Better bowels

Bowel-related problems are some of the most common issues that pharmacy staff encounter, so it’s important to be able to help break down taboos and offer advice and support

According to the Bladder and Bowel Community website, one third of the population regularly suffer from bowel-related problems such as irritable bowel syndrome, constipation, diarrhoea, stomach ache, nausea and sickness.

Everyone’s bowels work differently, which means we all have our own 'normal' bowel habits. But it’s important for people to remain vigilant to see if anything changes from what is normal for them, and to seek advice from a GP if changes don’t go away on their own. To underline the importance of this, in December 2021, a campaign called 'Check for Change' was launched by Essity, a global health and hygiene organisation.

A survey conducted for the campaign, in partnership with UK charity Bladder & Bowel UK and Northern Devon NHS Healthcare Trust, found that more than a quarter of respondents had delayed visiting their doctor for something they considered to be embarrassing, and 45 per cent said they 'often' self-diagnosed – whether symptoms were serious or not – based on online resources. This shows that there is a definite need to make bowel problems part of everyday health discussions.

Negative impact

In October 2021, two research studies presented at United European Gastroenterology (UEG) Week revealed how bowel-related symptoms can have a negative impact on people’s quality of life.

According to researchers from Belgium and Sweden, around 13 per cent of women and nine per cent of men frequently experience abdominal pain when they eat meals. These people are also more likely to suffer from bloating, a swollen tummy, feeling too full after eating or feeling full too quickly, constipation and diarrhoea. They are also more prone to anxiety and depression.

Another study, conducted in the US and Mexico, found that breaking wind was the most frequently reported digestive issue, affecting eight out of 10 adults in a 24-hour period. Other gas-related symptoms include stomach rumbling, belching and bad breath, trapped wind, swollen tummy and bloating.

Keeping things healthy

According to Bladder & Bowel UK, to keep the bowel healthy, it is important to eat a healthy diet and take regular exercise.

Nutritionist Jenna Hope from jennahopenutrition.com says that pharmacy teams are well placed to discuss the importance of lifestyle factors with customers. "They should highlight the role of stress and offer advice on meditation and relaxation apps, which can support stress reduction," she says. "Offering handouts explaining the role of mindful eating can help to encourage a slower eating process to support bowel health.

"Offering diet and lifestyle consultations (in person or by phone) can help provide guidance to those suffering with top-level bowel symptoms."

Our gut microbiome contains microbes that help to digest food and produce important substances like vitamins. Changes in the variety and volume of bacteria in the gut microbiome may be linked to certain digestive problems, such as inflammatory bowel disease, irritable bowel syndrome and acid reflux.

The gut microbiome accounts for around 70 per cent of our immune system, so changes can influence inflammation (associated with conditions such as heart disease, type 2 diabetes and obesity) and susceptibility to infections, including Covid-19.

"There are many factors which contribute to a healthy microbiome, including limiting stress, engaging in regular low intensity physical activity, optimising sleep, limiting artificial sweeteners, smoking and alcohol, and consuming a plant-focused, fibre-rich diet," says Jenna.

The more diverse our diet is, the more diverse our gut microbiota is likely to be. Some foods seem to be more beneficial in achieving this than others. Research published in the journal Gut last April found that a diet high in animal products, processed foods, alcohol and sugar is linked to an 'inflammatory' gut microbiome, while a high intake of plant-based foods (e.g. nuts, fruit and vegetables) and oily fish is linked to 'friendly' anti-inflammatory microbes.

Prebiotic or probiotic supplements may improve the make-up of the gut microbiome, especially in people who have digestive problems, are taking antibiotics or are feeling stressed or run down. Probiotics are available in a variety of forms, but they need to be taken every day to have an effect.

Exercise is important for the bowel too, as is taking time to use the toilet. "A brisk walk, swim, or even gardening are great ways to improve natural movement, which also helps improve bowel movements," says Cheryl Lythgoe, matron at healthcare services provider Benenden Health. "A lack of exercise can slow down the natural movement of faeces in the bowel, leading to constipation. It is important to try to relax and give yourself time to go to the toilet. If you are regularly stressed or anxious, bowel movements can be affected."

