It’s not easy for everyone to admit to bowel health problems, but some are more serious than others and early advice from the pharmacy team could prove to be lifesaving

From stomach ache and bloating to bouts of constipation or diarrhoea, everyone will have experienced their bowels playing up at some point in their lives. For most people, it may be a tummy bug or a spot of over-indulgence, but for others, there may be underlying issues that need to be addressed.

Knowing the warning signs of when a customer’s seemingly simple enquiry about their bowel health could be something more serious is important for all pharmacy teams, as well as being aware of the next steps that should be taken and the support that’s available.

Inflammatory bowel disease

At least 300,000 people in the UK live with inflammatory bowel disease (IBD), and every 30 minutes someone in the UK is diagnosed with Crohn’s disease or ulcerative colitis – the two main forms. While ulcerative colitis only affects the colon (large intestine), Crohn’s disease can affect any part of the digestive system, from the mouth to the anus.

IBD can affect people of any age, but it is usually diagnosed between the ages of 15 and 40. It is thought to be caused by a combination of factors, including genetics – an individual is more likely to get IBD if they have a close relative with the condition – or a problem with the immune system. Smokers are also twice as likely to get Crohn’s disease than non-smokers.

Symptoms of IBD include pain, cramps or swelling in the stomach; recurring or bloody diarrhoea; weight loss; and extreme tiredness. These symptoms can flare up and be followed by long periods of remission.

There is currently no cure for ulcerative colitis or Crohn’s disease, and treatment – such as specific diets, lifestyle changes, medicines and surgery – aims to relieve the symptoms and prevent them from returning.

Every 30 Medicines to treat ulcerative colitis or Crohn’s disease include:

• Aminosalicylates or mesalazines, which can reduce minutes inflammation in the gut 
• Immunosuppressants such as steroids or azathioprine to reduce the activity of the immune system
• Biological and biosimilar medicines, which are antibody-based treatments given by injection that target a specific part of the immune system
• Antibiotics.

Julie Thompson, information manager at the charity Guts UK, says there are some red flags that pharmacy teams should look out for in customers who are known to have IBD. These include “fever, change in bowel habit, blood in stools, weight loss, vomiting and abdominal pain”. If a customer presents with any of these symptoms, refer them to the pharmacist as they may need to contact their IBD treatment team, if they have one.

Every 30 minutes someone in the UK is diagnosed with Crohn’s disease or ulcerative colitis

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a common disorder of the gut-brain interaction, which leads to abdominal pain, bloating, diarrhoea and/or constipation. It is thought to affect up to 12 million people in the UK.

Symptoms can include constipation, diarrhoea, abdominal cramps, pain and bloating, tiredness, nausea, heartburn and indigestion, backache, needing to pass urine frequently, headaches, muscle pain, anxiety and depression.

“There is no specific cause for IBS and no single effective treatment,” says Alison Reid, chief executive of The IBS Network. “It is important to receive a diagnosis based on a typical history and examination and have been tested to exclude other conditions, such as coeliac disease and inflammatory pathology, within the gut.”

Once a person has an IBS diagnosis, considering their diet and lifestyle is the first-line treatment. “Start by encouraging them to keep a 12-week wellness diary, available from The IBS Network, where they record food, mood and events that are happening

in their life,” says Alison. “They can then use this information to better understand their symptoms and triggers and identify any patterns to their IBS.”

The next step is to recommend they:

• Eat three to four meals a day, avoiding spicy or fatty foods
• Drink plenty of fluid, especially water
• Limit alcohol intake to no more than two units per day and have at least two alcohol free days a week
• Reduce caffeine intake
• Limit fresh fruit to three portions per day.

Of course, if a customer complains of any of the red flag symptoms, such as bleeding from the rectum, change in bowel habit for no obvious reason, weight loss when they are not trying to lose weight or a persistent fever, they should be referred to a GP.

Coeliac disease

Coeliac disease (pronounced see-lee-ac) is a lifelong autoimmune disease caused by a reaction to gluten – a protein found in wheat, barley and rye – and a similar protein called avenin that is found in oats. When someone with coeliac disease eats either of these proteins, the body’s immune system attacks its own tissues, which causes damage to the lining of the gut.

