Indigestion, Heartburn and Gastritis Indigestion, heartburn and gastritis are common gastrointestinal disorders that may produce similar symptoms. Indigestion (dyspepsia) Indigestion – also known as dyspepsia – is a description of symptoms, rather than a diagnosis. It is the general term used to describe pain or discomfort centred in the upper abdomen, often after meals. It most commonly occurs soon after eating and usually happens when people eat too much or too fast, or when certain foods or medicines don’t agree with them. Other symptoms often associated with indigestion include feeling full within a few minutes of beginning a meal, bloating, belching, nausea and vomiting. Symptoms can occur ocassionally or happen all the time. Indigestion can also occur after smoking or drinking alcohol and may also be caused by certain stomach problems such as gastritis or a stomach ulcer. To be considered significant, symptoms need to recur regularly, usually for at least three months. Very rarely, indigestion can be a symptom of stomach cancer. Stomach cancer affects less than 0.5% of people with indigestion, and is mostly found in those aged older than 50. In 70% of people, no cause is found for the dyspepsia (called functional dyspepsia). Heartburn (reflux) Heartburn is usually described as a burning sensation behind the sternum, often with a feeling of regurgitation of acid. This burning feeling may extend to the neck and jaw and tends to worsen when bending over or lying down. Most cases are attributed to gastro-oesophageal reflux disease (GORD), which is thought to be caused by an ineffective lower oesophageal sphincter muscle. This muscle is unable to prevent regurgitation of stomach acid contents up the oesophagus. Symptoms generally occur after eating, exercising, bending over or lying down and are often associated with indigestion. Obesity is a risk factor and the condition is more common in women who are pregnant and in those who eat a high-fat diet, who smoke, or who are under stress. Although the term heartburn has nothing to do with the heart, it is important to realise that symptoms of a heart attack (chest pain or discomfort that radiates up the neck and to the jaw) may be similar. Refer to the pharmacist if you are unsure. Babies can also get reflux, and symptoms include vomiting straight after a feed, failure to thrive, and prolonged bouts of crying. Refer any children under 12 with symptoms of reflux or indigestion to the pharmacist. Gastritis Gastritis has similar symptoms to indigestion, except the pain or burning feeling TREATMENT OPTIONS Category Examples Comments Antacids Alginates H2 antagonists Proton pump inhibitors Anti-flatulence agents Natural / herbal products / supplements [GENERAL SALE] eg, aluminium, magnesium and simethicone (Mylanta Original/Double Strength) [GENERAL SALE] eg, Gaviscon Liquid*/Tablets*, Gaviscon Double Strength Liquid*/Tablets*, Gaviscon Dual Action Liquid*/Tablets*, Gaviscon Infant*) [PHARMACY ONLY MEDICINE] eg, ranitidine (Ranitidine Relief, Zantac*, Zantac Extra) [PHARMACY ONLY MEDICINE] eg, omeprazole 10mg (Dr Reddy's, Losec) eg, omeprazole 20mg (Dr Reddy's, Losec Extra) [GENERAL SALE] eg, simethicone (De-Gas) eg, apple cider vinegar and manuka honey (Radiance ManukaGuard Nutralize) eg, kawakawa and hoheria (Kiwiherb Herbal Digestive) eg, ginger, slippery elm eg, digestive enzymes (Nutralife, Radiance DigestAid, Thompson's Digestion Manager) Antacids neutralise stomach acid and are recommended for people with mild, occasional, indigestion-like symptoms. Most contain two to four constituents with different onsets and durations of action. The alginate precipitates out when in contact with gastric acid forming a raft that sits on top of the stomach contents. It protects the lining of the oesophagus when the contents regurgitate upwards. Many products also contain calcium carbonate and/or sodium bicarbonate so are effective for the treatment of indigestion as well. Block the action of histamine on gastric acid cells, reducing acid release. Delayed onset of effect, compared with antacids, but they can last for up to 12 hours. May be used before meals if meal likely to result in indigestion. Restrict use to two weeks unless under medical advice. Used for the short-term symptomatic relief of reflux-like symptoms in adults aged 18 years and over. Act directly on gastric acid releasing cells in stomach. Seek further medical advice if symptoms don’t improve after two weeks.Take in the morning, 30 minutes before food, for optimal acid suppression. Simethicone breaks up large bubbles of air in the stomach and relieves burping and flatulence. Apple cider vinegar has an acid/alkaline balancing effect and manuka honey has a natural antibacterial action. Kawakawa and Hoheria may help soothe the digestive tract. Slippery elm tablets may help soothe heartburn. Ginger may help with the absorption of food and symptoms of indigestion. Digestive enzymes help reduce symptoms of indigestion and bloating associated with low stomach acid. Take with food. Products with an asterisk have a detailed listing in the Indigestion, Heartburn & Gastritis section of OTC Products, starting on page 245. HEARTBURN? TRY Please see product packaging for further information and full product details. Reckitt Benckiser, Auckland. 0800 40 30 30. TAPS DA1703DB. ® Page 94 HEALTHCARE HANDBOOK 2017-2018 Common Disorders
