Indigestion (dyspepsia) is commonly presented in community pharmacies and is often self-diagnosed by patients, who use the term to include anything from pain in the chest and upper abdomen to lower abdominal symptoms. Many patients use the terms indigestion and heartburn interchangeably. The pharmacist must establish whether such a self-diagnosis is correct and exclude the possibility of serious disease.
What you need to know
Symptoms, Age, Adult, child, Duration of symptoms, Previous history, Details of pain
Where is the pain?
What is its nature?
Is it associated with food?
Is the pain constant or colicky?
Are there any aggravating or relieving factors?
Does the pain move to anywhere else?
Loss of appetite
Alteration in bowel habit
Any recent change of diet?
Medicines already tried
Other medicines being taken
Significance of questions and answers
The symptoms of typical indigestion include poorly localised upper abdominal (the area between the belly button and the breastbone) discomfort, which may be brought on by particular foods, excess food, alcohol or medication (e.g. aspirin).
Indigestion is rare in children, who should be referred to the doctor. Abdominal pain, however, is a common symptom in children and is often associated with an infection. over the counter treatment is not appropriate for abdominal pain of unknown cause and referral to the doctor would be advisable.
Be cautious when dealing with first-time indigestion in patients aged 45 years or over and refer them to the general practitioner for a diagnosis. Gastric cancer, while rare in young patients, is more likely to occur in those aged 50 years and over. Careful history taking is therefore of paramount importance here.
Indigestion that is persistent or recurrent should be referred to the doctor, after considering the information gained from questioning. Any patient with a previous history of the symptom which has not responded to treatment, or which has worsened, should be referred.
Details of pain/associated symptoms
If the pharmacist can obtain a good description of the pain, then the decision whether to advise treatment or referral is much easier. A few medical conditions that may present as indigestion but which require referral are described below.
Ulcers may occur in the stomach (gastric ulcer) or in the first part of the small intestine leading from the stomach (duodenal ulcer). Duodenal ulcers are more common and have different symptoms from gastric ulcers. Typically the pain of a duodenal ulcer is localised to the upper abdomen, slightly to the right of the midline. It is often possible to point to the site of pain with a single finger. The pain is dull and is most likely to occur when the stomach is empty, especially at night. It is relieved by food (although it may be aggravated by fatty foods) and antacids.
The pain of a gastric ulcer is in the same area but less well localised. It is often aggravated by food and may be associated with nausea and vomiting. Appetite is usually reduced and the symptoms are persistent and severe. Both types of ulcers are associated with H. pylori infection and may be exacerbated or precipitated by smoking and non-steroidal anti-inflammatory drugs.
Single or multiple stones can form in the gall bladder, which is situated beneath the liver. The gall bladder stores bile. It periodically contracts to squirt bile through a narrow tube (bile duct) into the duodenum to aid the digestion of food, especially fat. Stones can become temporarily stuck in the opening to the bile duct as the gall bladder contracts. This causes severe pain (biliary colic) in the upper abdomen below the right rib margin. Sometimes this pain can be confused with that of a duodenal ulcer. Biliary colic may be precipitated by a fatty meal.
When a person eats, food passes down the gullet (oesophagus) into the stomach. Acid is produced by the stomach to aid digestion. The lining of the stomach is resistant to the irritant effects of acid, whereas the lining of the esophagus is readily irritated by acid. A sphincter (valve) system operates between the stomach and the esophagus preventing reflux of stomach contents.
When this valve system is weak, e.g. in the presence of a hiatus hernia, or where sphincter muscle tone is reduced by drugs such as beta-blockers, anticholinergics and calcium channel blockers, the acid contents of the stomach can leak backwards into the oesophagus. The symptoms arising are typically described as heartburn but many patients use the terms heartburn and indigestion interchangeably. Heartburn is a pain arising in the upper abdomen passing upwards behind the breastbone. It is often precipitated by a large meal or by bending and lying down. Heartburn can be treated by the pharmacist but sometimes requires referral.
