Clinical update: Gut reaction

Potential complications

For most people, heartburn and dyspepsia are a nuisance rather than anything more serious but prolonged acid reflux can sometimes cause severe irritation, inflammation, bleeding and ulceration of the oesophagus (oesophagitis). 

Long-term reflux can also lead to Barrett’s oesophagus, in which changes occur to the cells lining the lower part of the oesophagus. Although these altered cells aren’t cancerous, there is a small risk that they will become so over time.

Symptoms of reflux that wake someone at night are a particular risk factor for Barrett’s oesophagus, says Julie Thompson, information manager at the Guts UK charity. “It can be challenging to distinguish between Barrett’s oesophagus and reflux on symptoms alone.” 

“NICE guidelines suggest referring someone for endoscopy to check for Barrett’s oesophagus if they show the following risk factors: GORD, long duration of symptoms, increased frequency of symptoms, a previous diagnosis of oesophagitis, hiatus hernia, oesophageal ulcers or oesophageal strictures, and other risk factors such as older age, male sex, family history, obesity, smoking and a hiatus hernia.”

Lifestyle approaches

NICE guidance recommends offering patients simple lifestyle advice as the first-line manage-ment for heartburn and indigestion symptoms. “Lifestyle interventions include stopping smoking with stop smoking services if needed,” says Julie Thompson, “reducing alcohol intake to within healthy guidelines and weight management if the person’s weight is unhealthy. In respect to particular dietary aspects, reduce caffeine intake, fizzy drinks and rich meals high in fat.”

Stress and anxiety can be a cause of functional dyspepsia, so psychological therapies such as cognitive behavioural therapy (CBT) or psychotherapy may be helpful. Medicines that may cause or worsen symptoms include aspirin, benzodiazepines, beta-blockers, bisphosphonates, calcium-channel blockers, corticosteroids, NSAIDs and tricyclic antidepressants.

Other self-management tips include:

• Avoid any specific food and drink triggers, such as acidic foods (citrus- and tomato-based products), onions, garlic and peppermint
• Eat smaller meals
• Avoid eating the main meal within three hours or drinking two hours before bedtime
• Raise the head end of the bed by 10-20 cm, if possible
• Lie on the left-hand side to help reduce night-time reflux episodes
• Don’t use additional pillows, as this may put more pressure on their abdomen and worsen symptoms
• Avoid wearing tight clothing (including tight belts)
• Avoid bending over frequently.

Customers can be directed to the Guts UK website for more information.

Medical management

If lifestyle interventions aren’t working for indigestion and heartburn, NICE guidance recommends self-treatment with an antacid and/or alginate but these are only suitable for short-term use. NICE advises that, if these aren’t effective, patients can be offered a proton pump inhibitor (PPI), such as omeprazole, to help reduce the production of stomach acid. Once-daily PPI tablets can be sold over the counter for up to 14 days’ use. 

A GP may initially prescribe a four-week PPI course to see if the symptoms improve, or test for H. pylori. An H. pylori infection is treated with PPIs and a combination of antibiotics. “It should be noted that the NICE guidelines recommend leaving a ‘two-week washout period after proton pump inhibitor (PPI) use before testing for Helicobacter pylori with a breath test or a stool antigen test’,” says Julie Thompson.

People on long-term treatment for uninvestigated dyspepsia should be offered an annual review. They should also be advised to reduce their use of prescribed medicines stepwise by using the lowest effective dose ‘as needed’, and by returning to self-treatment with antacids and/or alginates (unless there is an underlying reason why PPIs should be continued). 

If patients are diagnosed with GORD following an endoscopy, their GP may prescribe a PPI for four or eight weeks. If this fails to help the symptoms, patients may be prescribed an H2-receptor antagonist. 

If someone has proven severe oesophagitis, they should be prescribed a full-dose PPI for eight weeks to aid healing and a full-dose PPI in the long-term as maintenance therapy. It is important they speak to their GP if symptoms persist or return, or if they develop any new symptoms, in which case they may need to be referred to a gastroenterologist or upper gastrointestinal surgeon.

Red flags

There are concerns among some healthcare professionals that many people with indigestion and heartburn symptoms are self-medicating with OTC medicines for long periods and that complications and underlying conditions aren’t being diagnosed. 

“In some people, heartburn can be a warning for more serious underlying damage to the oesophagus, and early diagnosis makes all the difference to stop cancer in its tracks,” says Professor Rebecca Fitzgerald, director of the Early Cancer Institute and trustee of the Heartburn Cancer UK (HCUK) charity.

According to HCUK’s website (heartburncanceruk.org), 10 per cent of people suffer with heartburn every week. Half a million people in the UK have undiagnosed Barrett’s oesophagus, and 50,000 of these may go on to develop oesophageal cancer. Around 8,000 people die of oesophageal cancer each year.

“The public may be unaware that the medication they are buying is masking symptoms and not solving any underlying problem,” says Mimi McCord, chair of Heartburn Cancer UK. “We recommend that the public should consult with their GP if they have persistent heartburn three or four times a week for three weeks or more. There are tests available to spot any warning signs and treatment is very effective for early disease.”

Customers aged 55 years and over who are experiencing heartburn and indigestion for the first time should be referred to their GP, as they may require an endoscopy to check for any underlying causes. 

In some areas of the UK, patients can have a new test for Barrett’s oesophagus called the Cytosponge. This involves swallowing a small capsule containing a sponge that is attached to a piece of string. After a few minutes, the capsule dissolves in the stomach and the sponge is released. The nurse then pulls on the piece of thread. On its way back up the oesophagus, the sponge collects oesophageal cell samples that can then be analysed in a laboratory. 

Dr Pratsides says that other red flag signs include unintentional weight loss, difficulty swallowing with food or water getting stuck in the throat, vomiting blood, severe abdominal pain or dark blood in the stools. “If I was concerned about a bleeding ulcer, I would arrange for the patient to be seen immediately in A&E,” he says. “If I was concerned about cancer, I would refer them to a cancer pathway to be seen urgently in hospital outpatients. On this pathway, patients are usually seen within two weeks.”

Test your team

What does your pharmacy team know about the management of constipation?

Sources

• BNF NICE guidance 
• NICE CKS guidance.