Pharmacy teams should be prepared for a potential new wave of long-term GI disorders brought on by the Covid-19 pandemic, especially in people who experienced severe infection requiring hospitalisation.
According to new research published recently in the journal Gut, prior infection with Covid-19 may increase the risk of developing persistent GI symptoms.
The study looked at over 2,000 patients hospitalised with Covid across 14 different countries. The occurrence of GI symptoms was over 20 per cent higher in those who had contracted Covid (around 60 per cent) versus controls (approximately 40 per cent) – with a notable increase in new diagnoses of irritable bowel syndrome (IBS).
“Covid-19 is associated with a modest increased risk of long-term gastrointestinal symptoms and IBS,” confirmed the study authors. “Given the high prevalence of Covid-19 globally, an increase in new-onset disorders of gut-brain interaction should be expected due to Covid-19, especially after hospitalisation for this disease.”
Postulating about potential mechanisms underlying the persistence of GI symptoms after Covid, the researchers speculated that this may be due to modifications in gut microbiota triggered by the viral infection, as well as possible changes in gut mobility and intestinal permeability.1
Common GI conditions
Inflammatory bowel conditions
Inflammatory bowel disease (IBD), which encompasses both Crohn’s disease and ulcerative colitis, is a serious long-term condition producing symptoms such as persistent diarrhoea, rectal bleeding/bloody stools, stomach pain, fatigue and weight loss.
The condition is characterised by inflammation and tissue damage, which can occur anywhere along the GI tract from the mouth to the anus. It is typically managed at secondary care level by a gastroenterologist, with treatment options including steroids, 5-aminosalicyclic acids and biologic drugs that target the underlying mechanisms of immune dysfunction. Surgery may even be required in some cases. Choice of treatment depends on the severity of the symptoms and how much of the gut is affected.
Pharmacists can help IBD sufferers manage their medications as well as providing useful lifestyle advice, particularly on fatigue management. The charity Crohn’s & Colitis UK provides a raft of useful information for IBD sufferers and should be a key signpost by pharmacy teams.
Blood or mucus in stools
Although black, tar-like blood in the stools is a key red flag for referral, bright red blood brought on by passing a stool (and often seen on the toilet paper when wiping) is a typical symptom of external haemorrhoids.
These are swollen veins close to the anal opening which are often sore and cause itching or discomfort. Haemorrhoid sufferers may also pass a jelly-like anal discharge.
In cases where haemorrhoids are identified as the cause of anal bleeding, a range of cream, gel, ointment and spray treatment options are available OTC containing active ingredients such as astringents, anti-inflammatories and local anaesthetics.
Another possible cause of mucus in the stools is irritable bowel syndrome. Symptoms tend to come and go, with flare-ups typically triggered by food, drink and/or stress. Other symptoms of IBS may include stomach pain or cramps, bloating, and diarrhoea and/or constipation.
As a precautionary measure, any customer complaining of blood in the stools or bleeding from the bottom should be encouraged to visit their GP to confirm a diagnosis of haemorrhoids (if these are suspected) and/or to rule out other potentially seriously underlying causes.
Abdominal cramping or distension
Stomach cramping and/or bloating are both hallmark symptoms of IBS and can also be caused by food intolerances. Exactly what causes IBS is unclear but it appears to be due to dysfunction in the normal peristaltic movements of the intestine – often associated with emotional tension such as stress or anxiety.
To relieve cramping, pharmacy teams can recommend OTC treatments containing antispasmodic agents such as hyoscine and mebeverine. These act on muscles in the wall of the bowel to relax them and relieve painful cramps.
Peppermint also has a natural antispasmodic effect and is available to buy as oral capsules or can be drunk as a tea. Antiflatulence agents such as simeticone may help to break up trapped wind, which can contribute to symptoms of bloating.
Women experiencing frequent bouts of distension or bloating (roughly 12 or more times per month) should also be advised to visit their GP as this could be a red flag symptom of potential ovarian cancer.3
Look out for GI red flags
Due to the commonplace nature of GI disorders, it can sometimes be difficult to determine when symptoms warrant onward referral.
As a general rule, anyone with persistent or recurrent GI problems should be referred to their GP for further investigation — especially in cases where symptoms fail to respond to OTC medication or recommended lifestyle measures. If prescribed medication is suspected as a potential cause of a patient’s GI complaints, then a medication review and a move to alternative drug options may be advisable.
Specific red flag GI symptoms that should always trigger an onward referral include:
- Severe pain in the stomach or rectum
- GI symptoms accompanied by unintentional weight loss
- Heartburn that occurs most days for three weeks or more
- The feeling of food sticking in the throat
- Frequent vomiting
- Black tar-like blood mixed in with the stools or bloody diarrhoea
- A hard lump or swelling in the stomach.
Expectant mothers with GI problems such as heartburn should also be encouraged to speak to their midwife for further advice on pregnancy-safe treatment approaches.
Customer advice on GI problems from Care
Stomach and bowel complaints are very common and today’s busy lifestyles with snatched, poorly balanced meals contribute significantly to how often they occur. Whilst almost everyone suffers at some time from GI issues, these problems can usually be fixed with lifestyle changes and OTC pharmacy remedies.
For any customers feeling particularly embarrassed, it is important to show empathy and provide them with reassurance that you’re here to help and by acknowledging you realise the situation is uncomfortable. Watch your body language and make sure you don’t look surprised or uncomfortable. Instead maintain eye contact and nod your head while reassuring them. Actively listen to the customer and be direct, avoiding jargon while you give them the information they need.
It is important to ask about the incidence of symptoms relating to eating and exercise, as this is typically a distinguishing factor of different gastrointestinal conditions. Many GI conditions are affected or triggered by different types of foods, including dyspepsia, GORD and IBS – so it helps if patients can identify their triggers, suggesting that they keep a food diary is also useful.
Diarrhoea and constipation can be symptoms of GI disorders for patients presenting new and worsening constipation, or persistent diarrhoea that lasts more than three days – they should be referred to their GP. Flare-ups of IBS can also be treated over the counter but again, if the patient has not been diagnosed by the GP, they should be referred.
It is important to remember side-effects of some medications, so it is essential to ask patients about anything being taken on prescription or bought over the counter.
Eating a well-balanced diet, avoiding excess alcohol consumption, exercising regularly, eating smaller portions, keeping junk food to a minimum and reducing caffeine intake are just some of the lifestyle changes pharmacy teams can recommend to customers to reduce the risk of GI symptoms.
- Marasco, G. et al. (2022). Post Covid-19 irritable bowel syndrome. Gut. doi.org/10.1136/gutjnl-2022-328483
- BNF. NICE treatment summaries. Gastro-oesophageal reflux disease