Coping With Common Gastrointestinal Symptoms in the Community

Abstract

FigureINTRODUCTION This guideline on a World Digestive Health Day theme is the first to take 4 key gastrointestinal (GI) symptoms as its starting-point: heartburn, abdominal pain/discomfort, bloating, and constipation. It is also unique in featuring 4 levels of care in a cascade approach: self-care and “over-the-counter (OTC)” aids; the pharmacist’s view; the perspective of the primary care doctor—wherein symptoms play a primary role in patient presentation; and the specialist. This paper focuses on the first 3 levels; algorithms for the specialist can be found in the full version of this guideline on the World Gastroenterology Organisation (WGO) Web site. The aim is to provide another unique and globally useful guideline that helps in the management of common, troubling but not disabling GI complaints. A team of GI and primary care experts, as well as the International Pharmaceutical Federation, were involved in the creation of the guideline. GI symptoms—with the possible exception of heartburn—usually occur as chronic or recurrent complaints attributed to the pharynx, esophagus, stomach, biliary tract, intestines, or anorectum. Whereas some data are available on the epidemiology of individual symptoms, there are more on the symptom clusters or aggregations known as functional GI disorders (FGIDs)—disorders as yet not explained by structural or biochemical abnormalities. These disorders affect a large segment of the population, and comprise a large proportion of primary care and gastroenterology practice. A categorization of these symptoms into discrete FGIDs has been developed in a multinational consensus in accordance with predefined symptom criteria.1 Relatively few data are available on the epidemiology of individual symptoms (with the exception of constipation), although there are considerable data on FGID syndromes. The latter are frequently used as a surrogate for the former throughout this guideline—eg, gastroesophageal reflux disease (GERD) for heartburn, irritable bowel syndrome (IBS) for abdominal pain/bloating. In addressing any disorder in the community, it is important to distinguish between diagnosed and undiagnosed GI problems; there is a huge reservoir of people who have problems and who have not been given a specific diagnosis by their clinician.2 In dyspepsia, there is evidence that only 50% of sufferers actually consult their doctor.3 The reasons for consultation may be determinants of management. Local or regional disease epidemiology is relevant to the management of these GI problems: the prevalence of parasitic diseases such as worms, Giardia, and viruses, as well as the incidence of malignant diseases, need to be considered. For example, in Mexico, giardiasis; in South-East Asia, hepatitis viruses; and in the southern regions of the Andes, gastric and gallbladder cancer, need to be considered in the differential diagnosis. There are also cultural and religious aspects that modify the patient’s response to symptoms: the Japanese population is recognized for being pain-tolerant; in other cultures, showing resistance to pain or other complaints may be regarded as a sort of sacrifice that can be beneficial for the soul and future life. Coping with environmental or psychological stressors such as war, migration, starvation, sexual abuse, or bullying may be very important in the causation of diseases and symptoms. Finally, in some cultures, spicy foods are a real issue. EPIDEMIOLOGY OF FUNCTIONAL GI SYMPTOMS Between-country variations in the occurrence rates for abdominal symptoms must be interpreted with caution; they may also reflect differences in culture, language, or expression, as well as study methods.4 Cultural differences are likely to cause differences in5: Perception of symptoms—differences in ideas and concerns. Presentation to medical care (including access to care) Use of medication. Preferred types and patterns of treatment. Expectations for treatment outcome. Relative availability of OTC and prescription drugs. Region-specific information on the epidemiology of functional GI symptoms can be found in the full version of this guideline online on the WGO Web site. WGO Cascades The WGO has developed diagnostic and treatment cascades for the WGO guidelines to provide resource-sensitive recommendations rather than focusing on a gold standard. However, for this guideline, a different approach has been chosen, on the basis of the point of care: from self-care to pharmacist, general practitioner/family physician, and finally, GI specialist. For the GI specialist, no extensive instructions are provided here, as sufficient sources are available on the Internet and in the published literature; references are provided throughout this guideline (see also the full version of this guideline on the WGO Web site). Patients who are taking medications should consult a pharmacist to see whether the self-medication options mentioned in this document have any labeled contraindications or known interactions with other drugs they may be taking. In some countries, OTC medicines are only available through community pharmacies. In most countries in the world, pharmacists can only recommend OTC medicines (as they do not have prescribing rights) to help patients, whereas in some other countries there is an intermediate class of medicines: pharmacy-only medicines. It is therefore often challenging to distinguish between management decisions that are based on a pharmacist’s recommendation and those that are truly a choice of self-care. To resolve this issue, both the process (self-care vs. pharmacist-driven) and the solution have been considered here (OTC medicines in both cases). Still, it should be taken into account that pharmacists systematically review medications for 2 purposes: To determine whether the GI symptoms could be a side effect of a medication To determine whether medicines used to treat GI symptoms have any known drug interactions with medicines