“Coeliac disease is common and affects around one in 100 people,” says Ruth Passmore, head of health policy at the charity Coeliac UK. “However, only approximately 30 per cent who have the condition have currently been diagnosed, so there are nearly half a million people who have coeliac disease but don’t yet know.”

In a community pharmacy setting, coeliac disease can present a range of symptoms that may vary from person to person. These can include:

• Persistent constipation, diarrhoea, feeling sick and vomiting
• Unexpected weight loss
• Faltering growth in children
• Feeling tired all the time
• Severe and persistent mouth ulcers.

As many of the gut symptoms are similar to those of IBS, Ruth says: “A test for coeliac disease should be carried out before a diagnosis of IBS is made.”

The only treatment is strict, lifelong adherence to a gluten free diet, and Ruth says pharmacy teams can play a key role after diagnosis by providing information on the gluten-free diet, including information on gluten-free foods available on prescription. “You can also remind patients there are some vaccinations which are recommended for people with coeliac disease,” says Ruth. Information on both of these can be found at Coeliac UK.

Remember to respect the customer’s privacy and talk out of earshot of other customers

Bowel cancer

Bowel cancer is one of the most common types of cancer in the UK and most people diagnosed are over the age of 60. The exact cause is not known.

The main symptoms of bowel cancer are a persistent change in bowel habit; persistent blood in stools; and persistent lower abdominal pain, bloating or discomfort always caused by eating and possibly associated with loss of appetite or significant unintentional weight loss.

Red flags to look out for, according to Julie, include “other symptoms that might suggest investigation for metastatic spread [the spread of cancer cells to other areas of the body], such as jaundice, shortness of breath and cough”, at which point pharmacy teams should strongly encourage the customer to see a GP immediately.

The NHS offers two types of bowel cancer screening to adults registered with a GP in England. All men and women aged 60 to 74 are invited to carry out a FIT or FOB test every two years, using a home test kit. Anyone aged 75 or over can request this test by calling freephone: 0800 707 60 60. An additional one-off test called ‘bowel scope screening’ is gradually being offered in England to people at the age of 55. This involves a doctor or nurse looking inside the lower part of the bowel using a camera on the end of a thin, flexible tube.

It is worth encouraging customers to take part in bowel cancer screening, as removing any polyps – small growths that can develop on the inner lining of the rectum – found during bowel scope screening can prevent cancer.

Depending on how far it has spread by the time it is diagnosed, bowel cancer can be managed using a combination of treatments including surgery, chemotherapy, radiotherapy, and targeted therapies – a newer group of medicines that increase the effectiveness of chemotherapy and prevent the cancer from spreading.

As ever, prevention is better than cure, and there are several ways people can lower their chances of developing bowel cancer that pharmacy teams are ideally placed to advise customers about. Like so many aspects of health maintenance, these include stopping smoking and cutting down on alcohol, eating a healthy balanced diet, losing weight and keeping fit.

Broaching sensitive subjects

Although pharmacy teams may be familiar with the symptoms and treatments for these problems, and be happy to discuss them, customers may feel awkward or embarrassed. Here are some tips to help with these conversations:

• Privacy: remember to respect the customer’s privacy and talk out of earshot of other customers or, if appropriate, use a consultation room. This can mean that customers are more likely to speak openly, as they know the conversation is not being overheard
• Body language: maintain open, relaxed body language as this will help the customer to feel at ease. Acting cagey or uncomfortable means customers will be less likely to open up about any problems they are experiencing. This is especially true if the subject is sensitive
• Confidence: try not to feel awkward, as the customer will pick this up. Practising these conversations with colleagues may help. If a member of the team doesn’t feel comfortable discussing bowel health, the customer can be referred to a more experienced colleague or to the pharmacist
• Language: try to reflect the type of language the customer uses – if they use the word “piles”, you should also say piles because saying haemorrhoids instead may cause confusion. The same goes for bowel movements – reflect the customer’s terminology
• No judgement: take care when giving lifestyle advice not to make assumptions or judgements. For example, rather than saying “you should eat more fibre”, try something like “some people don’t always eat enough fibre, and that can cause constipation. Do you think that might be an issue for you?”

No matter how tactful a conversation is, the fact remains that many people will be embarrassed to talk about their bowel health. Being able to recognise those who may need advice and offering them appropriate support could make all the difference when it comes to spotting serious bowel health problems early and making individuals feel more comfortable.