MCA Training Made Easy

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1 MCA Training Made Easy MODULE 8 Indigestion and Bowel Problems Learning objectives After reading this module you will: Understand the symptoms and causes of indigestion and heartburn and how to treat them Know the causes of diarrhoea and wind and be able to offer advice on treatment and management Be aware of the link between constipation and haemorrhoids, how they can be treated, and what lifestyle changes can help in managing these conditions Recognise the symptoms of irritable bowel syndrome and know how to treat and manage diagnosed sufferers Be able to recommend treatments for nausea and vomiting Be aware of coeliac disease, its causes and the role you can play in helping sufferers manage their condition Recognise when customers with indigestion and bowel problems need to be referred to the pharmacist 1 Lifestyle changes are the first step in the management of indigestion or heartburn giving up smoking, losing weight, drinking less alcohol and avoiding fatty foods. The Track and Train Medicines Counter Assistant Course is accredited by the General Pharmaceutical Council as providing the essential knowledge required to work in a pharmacy as a Medicines Counter Assistant. ALWAYS REMEMBER WWHAM! When recommending a suitable medicine for a customer, always remember the WWHAM questions to help you get the right information for your decision: Who is the medicine for? What are the symptoms? How long have the symptoms been present? Has any Action been taken so far? Are any other Medicines being taken? PART 1: INDIGESTION AND HEARTBURN Why should I be careful about upset stomachs? Customers with indigestion may complain of many different symptoms as it is often a bit of a catch-all for anything that is not going quite right with the upper part of the gastro-intestinal (GI) tract! When one customer says they have an upset stomach, they may mean they have diarrhoea, but another might mean they have indigestion! For lots of these indigestion and bowel problems there is pain in the stomach area so it is important to get a full picture of this pain and any other symptoms such as nausea, bloating or belching, so you know what you are dealing with. After all, you don t want to recommend a laxative to someone with diarrhoea! Understanding indigestion What is indigestion? The symptoms of indigestion and heartburn include: Pain and discomfort in the stomach area Antacids Aluminium and magnesium salts, calcium carbonate (e.g. Remegel, Setlers) and sodium bicarbonate Acid in the throat Pain in the chest Flatulence Bloating Nausea It can be caused by eating too much food or eating too fast. There are also a number of things that can worsen symptoms or make a patient more likely to suffer: High alcohol intake Being over-weight Smoking Taking certain medicine such as non-steroidal anti-inflammatory (NSAID e.g. ibuprofen) Certain medical conditions e.g. stomach ulcers, hiatus hernia Patients who suffer from indigestion or heartburn regularly should be given lifestyle advice on the above. Refer these patients to the pharmacist. Managing indigestion The following OTC products can be used to treat both indigestion and heartburn. First line is usually antacids. MAIN ACTIVE INGREDIENTS OF OTC MEDICINES FOR INDIGESTION TYPE ACTIVE AGENT MODE OF ACTION NOTES Neutralise excess acid produced by the stomach Acts quickly but effects don t last long. Constipation (caused by aluminium salts) and diarrhoea (caused by magnesium salts) are possible side effects Cont

2 TYPE ACTIVE AGENT MODE OF ACTION NOTES Combination antacids e.g. Asilone Tablets, Bisodol Indigestion Relief, Rennie e.g. Maalox Plus Suspension Neutralise excess acid produced by the stomach As above Combination antacids + simeticone Bismuth H2 antagonists e.g. Pepto-Bismol Famotidine (Ranitidine e.g. Zantac) Antacid neutralises excess acid and simeticone added to relieve wind Coats stomach and prevents irritation. Relieves indigestion symptoms, nausea and diarrhoea Reduces the amount of acid produced by the stomach Can provide up to 12 hours relief from indigestion and heartburn As above Cannot be used in those under 16 years Effects not instant Used for a maximum of two weeks in people over 16 years of age. Cannot be used in pregnant or breastfeeding women Important points about antacids are: Sodium bicarbonate should not be taken by people who are on a salt-free diet or who have heart disease or high blood pressure Some antacids can be taken by pregnant women, but refer any such requests to the pharmacist Antacids can stop other drugs being taken up by the body if they are taken at the same time and can destroy the enteric-coating (which help reduce the risk of stomach irritation) which are on some tablets. For