Irritable bowel syndrome
Irritable bowel syndrome is a common, non-serious, but troublesome, condition in which symptoms are caused by colon spasm. There is usually an alteration in bowel habit, often with alternating constipation and diarrhea. The diarrhoea is typically worse first thing in the morning. Pain is usually present. It is often lower abdominal (below and to the right or left of the belly button) but it may be upper abdominal and therefore confused with indigestion. Any persistent alteration in normal bowel habit is an indication for referral.
Angina is usually experienced as a tight, painful constricting band across the middle of the chest. Atypical angina pain may be felt in the lower chest or upper abdomen. It is likely to be precipitated by exercise or exertion. If this occurs, referral is necessary.
More serious disorders
Persisting upper abdominal pain, especially when associated with anorexia and unexplained weight loss, may herald an underlying cancer of the stomach or pancreas. Ulcers sometimes start bleeding, which may present with blood in the vomit (haematemesis) or in the stool (melaena). In the latter the stool becomes tarry and black. Urgent referral is necessary.
Fatty foods and alcohol can cause indigestion, aggravate ulcers and precipitate biliary colic.
Smoking predisposes to, and may cause, indigestion and ulcers. Ulcers heal more slowly and relapse more often during treatment in smokers. The pharmacist is in a good position to offer advice on smoking cessation, perhaps with a recommendation to use nicotine replacement therapy.
Medicines already tried
Anyone who has tried one or more appropriate treatments without improvement or whose initial improvement in symptoms is not maintained should see the doctor.
Other medicines being taken
Gastrointestinal side-effects can be caused by many drugs, so it is important for the pharmacist to ascertain any medication that the patient is taking.
Non-steroidal anti-inflammatory drugs have been implicated in the causation of ulcers and bleeding ulcers, and there are differences in toxicity related to increased doses and to the nature of individual drugs. Sometimes these drugs cause indigestion. Elderly patients are particularly prone to such problems and pharmacists should bear this in mind. Severe or prolonged indigestion in any patient taking an non-steroidal anti-inflammatory drug is an indication for referral. Particular care is needed in elderly patients, when referral is always advisable. A study looked at emergency admissions to two hospitals in two areas of England for Gastrointestinal disease. When the results were extrapolated to the UK, the number of non-steroidal anti-inflammatory drug-associated emergency admissions in the UK per year would be about 12,000, with about 2500 deaths.
Over the counter medicines also require consideration; aspirin, ibuprofen and iron are among those that may produce symptoms of indigestion. Some drugs may interact with antacids.
When to refer
Age over 45 years if symptoms develop for first time
Symptoms are persistent (longer than 5 days) or recurrent
Pain is severe
Blood in vomit or stool
Pain worsens on effort
Treatment has failed
Adverse drug reaction is suspected
Associated weight loss
If symptoms have not improved within 5 days, the patient should see the doctor.
Once the pharmacist has excluded serious disease, treatment of dyspepsia with antacids or an H2 antagonist may be recommended and is likely to be effective. The preparation should be selected on the basis of the individual patient’s symptoms. Smoking, alcohol and fatty meals can all aggravate symptoms, so the pharmacist can advise appropriately.
In general, liquids are more effective antacids than are solids; they are easier to take, work quicker and have a greater neutralising capacity. Their small particle size allows a large surface area to be in contact with the gastric contents. Some patients find tablets more convenient and these should be well chewed before swallowing for the best effect. It might be appropriate for the patient to have both; the liquid could be taken before and after working hours, while the tablets could be taken during the day for convenience. Antacids are best taken about 1 h after a meal because the rate of gastric emptying has then slowed and the antacid will therefore remain in the stomach for longer. Taken at this time antacids may act for up to 3 h compared with only 30 min-1 h if taken before meals.
Sodium bicarbonate is the only absorbable antacid that is useful in practice. It is water soluble, acts quickly, is an effective neutraliser of acid and has a short duration of action. It is often included in over the counter formulations in order to give a fast-acting effect, in combination with longer acting agents. However, antacids containing sodium bicarbonate should be avoided in patients if sodium intake should be restricted (e.g. in patients with congestive heart failure). Sodium bicarbonate increases excretion of lithium, leading to reduced plasma levels. The contents of over the counter products should therefore be carefully scrutinised and pharmacists should be aware of the constituents of some of the traditional formulary preparations. The relative sodium contents of different antacids can be found in the British National formulary (BNF). In addition, long-term use of sodium bicarbonate may lead to systemic alkalosis and renal damage. In short-term use, however, it can be a valuable and effective antacid. Its use is more appropriate in acute rather than chronic dyspepsia.
