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Upper GI health: Making the connection

With patients often muddling their terminology when describing upper GI symptoms it is is important pharmacy staff ask the right questions and make the right connection.

Learning objectives

After reading this feature you should be able to:

  • Explain the causes of indigestion, heartburn and reflux
  • Advise customers on the most effective way to treat upper GI problems
  • Determine when symptoms indicate a more serious condition.

 

Upper GI problems affect most people from time to time, causing indigestion, dyspepsia and heartburn. Remedies for these common – and often troublesome – symptoms are a core pharmacy category, but customers are often confused about the causes of their symptoms and which OTC products they should be taking. This can lead to ineffective management or ‘red flag’ symptoms not being identified early on.

“Upper GI health is no different to any other pharmacy category,” says Ash Soni, member of the RPS English Pharmacy Board. “It is a case of pharmacists, and pharmacy staff, asking customers the right questions and checking that the medication they are using is the right one for them. Customers often use the same terminology to describe different symptoms, which can cause a lot of confusion, so pharmacists may need to ask for more details, especially exactly where the symptoms are and what the customer is experiencing.”

Symptom confusion

According to gastroenterologist Dr Neil Galletly, ‘indigestion’, ‘heartburn’ and ‘dyspepsia’ are the terms often used by patients, yet they may mean different things to different people. Some pharmacy customers may talk about having ‘acid reflux’ – but this isn’t a symptom; it is a disease that can cause heartburn and needs to be properly diagnosed. Patients also often use the term ‘indigestion’ to describe heartburn, excessive belching or a sensation of food coming back up.

“When people come to see me about their indigestion, they may mean a pain or discomfort – often burning – at the top of their tummy,” says Dr Galletly. “Others mean a dull burning pain behind the chest bone or an acid taste in the back of the throat that can come on after a heavy meal or in bed at night.

“Others may mean belching or burping more frequently, or experiencing frequent nausea, or getting bloating in the tummy after eating. And others may mean a sensation of food becoming stuck when they eat and sometimes having to wash food down or even regurgitate it out to get relief. The one thing that they have in common is that the symptoms are often made worse – or better – by food.”

It is not surprising that patients, GPs and other healthcare professionals often get confused by the many different terms being used. NICE guidance in September 2014 stated that: “Dyspepsia describes a range of symptoms arising from the upper gastrointestinal (GI) tract, but it has no universally accepted definition. The British Society of Gastroenterology (BSG) defines dyspepsia as a group of symptoms that alert doctors to consider disease of the upper GI tract, and states that dyspepsia itself is not a diagnosis. These symptoms, which typically are present for four weeks or more, include upper abdominal pain or discomfort, heartburn, gastric reflux, nausea or vomiting.”

When customers discuss their symptoms in a pharmacy setting, it is important to make sure they explain exactly what they are experiencing and feeling – and where. According to Dr Galletly, the site of the customer’s discomfort is the main way to differentiate between heartburn and dyspepsia.

“Heartburn is used to describe pain or discomfort felt deep behind the breastbone,” he says. “It is often burning in nature and can feel as if it is ‘rising’ in the chest. It is almost always felt in the centre of the chest rather than on the right or the left. Dyspepsia is a term used to describe burning or pain in the upper abdomen, which typically occurs after a meal.”

Common causes

Acid and bile are produced naturally inside the stomach during digestion, but in excess they can irritate the sensitive stomach lining. If the acidic stomach contents make their way up the oesophagus (reflux), this can cause further irritation, leading to heartburn. According to the charity, Core, acid reflux, also called gastro-oesophageal reflux disease (GORD), affects around a quarter of all adults – but many people aren’t aware that it is happening unless they experience symptoms.

Acid reflux is often caused by a leaky valve between the stomach and oesophagus due to the inappropriate relaxation of the oesophageal sphincter muscle. The symptoms – heartburn, an acidic taste at the back of the throat (known as acid brash), a persistent cough or hoarse voice – may be worse when the customer bends over or when lying in bed at night.

Certain factors can increase the risk of developing GORD, including being overweight, eating a high fat diet, smoking, excess alcohol intake, stress and pregnancy. Some medication (including calcium channel blockers and nitrates) can also trigger acid reflux, so it is important to ask customers about their prescribed and OTC medicine usage if they need advice on upper GI remedies.

