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Tackling those GI blues

As a group, gastrointestinal (GI) disorders can present with symptoms that are often vague and overlapping, making it difficult to pinpoint the underlying cause. And now there are the after-effects of Covid to consider. How should pharmacy teams approach their conversations with patients when talking about these problems?

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

Used to describe discomfort and pain in the upper GI tract associated with food intake, heartburn and indigestion are different conditions but common bedfellows. 

Heartburn results from dysfunction of the lower oesophageal sphincter – the job of which is to prevent stomach acid from entering the oesophagus. Gastric acid escapes from the stomach and refluxes up the oesophagus, causing irritation, discomfort and pain when it comes into contact with the delicate lining. 

Key causes of heartburn include being overweight, pregnancy, consumption of certain trigger foods or drinks, abnormal eating (e.g. large meals or eating ‘on the run’), smoking, stress, anxiety and hiatus hernia. Certain common medications can also increase the risk of heartburn such as non-steroidal anti-inflammatory drugs (NSAIDs). 

Indigestion is a more generalised term describing feelings of discomfort after eating.
It encompasses heartburn, as well as feelings of fullness or nausea, bloating and stomach ache. 

Treatment options for heartburn and indigestion are primarily focused on neutralising or reducing acid in the stomach. Antacids contain alkaline salts and work by chemically neutralising acid in the stomach; they provide rapid relief of symptoms but are short-acting. Alginates are rafting agents which form a floating barrier on top of the stomach contents to reduce reflux. Many also contain an antacid ingredient. 

Where first-line antacids or alginates prove ineffective for heartburn, proton pump inhibitors (PPIs) can be recommended. These targeted agents work by suppressing the production and secretion of acid in the stomach and afford longer-term relief from symptoms. Customers should be advised that PPIs do not offer immediate relief and maximum effects can take several days to build up. 

Although occasional heartburn elicited by over-indulgence is common, persistent heartburn and acid regurgitation are also the hallmark symptoms of gastro-oesophageal reflux disease (GORD). Other less common symptoms of GORD may include chest pain, hoarseness, cough, wheezing, asthma or dental erosions. GORD is usually a clinical diagnosis, although an endoscopy may be performed for confirmation. 

The aim of treatment is to manage symptoms and lower the likelihood of recurrence and complications. According to NICE treatment guidelines, patients with uninvestigated symptoms suggestive of GORD should be managed as though they have dyspepsia.

Proton pump inhibitors are the cornerstone of therapy for patients with an endoscopy-confirmed diagnosis of GORD and the initial treatment regimen lasts four to eight weeks.2 If a patient fails to respond to first-line PPIs, then H2 receptor antagonists are an alternative option.2 Long-term continuous usage of antacids is not recommended as a suitable treatment strategy for GORD.2

Key risk factors for developing GORD include a family history of the condition, older age, hiatus hernia and overweight/obesity. Stress, anxiety, smoking and alcohol consumption may also be additional contributory factors. Alongside pharmacotherapy, lifestyle measures can help in the management of GORD. Positive steps for sufferers include losing weight (if overweight or obese), eating healthily, avoiding heartburn trigger foods, stopping smoking, reducing alcohol consumption, and managing stress and anxiety. 

For any customer with suspected or diagnosed GORD, causative or exacerbatory medications should be reviewed. These are manifold and include anticholinergics, benzodiazepines, beta-blockers, bisphosphonates, calcium channel blockers, corticosteroids, NSAIDs, nitrates, theophyllines and tricyclic antidepressants.  

Constipation has a wide range of potential causes – the most common being insufficient fibre intake in the diet. Other factors can include not drinking enough liquid, lack of exercise or immobility, pregnancy and old age. Constipation is also one of the constellation of symptoms of IBS. 

In some cases, constipation can be medication related: potentially problematic drugs include codeine-containing painkillers, aluminum-based antacids, antispasmodics, antidepressants, diuretics, iron supplements and some anti-epileptic medication. Constipation can also occur as a rebound effect to long-term use of laxatives. 

The first step for managing constipation is lifestyle changes – notably an increase in fibre and fluid intake, alongside gentle exercise. 

Sufferers should be encouraged to drink plenty of liquid throughout the day and avoid holding back the urge to pass stools as this can exacerbate the problem. If lifestyle interventions fail to resolve the constipation, then numerous OTC treatment options are available – the most obvious being laxatives. 

Stimulant laxatives with active ingredients such as bisacodyl and senna work by stimulating nerve endings in the bowel to promote the movement of faeces. 

Bulk-forming laxatives like methylcellulose and ispaghula husk contain natural fibres that help increase faecal mass. This has the effect of boosting intestinal motility and also allows the stools to hold more water – making them softer and easier to pass. 

The final laxative type, osmotic laxatives, help to retain fluid in the bowel and the faeces. Lactulose is a key example. 

In addition to laxatives, stool softening agents (e.g. ducosate sodium) are also available to treat constipation. These work by softening and lubricating stools to make them easier to pass.

Diarrhoea can strike at any time and is most often a short-lived and self-limiting condition. It occurs due to inflammation in the large intestine, rendering it unable to absorb fluid as effectively and leading to increased liquidity of the ensuing stools. Sporadic episodes of diarrhoea can be caused by a flare-up of IBS or an underlying inflammatory bowel disease, or can occur due to stress/anxiety or certain types of food intolerances (e.g. diary products) 

Diarrhoea that lasts for several days or weeks is most often due to an acute viral or bacterial infection of the GI tract. These infections may be picked up during travel to foreign countries, particularly those with undrinkable tap water, or as a result of substandard food hygiene practices. It is also important to be aware of diarrhoea as a potential medication side-effect. Causative drugs include antibiotics (due to their bacteriocidal effects on gut microbiota), blood pressure medications and magnesium-containing antacids. 

Management advice for patients with diarrhoea should centre on avoiding dehydration. This is particularly important for the elderly and young children/babies where the condition can quickly become dangerous. Rehydration therapy for acute diarrhoea works to replace lost fluids and salts. 

Specific antidiarrhoeal medicines such as loperamide can also be recommended in cases where the swift resolution of diarrhoea is required (e.g. for work or special events). These work by slowing the transit time of food through the gut, allowing more water to be absorbed. 

OTC treatments containing bismuth sub-salicylate may be helpful for instances of bacterial diarrhoea because this salt directly targets the bacteria, as well as providing a protective coating over the stomach and intestines. 

If a diarrhoea sufferer has recently returned from foreign travel and is also experiencing high fever or other symptoms, they should be referred to their GP as treatment may be required for possible bacterial or parasitic infection. 

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.  


  1. Marasco, G. et al. (2022). Post Covid-19 irritable bowel syndrome. Gut.
  2. BNF. NICE treatment summaries. Gastro-oesophageal reflux disease
  3. NHS
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