the patient is already taking Increasing evidence suggests that dietary,6 lifestyle, cognitive, emotional/behavioral, and broader psychosocial factors may all play a role in the etiology, maintenance, and clinical effectiveness of treatments for FGIDs.7 DIAGNOSIS In interpreting the common symptoms considered in this guideline, a diagnosis of an FGID can be made if the patient’s symptoms are consistent with published diagnostic criteria for a given FGID8 in the absence of a history suggestive of any structural (organic) diagnosis that might provide an alternative explanation for the symptoms (see below). Age and sex (with no significant interaction) are the most clinically relevant variables. Diagnostic responsibility is usually limited to medical doctors, and generally excludes self-care and pharmacist’s interventions. A list of functional GI symptoms and a complaints profile can be found in the full version of this guideline online on the WGO Web site. Diagnostic Tests for Functional GI Symptoms Physical examination Basic diagnostic laboratory tests: Complete blood cell count. Erythrocyte sedimentation rate (ESR)/C-reactive protein (CRP). Biochemistry panel. Fecal occult blood (patient aged above 50 y). Pregnancy test. Liver function tests. Calprotectin or other fecal test to detect inflammatory bowel disease (IBD) in patients thought to have IBS, but in whom IBD is a possibility; now routine in many primary care settings (in the United Kingdom). Celiac serology; considered routine in areas with a high prevalence of celiac disease. Stool testing for ova and parasites. Endoscopy Visible abnormalities. Biopsy, histology. pH study—24-hour (48 to 72-hr with the Bravo esophageal pH capsule) esophageal pH or impedance-pH monitoring: measurement of esophageal acid exposure and assessment of the temporal association between heartburn symptoms and acidic reflux episodes. Manometry Esophageal motility study, high-resolution manometry. Anorectal manometry. Imaging GI barium series—air contrast swallow, meal and follow-through, enteroclysis. Double-contrast barium enema. Abdominal ultrasonography. Abdominal computed tomography, magnetic resonance imaging of the abdomen. Miscellaneous Breath tests: lactose, glucose, fructose.9 Dietary exclusion, followed by challenge with specific dietary components, may be considered a diagnostic test. Therapeutic trial of acid suppression [the “proton-pump inhibitor (PPI) test”] in patients with heartburn or other symptoms that might be related to acid reflux. Food allergy or intolerance, lactose intolerance, eosinophilic infiltrates. HEARTBURN It should be noted that not all common GI symptoms are functional. This concept is particularly relevant for the symptom of heartburn. Most patients presenting with heartburn have GERD, with or without visible lesions in the esophageal mucosa. According to the Rome III consensus, even endoscopically normal patients with heartburn are diagnosed as having reflux disease as long as there is evidence that their symptoms are caused by the reflux of gastric contents. This constitutes the diagnosis of nonerosive reflux disease. These patients do not have an FGID. Only when heartburn occurs in the absence of mucosal lesions, abnormal esophageal acid exposure, and a positive symptom-reflux association during reflux monitoring, and when it does not respond to acid-suppressive treatment, is it regarded as functional, and only then can a diagnosis of “functional heartburn” be made.10 Definition and Description Heartburn is a retrosternal burning or warm sensation that may move upward toward the neck, throat, and face. A synonym for it is “pyrosis.” Heartburn may also coexist with other symptoms referable to the upper GI tract. It may be accompanied by regurgitation of sour/acid-tasting fluid or gastric contents into the mouth—acid or food regurgitation. The symptoms are typically intermittent and may be experienced: In early postprandial periods, During exercise, While in a recumbent position, At night. In practice, there may be no clear differentiation between what are regarded as GERD symptoms and “dyspepsia”—indeed, the results of the Diamond study11 call into question the value of heartburn and reflux as indicative symptoms of GERD. Diagnostic/Symptoms Remarks It is important to determine whether or not acid may be associated with heartburn. This is most simply done by defining the response to antacids and acid suppression (or alginate preparations). Twenty-four-hour (48 to 72 h with the Bravo esophageal pH capsule) esophageal pH or impedance-pH monitoring can be carried out to assess the presence of esophageal acid exposure and a temporal association between heartburn and reflux episodes, using a measure such as the symptom-association probability. Patients with symptoms of GERD who do not respond to a PPI and have a negative endoscopy, with no evidence of acid reflux as a cause of their symptoms, should be diagnosed as having functional heartburn.12 The Rome III diagnostic criteria for functional heartburn are: Burning retrosternal discomfort or pain, Evidence that gastroesophageal reflux is not the cause of the symptom, Absence of histologically confirmed esophageal disorders, Criteria fulfilled for the previous 3 months, with symptom diagnosis. pain or discomfort that does not to the retrosternal should not be heartburn. does not play a role in heartburn and there is no for testing for with heartburn, symptoms of GERD may pain, may pain, or and other symptoms (as a of of into the or a by the in the esophagus, or a of both that may or other or In patients, a pH and study may be useful for a diagnosis. It can also on alternative of symptoms, such as esophageal and treatments that can esophagus, nonerosive reflux disease. esophageal in symptoms, recurrent GI Evidence of heartburn above 50 to history of esophageal heartburn usually has no and discomfort caused by heartburn, if can and of life. management and monitoring can symptoms and as in most may be reflux can be with Patients should foods that The of and For heartburn, the of the on or may are a used and OTC treatment. are very some that there may be with Most people with heartburn do not need and these are not of any who need treatment should be followed are now available OTC in many PPI who need gastric acid suppression should have an for PPI the need for should be The response to acid suppression (or in patients with functional heartburn by or and patients are of being for treatment for GERD. all patients with symptoms of GERD who are for should have pH monitoring to out functional heartburn if an diagnosis of GERD has not been provided by other for heartburn. some of the options are not available in all for Heartburn symptoms: For months, or heartburn. 