Managing common conditions

While some bowel symptoms don’t have an underlying cause, others may be due to a specific disorder, such as inflammatory bowel disease, irritable bowel disease or coeliac disease.

"Some people with inflammatory bowel disease may present atypically, and symptoms may also change over time, with periods of good health punctuated by flare-ups," says Rachel Ainley, head of research and evidence at Crohn’s & Colitis UK.

"By keeping alert to the symptoms of Crohn’s and colitis, community pharmacists can play a vital role in helping people get a diagnosis and put them on the path to treatment."

Aside from these conditions, there are many others that customers may present with in the pharmacy. Let’s take a look at some of the most common of these now.

Acute diarrhoea

Acute diarrhoea (passing loose or watery stools) lasts less than 14 days and starts to improve after two to four days without any treatment. It may be caused by various things, such as an infection (gastroenteritis), food poisoning, medicine side effects or anxiety.

If someone has diarrhoea, it’s important to prevent dehydration, especially in babies and older people. They should be encouraged to drink plenty of fluids (water, fruit juices or salty soups, but not caffeine or alcohol) or to use oral rehydration therapy products, which are available over the counter from the pharmacy. Eating carbohydrates (e.g. rice, pasta, salty crackers) may help to ease the diarrhoea.

Customers can take loperamide hydrochloride tablets if they want to stop diarrhoea quickly (for example, before an important meeting). But this should be avoided if they’re passing blood or have any significant tummy pain. Loperamide is not recommended for anyone under the age of 12.

Constipation

Constipation is thought to affect twice as many women as men, and older people are five times more likely than younger adults to suffer, says Cheryl. "A person is considered to have constipation if their bowel movements occur less often than usual or consist of hard, dry stools that can be painful or difficult to pass," she explains.

Increasing fibre in the diet may help to ease constipation, along with adequate fluid intake and exercise. However, suddenly increasing fibre intake can cause bloating or excess wind. Before recommending laxatives, it is important to make sure the customer is constipated, that lifestyle changes haven’t helped and that there is no underlying undiagnosed condition. Constipation may be a side effect of some medicines, such as opioid painkillers. Bulk-forming laxatives may help adults with small, hard stools if they can’t eat (or drink) more fibre, but laxatives should not be used regularly without a doctor’s advice.

IBS

Irritable bowel syndrome (IBS) affects around 10 to 20 per cent of the UK population. It causes stomach cramps, bloating, diarrhoea and constipation. The symptoms often come and go.

Over the counter treatments include anti-spasmodic medicines (e.g. alverine citrate, mebeverine hydrochloride, peppermint oil) to control bowel pain, laxatives for constipation (but not lactulose as this can cause bloating) and loperamide for diarrhoea.

If customers want to try probiotic supplements, National Institute for Health & Care Excellence (NICE) guidance recommends taking these for four weeks to see if they help.

Diet and lifestyle changes, such as watching fibre intake, drinking plenty of fluids and exercising, are important in IBS management.

Short-chain carbohydrates called ‘FODMAPS’ may aggravate IBS symptoms – these are found in various foods, including wheat, some fruits and vegetables, pulses, artificial sweeteners and some processed foods – so customers may benefit from cutting down on these.

NICE guidance says that if lifestyle measures and medicines haven’t helped after a year, patients may be referred for a psychological intervention, such as psychotherapy or cognitive behavioural therapy (CBT).

According to Dr Marianne Trent, clinical psychologist and founder of Good Thinking Psychological Services, IBS may be linked to stress, anxiety and trauma. "It can be useful to discuss with customers whether they are noticing any particular patterns," she says. "Ask whether flare-ups are happening more often before, during or after social encounters and whether they have been feeling stressed or upset recently."

Wind and burping

According to digestive health charity Guts UK, the average person breaks wind up to 40 times a day. Excessive wind can cause burping (belching), flatulence (farting), rumblings (tummy sounds) and bloating. This is usually nothing to worry about and may be caused by eating too quickly, drinking a lot of fluid with meals, chewing gum, smoking or wearing loose dentures. Some people naturally swallow a lot of air, especially when they’re stressed.