Aluminium and magnesium salts (e.g. aluminium hydroxide and magnesium trisilicate)
Aluminium-based antacids are effective; they tend to be constipating and this can be a useful effect in patients if there is slight diarrhoea. Conversely, the use of aluminium antacids is best avoided in anyone who is constipated and in elderly patients who have a tendency to be so. Magnesium salts are more potent acid neutralisers than are aluminium salts. They tend to cause osmotic diarrhea as a result of the formation of insoluble magnesium salts and are therefore useful in patients who are slightly constipated. Combination products containing aluminium and magnesium salts cause minimum bowel disturbance and are therefore valuable preparations for recommendation by the pharmacist.
Calcium carbonate is commonly included in over the counter formulations. It acts quickly, has a prolonged action and is a potent neutraliser of acid. It can cause acid rebound and, if taken over long periods at high doses, can cause hypercalcaemia and so should not be recommended for long-term use. Calcium carbonate and sodium bicarbonate can, if taken in large quantities with a high intake of milk, result in the milk-alkali syndrome. This involves hypercalcaemia, metabolic alkalosis and renal insufficiency; its symptoms are nausea, vomiting, anorexia, headache and mental confusion.
Dimeticone is sometimes added to antacid formulations for its de-foaming properties. Theoretically, it reduces surface tension and allows easier elimination of gas from the gut by passing flatus or eructation (belching). Evidence of benefit is uncertain.
Interactions with antacids
Because they raise the gastric pH, antacids can interfere with enteric coatings on tablets that are intended to release their contents further along the Gastrointestinal tract. The consequences of this may be that release of the drug is unpredictable; adverse effects may occur if the drug is in contact with the stomach. Alternatively, enteric coatings are sometimes used to protect a drug that may be inactivated by the low pH in the stomach, so concurrent administration of antacids may result in such inactivation. Taking the doses of antacids and other drugs at least 1 h apart should minimise the interaction.
Antacids may reduce the absorption of tetracyclines, azithromycin, itraconazole, ketoconazole, ciprofloxacin, dipyridamole, norfloxacin, rifampicin and zalcitabine. Absorption of angiotensin-converting enzyme inhibitors, phenothiazines, gabapentin and phenytoin, may also be reduced.
Sodium bicarbonate may increase the excretion of lithium and lower the plasma level, so a reduction in lithium’s therapeutic effect may occur. Antacids containing sodium bicarbonate should not therefore be recommended for any patient on lithium therapy.
The changes in pH that occur after antacid administration can result in a decrease in iron absorption if iron is taken at the same time. The effect is caused by the formation of insoluble iron salts due to the changed pH. Taking iron and antacids at different times should prevent the problem.
Famotidine and ranitidine
Famotidine and ranitidine can be used for the short-term treatment of dyspepsia and heartburn. Treatment with ranitidine is limited to a maximum of 2 weeks and with famotidine to 6 days.
Discussing the use of H2 antagonists with local family doctors would be valuable. Agreeing general guidelines or a protocol for their use could be a feature of the discussion.
Domperidone 10 mg can be used for the treatment of postprandial stomach symptoms of excessive fullness, nausea, epigastric bloating and belching, occasionally accompanied by epigastric discomfort and heartburn. It increases the rate of gastric emptying and transit time in the small intestine, and also increases the strength of contraction of the oesophageal sphincter. Domperidone can be used in patients aged 16 years and over. The maximum dose is 10 mg and the maximum daily dose 40 mg. When used as a prescription-only medicine medicine, domperidone is used to treat nausea and vomiting, but these indications are not included in the pharmacy (P) licence and patients with these symptoms would need to be referred.
