Upper gastrointestinal (GI) health problems affect many people from time to time. These can cause a range of symptoms, including indigestion and heartburn. According to research by IPSOS Healthcare, pharmacy teams should know the definition of frequent heartburn (heartburn occurring more than once a week) and the most suitable product recommendations. Almost half (48 per cent) of consumers agree that a pharmacist’s recommendation is important when deciding on the right way to manage their symptoms.
Some people are able to establish that certain lifestyle factors trigger their indigestion or heartburn – such as a big meal eaten late at night – and can treat their symptoms effectively with self help measures and over-the-counter (OTC) medicines. However, if the symptoms don’t clear up or are getting worse, they should contact their GP, especially if they are over 55, losing weight for no known reason or are being sick regularly. They should also see their GP if they are finding it hard to swallow, or they have blood in their vomit or poo.
Ongoing heartburn and indigestion symptoms could lead to more serious problems, and they may be the sign of an underlying condition that needs prescribed treatments.
Around four in every 10 people in the UK experience indigestion (also called dyspepsia) at some point. This vague term is used to describe symptoms of pain or discomfort just under the ribs or higher up the chest, a feeling of fullness, a burning feeling in the chest (heartburn), wind or bloating, or feeling or being sick. Everyone experiences indigestion differently, and the symptoms may vary from one episode to the next.
Indigestion may be caused by increased sensitivity in the bowel, or acid irritating the stomach lining. It’s often triggered by eating certain foods, such as fatty foods that delay the emptying of the stomach, or by drinking alcohol or coffee. Being overweight or stressed may make the symptoms worse.
Heartburn is associated with acid reflux rising towards the throat. It occurs if the sphincter muscle at the bottom of the oesophagus stops working properly, which means the stomach contents reflux upwards. This may happen if there is extra pressure on the stomach (e.g. when overeating, coughing or during pregnancy).
Heartburn causes a burning feeling in the chest, often after eating or bending over, and an unpleasant sour taste in the mouth. It may be accompanied by general indigestion symptoms, along with a chronic cough or hiccups, a hoarse voice, bad breath, bloating and feeling sick.
The symptoms may be worsened by:
- Certain food and drink – such as coffee, tomatoes, mint, alcohol, chocolate and fatty or spicy foods
- Being overweight
- Stress and anxiety
- Hormone fluctuations, such as progesterone and oestrogen
- Some medicines, including non-steroidal anti-inflammatories (NSAIDS) such as ibuprofen
- A hiatus hernia – when part of the stomach moves up into the chest.
The exact prevalence of gastro-oesophageal reflux disease (GORD) is difficult to establish as many people don’t seek advice from their GP for heartburn and indigestion symptoms. It is estimated that this chronic condition affects between 10-30 per cent of adults in developed countries. GORD becomes more common as people get older and affects more women than men.
Risk factors for GORD include smoking, alcohol, being overweight and taking medicines that relax the lower oesophageal sphincter (e.g. benzodiazepines, beta-blockers, bisphosphonates, corticosteroids and NSAIDs). Certain foods, such as coffee and chocolate, can also relax the sphincter muscle.
GORD may be diagnosed in people with heartburn, indigestion, hiccups or an unpleasant taste in their mouth for four weeks or more. “Most people will have experienced occasional heartburn and reflux, particularly if they have eaten a large rich meal, but persistent symptoms might suggest GORD,” says Julie Thompson, information manager at charity Guts UK. “This should be investigated if it occurs persistently (for three weeks or more) or treatment isn’t working.”
For most people with GORD, their symptoms are a nuisance but nothing to worry about. However, in a few people, especially where there is severe inflammation of the oesophagus, there is a risk of complications including internal bleeding and narrowing. One in 10 people with acid reflux has Barrett’s oesophagus (a condition in which some cells in the oesophagus grow abnormally). This condition can, very rarely, progress to cancer of the lower oesophagus over a long period of time. If someone is frequently being sick, is losing weight unintentionally or finds that food is getting stuck in their oesophagus, they should speak to their GP.
Peptic ulcer disease
If a pharmacy customer is having regular episodes of indigestion or heartburn, their GP may suggest they are tested for H. pylori bacteria (usually through a breath test or stool sample). According to Guts UK, around 30 per cent of people in the UK have H. pylori bacteria in their stomach, and around 15 per cent of these people have peptic ulcer disease.