these reasons, always advise that antacids are taken two hours before or after other medicines Understanding heartburn What is heartburn? Heartburn (or acid reflux) is a specific type of indigestion, which causes a burning sensation behind the chest bone and the back of the throat. The pain can be so bad that sufferers think they are having a heart attack. Sufferers may also find they have a bitter taste in their mouth and regurgitation of stomach acid. Heartburn develops when the acid contents of the stomach flow back up the food pipe called the oesophagus. There is a muscle, called a sphincter, which sits at the top of the stomach, acting like a lid to keep stomach acids in place. Sometimes this sphincter gets a bit weak or gets put under too much pressure, allowing acid to flow back up into the oesophagus. Triggers for heartburn include alcohol, smoking, caffeine drinks, citrus fruits, fatty and/or spicy foods, large portions of food, being overweight or pregnant and even wearing tight clothes. MAIN ACTIVE INGREDIENTS OF OTC MEDICINES FOR HEARTBURN TYPE ACTIVE AGENT MODE OF ACTION NOTES Alginates/rafting agents Sodium alginate (e.g. Gaviscon) Forms a thick layer, or raft at the top of the stomach, stopping acids from flowing back upwards into the throat Block the acid-producing mechanisms in the stomach Fast acting and should be taken after meals and before bedtime Can be taken during pregnancy and breastfeeding, but refer any such requests to your pharmacist Proton pump inhibitors Omeprazole (e.g. Zanprol) pantoprazole (e.g. Pantoloc Control) Only treatment recommended for recurrent heartburn (more than two bouts of heartburn a week) Take as short course (2 to 4 weeks) Can prevent further heartburn attacks for up to several weeks Take up to a couple of days to obtain full effect Not for use in patients under 18 or pregnant or breastfeeding women Refer to doctor if using longer than 2 weeks 2 Cont

3 MODULE 8 Indigestion and bowel problems Managing heartburn Heartburn can be treated with antacids (see table above), but there are some other OTC products that can be used to treat heartburn only. Indigestion and heartburn: WHEN TO REFER TO THE PHARMACIST Anyone asking for large amounts of indigestion remedies Middle-aged customers who are experiencing indigestion or heartburn for the first time If there is unexplained weight loss If there is difficulty in swallowing If there is pain in the centre of the chest If the pain is also felt in the neck, shoulder and down the left arm If for a pregnant woman with heartburn If there is no relief from heartburn after taking a proton pump inhibitor for two weeks If person is taking other medication in indigestion tips for indigestion and heartburn sufferers: 3 Eat smaller portions of food 3 Eat more slowly 3 Avoid large meals before bedtime 3 Eat low fat, less spicy food 3 Cut down on smoking and alcohol 3 Reduce stress 3 Lose weight, if necessary 3 If heartburn is the problem, avoid foods that can loosen the sphincter, such as fatty or spicy foods, caffeine, spirits and citrus fruits and tight clothing. It also helps to sit up straight and at night prop up the bed head or use a pillow to raise the upper body at an angle PART 2: DIARRHOEA AND WIND Understanding diarrhoea What is diarrhoea? It s a very lucky - and rare - person who does not know the symptoms of diarrhoea! For the rest of us, the signs are familiar: Loose watery stools The need to visit the toilet frequently and with great urgency Excess wind Abdominal cramps Headache caused by dehydration Diarrhoea is caused by a bacterial or viral infection picked up through contaminated food or water, especially when on holiday (see Module 3 Summer Health). However, some people find they get bouts when they have a change of climate, eat hot spicy foods, drink too much alcohol, get stressed or take certain medicines such as antibiotics. Most diarrhoea is short-term and is usually self-limiting but can be inconvenient and embarrassing, especially if the person is on holidays abroad. Irritable bowel syndrome (see later) can also cause diarrhoea attacks. Managing diarrhoea Always be concerned if the person with diarrhoea is a baby or an elderly person as they become dehydrated very quickly and you may wish to refer these patients to your pharmacist. For information on how to treat diarrhoea in children see Module 5 Children s Health. Always recommend a rehydration salt (e.g. Dioralyte or Electrolade) as diarrhoea sufferers can lose a great deal of fluid during attacks and these products help replace the fluids and essential salts which the body needs to function. Rehydration salts are made up by emptying the contents of the sachet into water, ideally fresh drinking water. For adults and children, one sachet should be given after