“The main causes of reflux of acid and bile from the stomach into the oesophagus are a hiatus hernia or a lax lower oesophageal sphincter,” says Professor Rebecca Fitzgerald from the Medical Research Council cancer unit at the University of Cambridge and spokesperson for United European Gastroenterology (UEG).

“Being overweight can also be a contributor and can itself lead to a hiatus hernia. Some foods exacerbate the symptoms as well. Dyspepsia can be caused by inflammation of the stomach, for example as a result of infection with Helicobacter pylori bacteria or irritants, including alcohol. Medicines such as aspirin and non-steroidal anti-inflammatory drugs can also cause indigestion.”

Red flag symptoms

Action Against Heartburn is a coalition of 18 charities and other organisations which raises awareness of oesophageal cancer and its early diagnosis.

“If heartburn lasts for more than three weeks, customers should start to think about whether there could be an underlying cause,” says Alan Moss, chairman of Action Against Heartburn.

“If pharmacists notice customers are buying heartburn medicines on a regular basis, they should remind them to see their GP. Some people are frightened off by the term ‘cancer’, so pharmacists should mention inflammation of the oesophagus or a stomach ulcer instead.”

Pharmacists should refer customers who:

  • Have taken an indigestion/heartburn remedy for two weeks with no relief of their symptoms
  • Are taking a prescribed medicine that could be causing the symptoms
  • Are experiencing new symptoms and are over 55 years of age
  • Are passing blood or black tarry stools
  • Have unexplained weight loss, persistent unexplained vomiting, difficulty (or pain on) swallowing and persistent stomach pain.

If the pain radiates to other areas of the body, it could indicate a non-GI problem. Pain down the inside of the left arm could be cardiovascular in origin.

‘Test and treat’ H. pylori

In most people, indigestion is mild and only occurs occasionally. However, it can also be a symptom of a peptic ulcer, an open sore on the inside lining of the stomach or small intestine. Stomach ulcers can affect around one in 10 people at some point in their life. They are usually associated with H. pylori bacteria or a prolonged course of NSAIDs.

Around 40 per cent of people in the UK have H. pylori bacteria in their stomach. Most people don’t experience any symptoms, so don’t even realise that they are infected, but around 15 per cent get ulcers in the stomach or duodenum. The bacteria irritate the stomach lining so that it is more prone to damage from stomach acid. Most stomach ulcers cause indigestion or no pain at all, but occasionally they become more serious, leading to bleeding or perforation.

Ideally, everyone with stomach ulcers who tests positive for H. pylori should be treated to eradicate the bacteria. Not only does this reduce the risk of a recurrence of the stomach ulcer, but H. pylori infection is also associated with a very small risk of cancer. A report by Public Health England in October 2016 on ‘Test and treat for Helicobacter pylori in dyspepsia’ to minimise use of antibiotics, revealed that certain people should be offered H. pylori testing. These include patients with/before:

  • Uncomplicated dyspepsia who are unresponsive to lifestyle change and antacids, following a single one month course of a proton pump inhibitor (PPI), without alarm symptoms
  • A history of gastric ulcer or duodenal ulcer, who have not previously been tested
  • Starting or taking NSAIDs, if they have a prior history of gastro-duodenal ulcers
  • Unexplained iron-deficiency anaemia, after negative endoscopic investigation has excluded gastric and colonic malignancy, and investigations have been carried out for other causes, including cancer, idiopathic thrombocytopenic purpura and vitamin B12 deficiency.

Patients with proven oesophagitis or predominant symptoms of reflux, suggesting gastro-oesophageal reflux disease (GORD), should not be tested for H. pylori.

The urea breath test is the most accurate one for H. pylori infection. A blood test is less accurate because it stays positive even if a previous H. pylori infection has been treated effectively. The urea breath test involves collecting a breath sample a short time after drinking a urea-containing drink. This test needs to be performed at least one month after a course of treatment has finished. If the test is positive for H. pylori, the infection can be treated with a one-week course of two antibiotics and a proton pump inhibitor (PPI).

H. pylori ‘test and treat’ has been available from certain pharmacies for some time as an extended service, as well as through GP surgeries. Professor Fitzgerald says that testing through pharmacies can reduce endoscopy referrals but is controversial.

“GPs are advised to do H. pylori screening as part of their initial treatment strategy,” she says, “but this should be done in the context of taking a history, checking which drugs the patient is on and confirming there are no warning symptoms.”

