Written by Professor Gerard Clarke, Consultant Gastroenterologist, Portiuncula Hospital and Adjunct Associate Clinical, Professor of Medicine, University of Limerick GEMS and Ashley Costello, BPharm, MPharm, Graduate Entry Medical School, University of Limerick
Dyspepsia
What is dyspepsia?
The term dyspepsia refers to a complex of symptoms arising from the upper gastrointestinal tract (GIT) presenting as epigastric pain or discomfort. It is a common condition affecting 20-40% of the world’s population at some point in their lives. 1 Affected individuals may complain of postprandial fullness, early satiety, bloating, belching or nausea.2, 3 Dyspepsia has an extensive differential diagnosis. It may occur secondary to organic causes such as Helicobacter pylori infection, peptic ulcer disease (rarely), gastrointestinal malignancies, gastroesophageal reflux disease or may be medication induced. However, up to 80% of patients with dyspepsia will have no explanation for their symptoms at endoscopy; known as functional or idiopathic dyspepsia. The global prevalence of functional dyspepsia is estimated between 5 and 11%.4
What causes it?
While the pathophysiology of functional dyspepsia is not well understood, several mechanisms have been suggested. Disturbances in gastrointestinal motility, impaired gastric accommodation, increased visceral sensitivity, abnormal gut-brain axis and gut microbiota dysbiosis have all been linked to the occurrence of functional dyspepsia. The latter hypothesis is supported by research demonstrating an increased likelihood of dyspepsia following infective gastroenteritis.5-7
Role of pharmacist
Community pharmacists often provide the first line of care for patients with dyspeptic symptoms. According to NICE guidelines, pharmacists should offer initial and ongoing help to patients presenting with symptoms of dyspepsia. Advice should encompass lifestyle modifications, use of over-the-counter (OTC) medications and highlight when it is appropriate to consult their general practitioner (GP).8 With this in mind, pharmacists should regularly remind themselves of red flag symptoms which should prompt urgent referral to the GP:
– Unintentional weight loss
– Anorexia
– Dyshagia or odynophagia
– Age 55 or over with new onset dyspepsia
– Epigastric mass
Management
1. Non-pharmacological management
Simple lifestyle measures for dyspeptic symptoms include weight loss if appropriate, eating smaller meals, cutting down on caffeine and high fat foods, avoiding late meals, raising the bedhead and adhering to alcohol consumption guidelines. This may also provide an opportunistic consultation for smoking cessation which may also improve symptoms. It may also be appropriate to carry out a medication review to identify any medications that might be causing or worsening symptoms, with one of the most common offenders being nonsteroidal anti-inflammatory (NSAIDs) but can also be caused by corticosteroids, bisphosphonates or iron supplements amongst others. 1 However, evidence supporting the use of lifestyle and dietary modifications for symptomatic relief is lacking meaning medical therapy is the mainstay of treatment. 2
2. Medication management available OTC
A short interview with the patient can identify the most appropriate course of action. Pharmacists should ask the patient to describe their symptoms in terms of the nature, frequency and severity along with careful screening for the presence of red flag symptoms as mentioned previously. Proton pump inhibitors (PPIs) omeprazole and esomeprazole are available OTC. PPIs inhibit gastric H,K-ATPase thereby inhibiting gastric acid secretion. Due to their short half-life, it takes about 48-72 hours to reach steady state inhibition of acid secretion. 9 Alternatively, H2-receptor antagonists such as famotidine are also available OTC. This class decreases gastric acid secretion by reversibly binding to histamine H2 receptors on gastric parietal cells thereby reducing acid release. They have a quick onset of action of approximately 60 minutes and provide relief for 4-10 hours. 10 However, while these medications can provide relief of symptoms, their OTC indication is for short term use only. Patients who are regularly purchasing these medications should be advised to attend their GP for further investigation.
Gastro-oesophageal reflux disease
What is Gastro-oesophageal reflux disease?
Gastro-oesophageal reflux disease (GORD) is a condition that develops when reflux of stomach contents into the oesophagus causes symptoms and/or complications.11, 12
Symptoms
GORD classically presents as heartburn and regurgitation. Heartburn or pyrosis is generally described as retrosternal burning postprandially while regurgitation the upward movement of gastric contents into the mouth or hypopharynx. 13 Other symptoms may include chest pain, a feeling of fullness in the throat, hoarseness or a chronic cough.14
What causes it?