Peptic ulcer disease causes ulcers in the stomach (gastric ulcers) or in the duodenum (duodenal ulcers). It can occur in people who take NSAIDs regularly. The ulcers can lead to haemorrhage or perforation if they remain untreated.
Functional (or non-ulcer) dyspepsia is diagnosed if chronic heartburn doesn’t have a specific underlying cause (after an endoscopy has ruled out an ulcer, oesophagitis or cancer). This is thought to be a disorder of the gut-brain interaction, possibly through a problem with the gut microbiota, acid secretion or nervous system hypersensitivity.
Functional dyspepsia may occur after acute gastroenteritis and has been associated with depression and anxiety. It is sometimes associated with a chronic
H. pylori infection. The symptoms include burning pain at the centre of the chest (epigastric pain syndrome) and fullness after eating (post-prandial distress syndrome). If functional dyspepsia isn’t treated, it can affect sleep, eating habits and day-to-day activities.
Many people with indigestion, heartburn, functional dyspepsia and GORD can manage their symptoms by making some dietary and other lifestyle changes. Julie Thompson suggests the following self-help measures:
- Avoid late-night, high-fat meals so as not to go to bed with a full stomach
- Eat the main evening meal three hours before going to bed
- Prop up the head of the bed or use a wedge pillow when sleeping to reduce night-time symptoms
- Eat smaller meals but more often, if necessary
- Try to avoid bending forward or wearing tight clothes as this can put extra pressure on the tummy
- Sleep on the left-hand side
- Quit smoking
- Keep body weight within a healthy range.
“Drinks containing caffeine (tea, coffee and some energy drinks) have been shown to cause heartburn, but evidence is inconclusive with respect to the benefits of reduction,” says Julie. “People can find that spicy food, food higher in fats, and tomato, are more likely to trigger their symptoms. Reduction of these foods may be helpful. There is no one approach to diet and reflux, and triggers can be very individual. Advice from a dietitian should be sought if people have significantly excluded foods from their diet as a result of their symptoms.”
People with occasional heartburn and indigestion may find that fast-acting alginates and antacids help to ease their symptoms. Antacids neutralise acid in the stomach so it’s less likely to cause irritation, while alginates create a raft on top of the stomach contents so the acid is less likely to rise. Some people take antacids and alginates when they experience symptoms or if they’re expecting a flare-up (such as before they go to bed). Liquid products tend to work better than tablets. Antacids and alginates aren’t recommended for long-term use. Aluminium- and magnesium-containing antacids shouldn’t be taken at the same time as many other medicines as they can affect absorption.
If antacids don’t work or customers need to take them regularly for GORD, proton pump inhibitors (PPIs) such as omeprazole or esomeprazole are usually recommended. PPIs work by stopping acid production in the stomach. They can be bought over the counter to be taken for up to 14 days, but if the symptoms persist, customers should speak to their GP. A GP may prescribe a longer course of PPIs for four weeks, suggest H. pylori testing and/or further tests or scans, such as an endoscopy.
PPIs are prescribed at the lowest dose for the shortest time possible. The aim of treatment is to ease the symptoms and prevent GORD complications. Side-effects of PPIs tend to be mild, such as headaches, diarrhoea, constipation or nausea, although these medicines can interact with other medicines such as warfarin and citalopram. Taking PPIs for long periods may increase the risk of bone fractures and Clostridium difficile infections, as well as stroke and chronic kidney disease.
If GORD has been confirmed with an endoscopy, PPIs may be prescribed for four or eight weeks. Severe inflammation of the oesophagus should be treated with a PPI for at least eight weeks, depending on other health conditions and possible interactions with other medicines.
If customers are diagnosed with H. pylori, a GP may prescribe a combined course of antibiotics for the infection as well as PPIs to reduce stomach acid. With PPIs, duodenal ulcers typically heal within four weeks and gastric ulcers within eight weeks.
Pharmacy teams can signpost customers to further support with their lower GI conditions to charity Guts UK at: gutscharity.org.uk where they can find information leaflets and helpful videos.