Increased wind production can be triggered by fizzy drinks, sorbitol (an artificial sweetener), fatty foods and high fibre foods (e.g. cabbage, Brussels sprouts, cauliflower, onions and pulses). It may also be due to underlying lactose intolerance or acid reflux.

Loud bowel noises may be due to hunger, anxiety or underlying conditions such as IBS or inflammatory bowel disease. Some people find that simeticone tablets or peppermint oil capsules help to ease bloating and discomfort.

Nausea and sickness

Feeling sick (nausea) or being sick usually goes away on its own. However, it may be caused by an infection, acid reflux, migraine, an ear problem, some medicines or anxiety.

If someone is feeling sick, they should get plenty of fresh air, take regular sips of a cold drink, try ginger or peppermint tea, eat ginger-containing foods (such as biscuits) and eat smaller, more frequent meals. Travel sickness may be eased with over the counter medicines.

If someone is being sick, they need to prevent dehydration by drinking plenty of fluids. They should consult their GP if the nausea or vomiting continue, or if it keeps coming back. A GP may prescribe anti-emetic medicines, depending on the cause.

Coeliac disease

Coeliac disease affects around one in 100 people in the UK. It is an autoimmune reaction to gluten, a protein found in wheat, barley and rye. It causes chronic inflammation of the small bowel, leading to diarrhoea, bloating and abdominal pain, and is diagnosed with a blood test and endoscopy.

The only effective treatment for coeliac disease is a strict, life-long, gluten-free diet. But people with coeliac disease may also need medicines to ease their symptoms and dietary supplements to reduce the risk of complications, which can include osteoporosis and anaemia.

Inflammatory bowel disease

Inflammatory bowel disease (IBD) is an umbrella term often used to describe two conditions: Crohn’s disease and ulcerative colitis.

One in 650 people in the UK have Crohn’s disease, a chronic inflammatory bowel condition affecting any part of the bowel. This can cause flare-ups of diarrhoea, fever, fatigue, tummy pain, rectal bleeding and mouth ulcers.

One in 240 people in the UK have ulcerative colitis, which affects only the large bowel. The symptoms vary, but include diarrhoea, tummy pain and rectal bleeding.

In some people, inflammatory bowel disease may also cause weight loss, joint pain, skin rashes and sore eyes.

There is no specific diet for inflammatory bowel disease. Most people are treated with anti-inflammatory medicines, and sometimes surgery to remove damaged parts of the bowel.

Cancer screening

Bowel cancer is the fourth most common cancer in the UK. It can cause a change in bowel habits and blood in the stools.

To help increase the chances of early diagnosis, the NHS Bowel Cancer Screening Programme is available to people aged 60 to 74 in England, 58 to 74 in Wales, 50 to 74 in Scotland, and 60 to 74 in Northern Ireland. In England, some people aged 56 are also being invited, as the programme gradually expands to include the over-50s.

A faecal immunochemical test (FIT) kit is sent every two years to everyone who is eligible. To use the kit, customers collect a small sample of stool on a plastic stick, put it in a sample bottle and send it to a lab, where it is checked for tiny amounts of blood.

If the test finds anything unusual, the person may be asked to have further tests to confirm or rule out cancer.

Bowel-related red flags

If customers experience any of the following symptoms, they must see their GP as soon as possible:

• Bleeding from the back passage
• Red or black stools
• New onset constipation, especially in people over the age of 50
• Persistent diarrhoea or constipation lasting three weeks or more
• Unexplained weight loss and tiredness
• Unexplained tummy pain or a lump in the tummy
• Excessive burping with chest discomfort (especially on exertion) or swallowing problems
• Bloating that persists or is accompanied by weight loss, tummy pain or diarrhoea.

Signposting

If customers want to know more about digestive health, they can visit the following websites:

• Guts UK
• Bladder and Bowel UK
• Crohn’s & Colitis UK
• IBS network
• Bladder and Bowel Community.

Tune in and learn more

Next month (February 2022), the Crohn’s & Colitis charity will be releasing a podcast episode for pharmacists and pharmacy teams, focusing on the symptoms of Crohn’s and Colitis, with the aim of increasing awareness of the conditions. Pharmacy teams can also sign up for the charity’s newsletter.