each loose bowel motion. For infants, doctors may advise that all feeds, except breastfeeding is stopped and rehydration sachets given instead. In these cases the amount of oral rehydration should be one and a half times the normal amount of feed given and always made up with freshly boiled and cooled water. Oral rehydration therapy is the mainstay of diarrhoea management as it helps the body to flush out any toxins or bacteria. However, some patients require more immediate relief of symptoms and OTC antidiarrhoeal agents such as loperamide (e.g. Imodium) can be recommended to adults with acute diarrhoea. Time Out Create a table of all the antacids that you stock in your pharmacy, noting whether they contain aluminium salts, magnesium salts, sodium bicarbonate and any additional ingredients. The table should also include the following information: the lower age limit for safe use, dosages, who cannot use the product, side effects patients may experience and any other advice you should give to customers before they use the product. 3

4 ACTIVE AGENT PRODUCT MODE OF ACTION NOTES Loperamide Imodium, Diocalm Ultra Delays the passage of stools, allowing more water to be absorbed back into the body Fast-acting Not for children under 12 No more than 8 capsules in 24 hours As above Loperaminde + simeticone Morphine with adsorbents (e.g. kaolin attapulgite) Imodium Plus As above, with simeticone to reduce wind Morphine reduces intestinal motility, delaying the passage of stools and allowing more water to be absorbed back into the body Adsorbents soak up the toxins produced by bacteria, helps make stools more solid and less watery J. Collis Browne s Liquid or Tablets, Diocalm Tablets Popular with drug abusers because of morphine content To relieve wind recommend antacids or simeticone, an anti-foaming agent which brings together small gas bubbles to create a large gas bubble that is easier to expel Diarrhoea: WHEN TO REFER TO THE PHARMACIST If the symptoms persist or do not respond to antidiarrhoeal treatments Anyone who has recently returned from a foreign holiday If there is blood or pus in the stools/dark stools In babies if there are other symptoms such as fever, vomiting, lack of interest in food and lots of loose watery nappies in diarrhoea tips for diarrhoea sufferers: 3 Switch to plain, high carbohydrate food like bread, potatoes, pasta, crackers and rice for 24 hours 3 Avoid all dairy products. (Breast fed babies can continue to feed) 3 Drink lots of water, soft drinks and herbal teas to prevent dehydration and have clear soups 3 Avoid dehydrating drinks, such as coffee and alcohol 3 Wash your hands with soap and water after using the toilet to reduce the risk of family or friends developing diarrhoea. 3 When travelling abroad drink water from sealed bottles or boil water before drinking it. 3 Only eat vegetables that have been boiled or peeled and avoid ice-cream and salads (which may have been washed with unclean water) the body when we eat, drink and digest food usually comes out as wind from the rectum (back passage), but it can also be expelled through the mouth (a belch or burp). Sufferers may also feel bloated or have a rumbling gurgling stomach. Some people find they also experience flatulence when they have indigestion, diarrhoea and irritable bowel syndrome. Managing wind If the customer s only problem is wind there is not much to worry about. But if they find the wind or bloating painful then you can recommend certain antacid products which can also relieve wind. Simeticone (e.g. Wind-Eze, Rennie Deflatine) is an anti-foaming agent which helps bring together small gas bubbles to create a large gas bubble that is easier to expel. For more information on treating flatulence associated with irritable bowel syndrome see later in this module. in wind management tips for flatulence sufferers: 3 Avoid foods that are likely to cause flatulence (Brussels sprouts, garlic, leeks, turnip, swede, kidney beans, onions, cabbage, cauliflower and apples) 3 Avoid rich or high fibre foods as these can be difficult to digest 3 Eat and chew food more slowly to prevent excess air being swallowed 4 Understanding wind What is wind? Wind or flatulence is an endless cause of amusement for children and most grown-ups too! Excess air that builds up in