The pathophysiology underlying the development of GORD is multifactorial, comprising both physiological and pathological factors. Transient lower oesophageal sphincter (LOS) relaxations, reduced LOS pressure, hiatal hernias, impaired oesophageal acid clearance and delayed gastric emptying are other factors identified in the literature.14, 15 Obesity is a known risk factor for GORD, potentially due to increased intragastric pressure.16, 17 Cigarette smoking is also a risk factor; it reduces pressure across the LOS and increases the time taken to clear acid from the oesophagus. 18 Despite an association between certain foods and GORD, evidence linking specific foods with GORD is lacking. Common triggers however, may include fatty foods, spicy foods, coffee, alcohol and fizzy drinks.19-22
How is it treated?
Similar to dyspepsia, the presence of ALARM or red flag symptoms should prompt urgent referral to the GP to rule out possible underlying malignancy.
1. Non pharmacological management
Non-pharmacological measures should include weight loss where appropriate; weight loss has strong evidence for efficacy and has been shown to have a dose-dependent association with reduction of symptoms. 11, 23 Other approaches include elevation of the head of the bed and avoiding large meals close to bedtime. 24 Fatty foods, caffeine and alcohol may exacerbate GORD as previously mentioned and should be minimised if known to trigger symptoms. Further, smoking cessation is also recommended. 12
2. Pharmacological management available OTC
Antacids are commonly used self-prescribed medications that provide symptomatic relief from the symptoms associated with GORD. They consist of calcium carbonate, sodium bicarbonate and aluminium or magnesium salts in various compounds and combinations. Once dissolved in the stomach, they partially neutralise gastric acid, thus raising gastric pH. This effect also inhibits pepsin activity, thereby reducing its proteolytic activity.25 They are available in both liquid and chewable preparations. Some antacids contain alginate, which have a unique mechanism of action – in the presence of acid, they precipitate into a gel forming a raft that localises to the acid pocket in the stomach.26 Antacids are best taken with food or after meals when symptoms are most likely to occur. For patients taking other medications, it is important to remind patients to avoid taking other medications within 2-4 hours of taking an antacid due to decreased absorption by chelation or adsorption of other drugs.25
It is important to counsel patients that while antacids can provide relief from symptoms, they do not treat the underlying cause and long-term use is not recommended as it may mask disease.
Gastroenteritis
Definition and causative agents Acute gastroenteritis is defined as diarrhoeal disease that has a rapid onset lasting less than two weeks in duration. It may be accompanied by vomiting, abdominal pain or fever.27, 28 Most cases of acute gastroenteritis are viral with norovirus being the most common offender. Norovirus is also known as the “winter vomiting bug” due to its pronounced peak during the winter months. 29 Other common viral pathogens include rotavirus, enteric adenovirus and astrovirus.30, 31 Non-viral causes may include bacteria such as Staphylococcus aureus, Campylobacter jejuni, Shigella spp, Salmonella spp and Escherichia coli. Less commonly, parasites such as Giardia and Cryptosporidium can cause acute gastroenteritis. In light of the current global pandemic, gastrointestinal manifestations of COVID-19 should not be overlooked as a differential diagnosis. Characteristics suggesting viral etiology include an intermediate incubation period (24-60hours), a short duration of symptoms (12-60 hours) and a high frequency of vomiting. 32 In terms of duration, Norovirus usually lasts ~2 days, rotavirus lasts between 3-8 days while Campylobacter and Salmonella last approximately 2-7 days.33
Management of symptoms
For most individuals, acute viral gastroenteritis is self-limiting and can be treated at home with supportive measures. Maintaining adequate fluid hydration is the mainstay for the management of acute gastroenteritis and can be achieved with water, sport drinks and oral rehydration solutions which are available OTC. Evidence supporting restriction of certain foods during acute gastroenteritis is weak and so patients should be encouraged to eat as tolerated.34 Anti-emetics such as domperidone may be appropriate for those experiencing nausea and vomiting and pharmacists should refer to the Pharmaceutical society of Ireland (PSI) guidance on the safe and appropriate sale of domperidone taking care to screen for any contraindications to its use.35 The use of anti-diarrhoeal agents such as Loperamide is generally not recommended unless a patient needs to shorten the length of time the diarrhoea lasts.
Alarm symptoms and signs identify those who may need referral to the GP or local emergency department and include:
– Severe abdominal pain
– Severe volume depletion/ dehydration
– Aged 65 or older
– Comorbidities e.g. immunocompromised
– Prolonged symptoms
– Recent hospitalisation or antibiotic use in the previous 3-6 months
References available on request
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