Indigestion in practice
Mrs Johnson, an elderly woman, complains of indigestion and an upset stomach. On questioning, you find out she has had the problem for a few days; the pain is epigastric and does not seem to be related to food. She has been feeling slightly nauseated. You ask about her diet; she has not changed her diet recently and has not been overdoing it. She tells you that she is taking four lots of tablets: for her heart, her waterworks and some new ones for her bad hip (diclofenac modified release 100 mg at night). She has been taking them after meals, as advised, and has not tried any medicines yet to treat her symptoms. Before the diclofenac she was taking paracetamol for the pain. She normally uses paracetamol as a general painkiller at home; she tells you that she cannot take aspirin because it upsets her stomach.
The pharmacist’s view
It sounds as though this woman is suffering gastrointestinal symptoms as a result of her non-steroidal anti-inflammatory drug. Such effects are more common in elderly patients. She has been taking the medicine after food, which should have minimised any Gastrointestinal effects, and the best course of action would be to refer her back to the doctor. It would be worth asking Mrs Johnson about the dose and frequency with which she took the paracetamol to see whether she took enough for it to be effective.
The doctor’s view
Referral back to her doctor is the correct course of action. Almost certainly her symptoms have been caused by the diclofenac. A large clinical trial showed that risk factors for serious complications with oral non-steroidal anti-inflammatory drugs were: age 75 years or more, history of peptic ulcer, history of Gastrointestinal bleeding and history of heart disease. If this woman were over 75 years and taking tablets for heart problems, she has two significant risk factors. The model predicts that for patients with none of the four risk factors, 1-year risk of a complication is 0.8%. For patients with all four risk factors, the risk is 18%.
She should be advised to stop the diclofenac. A blood test for H. pylori would be helpful and whilst awaiting the results she could be started on a proton pump inhibitor, such as lansoprazole. If the H. pylori test came back positive, she would also benefit from H. pylori eradication therapy.
Control of her primary symptom (hip pain) will then be a problem. Non-steroidal anti-inflammatory drugs should be avoided if possible. It may be possible to change the paracetamol to a compound preparation containing paracetamol and codeine or dihydrocodeine. If an non-steroidal anti-inflammatory drug is necessary to control the pain and there is a documented history of peptic ulceration, an non-steroidal anti-inflammatory drug can be given with a proton pump inhibitor (proton pump inhibitor). The non-steroidal anti-inflammatory drug can also be given concomitantly with misoprostol. Misoprostol is a prostaglandin analogue that protects the gastric mucosa and may limit damage from non-steroidal anti-inflammatory drugs. Research evidence shows that omeprazole was more effective than misoprostol in preventing unwanted effects.
Failure to control hip pain due to osteoarthritis may require referral to an orthopaedic surgeon to consider a hip replacement.
Ken Jones is a local milkman in his early fifties and he comes in to ask your advice about his stomach trouble. He tells you that he has been having the problem for a couple of months but it seems to have got worse. The pain is in his stomach, quite high up; he had similar pain a few months ago, but it got better and has now come back again. The pain seems to get better after a meal; sometimes it wakes him during the night. He has been taking Rennies to treat his symptoms; they did the trick but do not seem to be working now, even though he takes a lot of them. He has also been taking some over the counter ranitidine tablets. He is not taking any other medicines.
The pharmacist’s view
Mr Jones has a history of epigastric pain, which remitted and has now returned. At one stage his symptoms responded to an antacid but they no longer do so, despite his increasing the dose. This long history, the worsening symptoms and the failure of medication warrant referral to the doctor.
The doctor’s view
It would be sensible to recommend referral to his doctor as the information obtained so far does not permit diagnosis. It is possible that Mr Jones has a stomach ulcer, acid reflux or even a stomach cancer, but further information is required. An appropriate examination and investigation will be necessary.
The doctor would need to listen carefully, first by asking open questions and then by asking more direct, closed questions to find out more information; e.g. how does the pain affect him? What is the nature of the pain (burning, sharp, dull, tight or constricting)? Does it radiate (to back or chest, down arms, up to neck/mouth)? Are there any associated symptoms (nausea, difficulty in swallowing, loss of appetite, weight loss or shortness of breath)? Are there any other problems (constipation or flatulence)? What are the aggravating/relieving factors? How is his general health? What is his diet like? How are things going for him generally (personally/professionally)? Does he smoke? How much alcohol does he drink? What does he think might be wrong with him? What are his expectations for treatment/management?