5 MODULE 8 Indigestion and bowel problems PART 3: CONSTIPATION AND HAEMORRHOIDS Understanding constipation What is constipation? If you ask someone what their normal bowel habit is, you ll find the answer varies widely. The important thing to recognise is that there is no definite rule for what is normal. However, if customers complain of either having to go to the toilet less than usual, or going just as often but having small, hard stools they may be suffering from constipation. Customers with constipation may also have stomach ache and cramps and feel bloated. Constipation is more likely to affect children (see Module 5 Children s Health), women (especially before a period and when pregnant) and the elderly. Constipation is a symptom of many other conditions, some of which you can treat with OTC medicines (e.g. irritable bowel syndrome), but others are much more serious and require referral. It can also be a side effect of some medicines. Therefore it is important to ask questions discreetly when patients seek treatment for constipation to make sure that there are no other worrying symptoms (see when to refer box). In patients with constipation too much water is absorbed in the colon (which is part of the large bowel), leaving stools hard and dry and difficult to pass. The main causes of constipation are lack of fibre in the diet and not drinking enough water, although it can also be due to a change in eating habits (going on holiday for example), not exercising enough, taking certain medicines (e.g. aluminiumcontaining antacids or codeine-containing analgesics) or ignoring the call of nature. Constipation can become part of a vicious circle: straining to pass a dry hard stool can lead to haemorrhoids (or piles), and people avoid going to the toilet as they find it too painful which can worsen the situation. Managing constipation For many people constipation can be remedied by some simple lifestyle changes, such as increasing the amount of fibre in the diet (bran, fruit, vegetables), taking more exercise and drinking more water. A laxative can also be used and there are many different types you can recommend. These are available as tablets, capsules, liquids, granules, suppositories and enemas. Many of these should not be used in children. Bear in mind with any requests for laxatives, particularly stimulant laxatives, that they can be misused and are popular among anorexics to help keep them thin. Make a note of regular purchases and any other behaviour, such as using an in-store weight machine, that might lead you to suspect laxative misuse and refer the customer to the pharmacist. TYPE ACTIVE AGENT MODE OF ACTION NOTES Stimulant Senna (e.g. Senokot), bisacodyl (e.g. Dulcolax), sodium picosulfate (e.g. Dulcolax Perles) Increases the speed at which the contents move through the bowel Can act within minutes if a suppository is used, or overnight if a tablet is taken Cannot be used in people with a range of severe bowel problems Use for short periods as bowel can become over-reliant and lazy Osmotic Lactulose (e.g. Duphalac), macrogol (e.g. Movicol), magnesium sulphate (e.g. Epsom Salts) Attracts or retains water in the bowel which helps soften stools Lactulose-containing laxatives are unsuitable for customers who are lactose intolerant Softeners Docusate sodium (e.g. Docusol Adult Solution, DulcoEase) Help break up stools and allow them to be passed Liquid paraffin is no longer recommended as a softener because it can cause irritation of the anus, interfere with the absorption of fat soluble vitamins and lead to fat deposits in the lungs Bulk forming Bran, ispaghula (e.g. Fybogel, Regulan), methylcellulose, (e.g. Celevac) sterculia (e.g. Normacol) Adds bulk to stools making them softer and easier to pass Can take a few days to work. Users should be advised to drink plenty of water 5

6 6 Time Out Create a table of the following constipation and haemorrhoid treatments you stock, recording for each product its active ingredients, the lower age limit for safe use, dosages, how it should be taken, who cannot use the product, side effects patients may experience and any other advice you should give to customers before they use the product. Anusol Cream Anusol Suppositories Anusol Plus HC Ointment Celevac DulcoEase Dulcolax Tablets Dulcolax Perles Duphalac Fybogel Hi-Fibre Orange and Lemon Germoloids Ointment Germoloids Suppositories Preparation H Ointment Normacol Senokot Tablets Constipation: WHEN TO REFER TO THE PHARMACIST If there is any major change in bowel habits, especially in the middle-aged or elderly customer If there is blood or mucus in the stools Unexplained weight loss Loss of appetite If constipation persists, despite lifestyle changes and short-term laxative use If large amounts/regular purchases of stimulant laxatives are requested in constipation tips for constipation sufferers: 3 Increase daily fibre intake by eating more bran, wholemeal bread, cereals, fruit, leafy vegetables, potato skins, beans, and dried peas 3 Reduce the amount of processed foods such as white bread, ready meals and cheese 3 Increase water intake and avoid tea, coffee, alcohol and fizzy drinks 3 Do more exercise Understanding haemorrhoids What are haemorrhoids? Haemorrhoids or, as they are more commonly referred