Management approaches

Upper GI health problems can usually be treated with a combination of medication and lifestyle changes. Customers should be encouraged to lose weight if necessary, avoid any trigger foods (such as citrus fruits, spicy foods, too much caffeine, alcohol or chocolate), stop late-night eating, quit smoking and try some relaxation exercises to reduce stress. If these lifestyle measures fail to work, however, they may be able to take some OTC upper GI remedies, using a stepped approach.

Upper GI symptoms can often be improved by taking medication that suppresses stomach acid – either to neutralise the acid, stop it from rising into the oesophagus or preventing its production.

Antacids
Antacids (containing aluminium and magnesium compounds) are the first-line treatment for mild, occasional symptoms of acid indigestion. They counteract excess stomach acid and provide immediate relief. They should ideally be taken when the symptoms occur or are expected (e.g. before meals). Liquid remedies are more effective than tablet preparations.
Magnesium-containing antacids can have a laxative action, while aluminium-containing ones may be constipating. Taking antacids containing both magnesium and aluminium may reduce these side-effects. Antacids should preferably not be taken at the same time as other drugs since they may impair absorption and damage enteric coatings of other medications.

Alginates
Antacids can be combined with alginates, which create a protective raft over the stomach contents to reduce reflux and protect the oesophageal lining. Simeticone (activated dimeticone) is an antifoaming agent and may be added to an antacid to relieve wind and bloating.

H2 receptor blockers and PPIs
H2 receptor antagonists (e.g. cimetidine, ranitidine, famotidine), which reduce acid production, are available in lower strengths over the counter for use for a maximum of two weeks. However, proton pump inhibitors (e.g. esomeprazole and pantoprazole), which switch off stomach acid production, are generally considered to be more effective at providing symptom relief.

“Patients should start with an antacid and then move onto a proton pump inhibitor [PPI],” says Professor Fitzgerald. “However, if they are needing regular PPIs, they should see their GP and discuss whether an endoscopy is necessary, as the medication may be masking a problem such as an ulcer or severe inflammation and even in rare cases cancer.”

A GP may prescribe a full-dose course of a PPI for a month or more to see if the symptoms subside. After this, many patients are able to return to the occasional use of antacids and alginates. The side-effects and drug interactions of these products can be a problem for certain people and should be highlighted to customers at the point of sale or to patients on dispensing.

If patients need regular acid suppression with PPIs, this should be at the lowest dose possible for symptom control. PPIs can take time to work (usually a few days) and customers may need to use an antacid-alginate combination to ease their symptoms during this time period. The long-term use of PPIs has been associated with an increased risk of fracture. Patients who are at risk of osteoporosis should be advised to maintain an adequate intake of calcium and vitamin D, and, if necessary, receive other preventative therapy.

If customers are taking any other medication that could be affected by acid suppression (e.g. iron or tetracyclines), they should leave two hours between taking the different treatments.

Customers often use the same terminology to describe different symptoms

Regular monitoring

Short-term upper GI symptoms are usually nothing to worry about, but they should still be taken seriously if they persist or are severe. Customers who buy antacids or acid suppressants regularly should be referred to their GP so that any underlying problem can be diagnosed and treated.

Moderate to severe GORD can cause dental problems, due to stomach acid in the mouth, and ulceration of the oesophagus, which can cause bleeding. Around 10 per cent of people with GORD also develop a condition known as Barrett’s oesophagus, which is associated with a small risk of oesophageal cancer. It is not practical for everyone to have an endoscopy, so many cases of Barrett’s oesophagus are not being picked up.

Professor Fitzgerald is currently involved in developing the Cytosponge test as an alternative way for doctors to investigate heartburn without needing an endoscopy. A new trial, called BEST3, is due to start in primary care. The ‘Cytosponge’ sits within a pill which, when swallowed, dissolves to reveal a sponge that scrapes off cells when withdrawn up the gullet. It allows doctors to collect cells from all along the gullet, whereas standard biopsies take individual point samples.

At present, Barrett’s oesophagus and oesophageal cancer are diagnosed using biopsies, which look for the proliferation of abnormal cancer cells (dysplasia). This requires a trained scientist to identify abnormalities. An alternative way of spotting very early signs of oesophageal cancer would be to look for important genetic changes. However, variations in mutations across the oesophagus mean that standard biopsies may miss cells with important mutations. Professor Fitzgerald’s research found that a sample was more likely to pick up key mutations if taken using the Cytosponge.

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