checking timing and adherence, and identifying when escalation or reassessment is appropriate,” he says. “One of the most common issues I see is incorrect timing. PPIs work best when taken 30 to 60 minutes before food, yet many patients take them at random times of day. Pharmacists can dramatically improve symptom control simply by correcting this.”

Referral points

According to Professor Hobson, misdiagnosis of reflux is very common – and pharmacists are often the first to recognise when a patient’s journey has stalled. “Many patients labelled with ‘reflux’ don’t have acid reflux at all,” he says, “and this explains why PPIs often fail to provide relief; pH testing is the only way to know whether reflux is present, what type it is, and whether symptoms correlate with reflux events.

“If someone has been on PPIs for months or years with limited benefit, if their symptoms are predominantly throat-based, or if they describe fluctuating or atypical patterns, that is a strong indication that further investigation is needed.”

Sometimes, what seems to be heartburn has a more serious underlying cause. “Many people will go to their local pharmacy to grab a packet of indigestion tablets as they don’t think it is worth bothering their GP about,” says Ade Williams, pharmacist ambassador for Pancreatic Cancer Action.

“We would prefer that they have a word with the pharmacist while they are in there. As pharmacists, we can refer patients should we think this is necessary. A burning sensation in the chest or stomach, bloating and frequent burping could be misdiagnosed as GORD, gastritis or peptic ulcers. It could also signal stomach cancer, oesophageal cancer and pancreatic cancer.”

Red flag symptoms that indicate the need for a GP referral include:

• Experiencing heartburn/indigestion symptoms on most days
• The patient is over 55 years and their heartburn or indigestion symptoms keep coming back
• Swallowing difficulties or food is getting stuck in their throat
• Persistent or recurrent nausea or vomiting
• Blood in their vomit or stools
• Unintentional or unexplained weight loss
• Feeling abnormally full after eating 
• Pain across the back or radiating down the arms (which could indicate angina or a heart attack)
• Lifestyle changes and pharmacy medicines are not helping the heartburn or indigestion symptoms.