to, piles, is a subject that most sufferers feel very embarrassed about. It is almost guaranteed that you will know someone who is a secret sufferer, as it is a condition that affects almost half of us at some time in our life! Haemorrhoids are varicose veins that occur in or around the rectum. They can be internal or external piles, depending on where they occur. Symptoms include anal itching, soreness and discomfort after a bowel movement, some traces of fresh blood on the toilet paper or the surface of the stools and swelling around the anus. The most common cause of haemorrhoids is constipation, as straining to pass a stool can cause damage to the anal lining. Other causes include pregnancy, childbirth and being overweight. Contrary to popular opinion sitting on a cold surface, standing for long periods and sitting at a desk all day, do not cause piles! Managing haemorrhoids Many people with haemorrhoids will seek your advice first before going to see their doctor. In mild cases you can recommend lifestyle changes such as increasing the amount of fibre eaten, taking fibre supplements, and drinking more fluids and in such patients the haemorrhoids may clear up on their own. However, sufferers may want more instant relief and you can recommend from a range of cream, ointment, gel, suppository and spray formulations. Creams and ointments are good for internal and external piles - the ointment is greasier so is good if the skin is also sore and dry. Suppositories are generally used for internal piles. Haemorrhoid treatments should be used morning and night after each bowel movement. Most haemorrhoid products contain a combination of the following ingredients: Local anaesthetics, such as lidocaine (e.g. Germoloids, Anodesyn), cinchocaine, benzocaine (e.g. Lanacane) numb the affected area. However, anaesthetics can also irritate the skin and customers should stop using the product if a rash develops. Haemorrhoid products containing local anaesthetics should not be used for long periods and if the haemorrhoids last for longer than a week with treatment then advise the customer to see their doctor Antiseptics, such as balsam peru (e.g. Anusol) to help prevent infection Astringents, such as zinc oxide and bismuth oxide, to reduce the swelling and soothe and protect skin Some haemorrhoid products also contain hydrocortisone to reduce swelling e.g. Anusol Plus HC. These products can only be used for a maximum of a week and should not be used in those under 18 years of age or in pregnant women. You may get some strange requests for haemorrhoid treatments as women s magazines regularly feature the benefits of using haemorrhoid creams around the eyes to reduce bags and wrinkles. However, customers should be discouraged from trying this as it is not a recommended use. Haemorrhoids: WHEN TO REFER TO THE PHARMACIST If there is a significant amount of bleeding or the blood is dark If the stools are dark with the blood mixed in rather than on the surface If the patient is a pregnant woman in haemorrhoids tips for haemorrhoid sufferers: 3 Increase fibre intake this produces softer stools and helps prevent constipation (see constipation management box) 3 Drink lots of water, at least 12 cups of caffeine-free liquid each day 3 Maintain good toilet hygiene to reduce itching and irritation 3 Wash the area with soap and water before using a haemorrhoid treatment 3 Use moist toilet tissues as these are softer on the skin than toilet paper

7 MODULE 8 Indigestion and bowel problems PART 4: IRRITABLE BOWEL SYNDROME Understanding irritable bowel syndrome What is irritable bowel syndrome? Irritable bowel syndrome, or IBS, is a long-term condition that affects up to 20% of us at some time. The symptoms, which can vary between people, and between attacks, include: Abdominal pain Cramping Diarrhoea Constipation (some people find they have alternate constipation and diarrhoea) Wind/belching Bloating IBS usually affects people aged between years and is more common in women. There is no known cause for IBS; it can start after a period of stress or after a stomach infection. People have their own triggers, such as stress or certain foods, that will cause a bout of IBS. As the symptoms of IBS are often vague and are also signs of other, more serious conditions, such as ulcerative colitis and Crohn s disease, it is best to refer such patients to the pharmacist or their GP for diagnosis. Managing IBS You can only recommend treatment for people who have already been diagnosed with IBS. Treatment should target the symptoms the customer is suffering from: SYMPTOMS TREATMENT ACTIVE AGENT Diarrhoea Constipation Abdominal pain and spasms and wind Antidiarrhoeals Dietary changes. If these do not work then osmotic or bulk forming laxatives Antispasmodic drug Loperamide (e.g. Imodium) Lactulose (e.g. Duphalac) Ispaghula (e.g. Fybogel) Mebeverine (Colofac IBS, Fybogel Mebeverine), Hyoscine (Buscopan IBS Relief) Alverine (Spasmonal) Peppermint oil (Colpermin) Warning Hyoscine (Buscopan IBS Relief) should not be used in people with glaucoma, those under 12 years of age or who have certain colon problems. Care should be taken when recommending hyoscine as an IBS treatment for the elderly, those with Down s syndrome, pregnant and breastfeeding women and those with heartburn and high blood pressure. Side effects of hyoscine include heart palpitations, dry mouth, dry, flushed skin and sensitivity to light. IBS: WHEN TO REFER TO THE PHARMACIST If sufferer has not been diagnosed with IBS If there is also weight loss If there is blood in the stools/dark stools If sufferer also has anaemia-like symptoms (tiredness, breathlessness, palpitations, dizziness and headache) in IBS tips for IBS sufferers: 3 Try to identify triggers and, where possible, avoid these 3 Develop stress management techniques 3 Increase fibre intake if constipation is a problem symptom 3 Drink more fluids, but avoid caffeine and alcohol 3 Cut out spicy and fatty foods and wind-inducing foods, such as beans 3 Acupuncture, probiotic supplements/drinks and Chinese herbal medicines have been used by some sufferers PART 5: NAUSEA AND VOMITING Understanding nausea and vomiting What are nausea and vomiting? Nausea is a condition we are probably all familiar with a sense of queasiness, stomach churning and the feeling of being sick. In some cases this progresses to vomiting, where the contents of the stomach are forced back upwards out of the mouth. Nausea and vomiting on their own are not necessarily a problem as they are usually symptoms of another condition, such as gastro-enteritis (food poisoning), stomach ulcers, travel sickness, heartburn/indigestion, migraine or pregnancy. Managing nausea and vomiting Recommending an appropriate treatment for nausea, often depends on what the likely cause is (see table on next page). Time Out Consider the following customers. What action or treatment could be recommended? Which of these situations could you deal with and which should you refer to your pharmacist? A middle-aged man who thinks he might have indigestion but he is not sure as he has never had it before A woman in her twenties who has IBS and is suffering mainly from diarrhoea and abdominal cramping pains A regular customer who is asking for a bottle of Gaviscon, but you remember them buying a bottle earlier in the week A young mum who still has her pregnancy piles even after she has had her baby A man in his thirties who asks for something for diarrhoea and mentions that kaolin and morphine is supposed to be good A woman who has recently had gastro-enteritis and since then, she gets regular bouts of diarrhoea, but in between times can be very constipated 7

8 There are many possible causes of nausea, therefore treatment depends on the likely cause, e.g. nausea with migraine requires an analgesic with an anti-emetic. If the customer is unsure of the underlying cause and it is not a persistent problem then recommend bismuth salicylate salt product, which cannot be used in children under 16 years and should not be taken with aspirin. If the customer is vomiting, recommend an oral rehydration solution Coeliac disease must be diagnosed by the doctor and can be managed by cutting out all gluten in the diet. Gluten-free foods are available to buy and on prescription CAUSE TREATMENT NOTES Migraineinduced nausea Nausea with indigestion Morning sickness Prochlorperazine (Buccastem M) or combined with an analgesic (Pink Migraleve) Indigestion remedy (Pepto-Bismol) Ginger (either fresh or in tea) Sea-Bands acts on acupressure points to reduce nausea Buccastem M tablets should be placed between upper lip and gum. Not suitable for patients under 18 years, or those with glaucoma, epilepsy, who have liver or blood problems or are pregnant Advise patient to eat lightly for next 24 hours and avoid fatty foods and alcohol Once a person has started vomiting there is little you can offer them to treat it. Advise them to fast for 24 hours, and if they are hungry to only eat plain bread, rice or potatoes and avoid dairy, meat and alcohol. If they start to feel better after this time they should re-introduce other food slowly. Oral rehydration solutions (e.g. Dioralyte) can be used to help maintain fluid and body salt levels which can become depleted through prolonged vomiting. Nausea and vomiting: WHEN TO REFER TO THE PHARMACIST Prolonged or repeated vomiting If vomit is stained with green or yellow bile or blood If there is repeated forceful vomiting in new born babies If there are other symptoms, such as fever, rash, diarrhoea, headache, drowsiness or