CONTINUING OTC EDUCATION felt around the stomach area tends to be present for most of the day. Some people may feel nauseous, and/or vomit. Gastritis can occur as a result of increased acid production, certain medicines, alcohol, stomach ulcers, or a bacterium called Helicobacter pylori. As with indigestion, very rarely it may be a symptom of stomach cancer. Refer anybody with suspected gastritis to the pharmacist. Initial assessment Although many customers self-select their own indigestion and heartburn treatments; many would probably benefit from further information about the condition and some lifestyle advice, which could be offered at the point of sale. Refer any customers with obvious RED FLAGS (see Refer to the Pharmacist) to a pharmacist, as these increase the likelihood that the customer has a more serious condition requiring further investigation. Asking other Refer to Pharmacist questions can help you decide which customers are amenable to self-treatment and who else needs to be referred to the pharmacist. Treatment Many people are able to manage their indigestion and heartburn by making simple lifestyle adjustments, such as including more vegetables and fibre in their diet and reducing fat intake; limiting the intake of caffeine, spicy or acidic foods known to exacerbate symptoms; losing weight; stopping smoking; limiting alcohol intake or NSAID use; and staying upright for a period of time after a meal. Proton pump inhibitors (PPIs) are the preferred treatment for both heartburn due to GORD, and indigestion. Customers who don't respond or those with recurring symptoms should be referred to a doctor for further evaluation and possible H. pylori testing. H2 antagonist therapy may be used as an alternative to PPIs for maintenance therapy in customers with GORD who experience relief with these medicines. Antacids or alginates should be reserved for intermittent use in customers with infrequent symptoms. Advice for customers • Avoid tight waistbands, bending over or lying down soon after a meal. • Talk to your doctor if you suspect your medicines may be causing your symptoms. »» Iron tablets, bisphosphonates, calcium channel blockers, oral corticosteroids, NSAIDs and aspirin can aggravate indigestion or heartburn. • Antacids and alginates may reduce the absorption of some medicines so need to be taken two hours apart from them – check with your pharmacist. • Raising the bed head and avoidance of meals two to three hours before bed may help people with nocturnal symptoms. Refer to PHARMACIST Seek urgent medical help for anyone describing pain which radiates through their jaw, neck, shoulders or arm and/or gets worse with exercise, since symptoms of a heart attack can be similar to those seen with indigestion or heartburn. RED FLAGS (ALARM SIGNALS) – REFER TO A DOCTOR • Age 50 years or older (or 40 years or older if of Maori, Pacific Island or Asian descent) and first presentation • Coughing spells or nocturnal aspiration • Difficulty in swallowing, persistent/protracted vomiting • Family history of gastric cancer before the age of 50 • Iron deficiency anaemia • NSAID use, including aspirin and OTC use • Palpable abdominal mass • Previous peptic ulcer disease, especially if complicated • Severe or persistent symptoms • Signs of bleeding from rectum or blood in vomit • Unexplained weight loss. For all other customers, ask the following questions (if appropriate) and refer any people with “yes” answers to the pharmacist. • Does the person have any other health conditions? • Does the person take any other medication, either prescribed by a doctor or bought from a shop or supermarket (including herbal/ complementary medications)? • Is the person aged less than 12 years? • Do their stools look black or contain black flecks (like kiwifruit pips or coffee granules)? • Are there other symptoms, eg, pain (especially in the neck or arm), shortness of breath, sweating, or constipation? • Is the person on a sodium-restricted diet? • Does the person have any allergies to medicines? • Alginate forms a protective barrier • Antacid helps neutralise stomach acid INDIGESTION? Page 95
According to Stéphane Rossini, incoming Chairman of the Agency Council, the culture of collaboration will remain a factor in ensuring that Switzerland is successful in retaining a high-quality medicines control system: “A globalised economy and the international consumption of therapeutic products entail synergies and collaboration.”
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