dehydration PART 6: COELIAC DISEASE Understanding coeliac disease intestine which become inflamed and stops absorbing food effectively. The end result is that coeliac sufferers take in fewer nutrients, like vitamins and minerals and also suffer from diarrhoea. Coeliac disease affects up to 1 in 200 people and there is a strong family history of the condition. The condition can develop in babies, often after weaning when cereals are introduced to the diet, but it can also spring up in later life, possibly as a result of severe stress, injury or surgery, infection, pregnancy, childbirth or surgery. Coeliac disease must be diagnosed by a doctor. Symptoms can vary depending on the age that coeliac disease first appears: Babies smelly diarrhoea, vomiting, bulky/pale stools, swollen tummy, failure to gain weight and an itchy rash on the knees, buttocks, elbows and shoulders Older children symptoms might not be very obvious but include pale, smelly stools, poor growth and anaemia (tiredness, breathlessness), caused by the lack of nutrients Adults diarrhoea, anaemia, mouth ulcers, weight loss, vomiting and abdominal pain Managing coeliac disease The only way to manage coeliac disease is to cut out all gluten in the diet. Rice, corn and soya foods can be eaten instead. Once a sufferer has changed their diet, they should start to feel better within days and the intestine heals in three to six months. Another important aspect of managing coeliac disease is replacing vitamins and minerals. People with coeliac disease may need iron tablets, folic acid supplements (especially when pregnant or planning to get pregnant) and calcium. Many sufferers get gluten-free food on prescription; these are also available to buy. There is a valuable role for you to play in helping to provide information and alert customers to new products and special offers that are available from the manufacturers. 8 What is coeliac disease? Coeliac disease is a sensitivity to the protein gluten, which is found in wheat, rye and barley. In people with coeliac disease the intestine thinks gluten is harmful and creates antibodies to fight it but these also damage the lining of the

9 AT A GLANCE: MEDICINES USED IN THIS MODULE Drug Main Actions Main Side Effects Aluminium and magnesium Salts (e.g. Maalox suspension) Bisacodyl (e.g. Dulcolax) Bismuth (e.g. Pepto-Bismol) Bran Calcium carbonate (e.g. Remegel, Setlers) Docusate sodium (e.g. DulcoEase capsules) Ispaghula (e.g. Fybogel, Regulan) Kaolin (Junior Kao-C) Lactulose (e.g. Duphalac) Loperamide (e.g. Imodium capsules) Macrogol (e.g. Movicol sachet) Magnesium sulphate (e.g. Epsom Salts) Mebeverine (e.g. Colofac IBS tablets) Methylcellulose (e.g. Celevac tablets) Morphine (e.g. J.Collis Browne Mixture) Omeprazole (e.g. Zanprol capsules) Oral Rehydration (e.g. Diarolyte Sachets) Antacid for indigestion For indigestion or diarrhoea and IBS Antacid for indigestion Adsorbent agent for diarrhoea Anti motility drug for diarrhoea Anti-spasmodic agent to relieve symptoms of IBS Opiate anti motility drug for diarrhoea Proton pump inhibitor for heartburn Rehydration during diarrhoea Magnesium-containing antacids tend to be laxative whereas aluminium-containing antacids may be constipating Abdominal cramp and diarrhoea Constipating and can be neurotoxic Flatulence, abdominal distension Gastro-intestinal disturbances Abdominal discomfort Flatulence, abdominal distension None known Flatulence, cramps, and abdominal discomfort Abdominal cramps, dizziness, drowsiness, and skin reactions Abdominal distension and pain, nausea Colic Rare Flatulence, abdominal distension Drowsiness Gastro-intestinal disturbances and headache Cont 9

10 AT A GLANCE: MEDICINES USED IN THIS MODULE Drug Main Actions Main Side Effects Pantoprazole (e.g. Pantoloc Control tablets) Peppermint Oil (e.g. Mintec capsules) Prochlorperazine (e.g. Buccastem M tablets) Ranitidine (e.g. Zantac tablets) Senna (e.g. Senokot tablets) Sodium alginate (e.g. Gaviscon liquid) Sodium bicarbonate (e.g. Eno powder) Sodium picosulfate (e.g. Dulcolax Perles) Sterculia (e.g. Normacol) Proton pump inhibitor for heartburn Anti-spasmodic for IBS Phenothiazine to treat nausea during migraine H2 antagonist for indigestion, heartburn Alginates/rafting agents for heartburn Antacid for indigestion Gastro-intestinal disturbances and headache Heartburn Movement disorders Diarrhoea and other gastro-intestinal disturbances Abdominal cramp and diarrhoea Very rarely allergic reaction Belching, flatulence, stomach cramps Abdominal cramp Flatulence, abdominal distension Complete your learning Well done on completing the module! Now visit to access: Weblinks to learn more and signpost your customers Forum to chat with other MCAs about your learning Online assessment to make sure you are on track