2 of treatment with a or when taking a prescription or heartburn above 50 to or of GI blood or or Symptoms or of or Symptoms suggestive of to neck, and of or of for for the most common and these to the of acid reflux symptoms. if the most important or or or spicy more the of the to on or food or for 3 for between for or intermittent antacids gastric and acid with of of gastric acid to to gastroesophageal but few drugs are available for clinical and in clinical has been should be The of are to and an of by using the most and is not patients are to a care for diagnostic A should be made for any medications that may be to drugs any of these drugs are being to a general practitioner/family The patients should and other In to and dietary a of and or or PPI (in OTC should be considered. and a patient is above or aged 50 to and has factors for to a there is no 2 to general practitioner/family history of food or eosinophilic to be from food the response to PPI that PPI is being taken in the in to There is no evidence that the PPI in response to an response to a is However, taking a PPI food may the response in some of PPI are a to The patient should any food or the of the meal of the treatment is the should be to the treatment should be considered. should be taken if there are visible if is an presenting symptom, or if or eosinophilic is a diagnostic review should be to patients who management of symptoms. is not for patients without for is for patients above of with could be considered in areas with a high incidence of gastric of the specialist management of heartburn are the of this guideline, and the is to the relevant guidelines on the management of Definition and Description A or or pain in the abdominal (or is a chronic or recurrent pain in the upper with a sensation of and early when It may be accompanied by bloating, or heartburn. It is frequently associated with GERD and may be the first symptom of disease and of gastric Diagnostic/Symptoms Remarks Abdominal pain accompanied by is usually labeled The Rome III diagnostic criteria for functional abdominal pain disorder are: or abdominal or only an between pain and or of The pain is not There are symptoms to the criteria for another FGID that the The criteria have been fulfilled for the previous 3 months, with symptom diagnosis. There are many possible of abdominal The here be on common of chronic abdominal pain, with as the presenting However, it must be in that specific GI may cause abdominal pain, and and pain is associated with bowel and to or with from and are pain, typically in may also food are and and and the for and Functional or pain pain is to the is and does not the criteria for gallbladder disease or of the rates high in many countries, of and of acid and constipation. Celiac disease. of any example, disease. pain is by and is out of proportion to the in patients, history of symptoms of and may be associated and it should be that is often with of abdominal are: inflammatory and or and be to and with abdominal A examination should be carried and should to a and and on Age GI history of abdominal abnormal function or positive fecal occult blood test. of symptoms without Abdominal The community care and medication related to abdominal are high but between In the United and of medications for abdominal pain has been than in vs. drugs have been most in and antacids in and the United has the of to in is taken on to a pain In a on of treatment, of as the most important followed by and The choice of drug by a followed by or to play a role to in the United A of is that during the from to for chronic abdominal pain more than in the United study has that are for chronic abdominal of may other GI symptoms, particularly and and may to Abdominal to medical care rather than symptoms a full of prescription or OTC Symptoms and with to consult a that all the but into the accompanied by or with to move the or pain, to that to from the pain accompanied by pain into the neck, with of or or in abdomen. of blood or or bowel OTC medication for and constipation. and dietary interventions. The treatment for generally of a with medication pain, Evidence is now to that specific dietary should be dietary may also be of such as in the in the presence of or with evidence of in and are for abdominal and may cause they can actually pain in more for upper (as in patients aged with symptoms: Physical and or and for and of or psychosocial abuse, and laboratory blood to for and glucose, and for function and particularly in patients with upper abdominal inflammatory and to help and fecal occult blood (patient 50 of celiac serology; test. for culture, and and to for or it should be that the association of with parasitic is from and to be more or testing for in patients with upper GI symptoms on prevalence and test fecal or in with and abdominal and Dietary lactose, or inhibitor The of in patients with functional abdominal pain disorder may to the of bowel by of medications for pain with the of 3 to of treatment. the Rome III for Functional to of psychosocial diagnostic and to GI pain Definition and Description postprandial abdominal and are rather and to with as a of the In and are is a symptom and is an and of the abdomen. This is not possible in other such as In countries, to a of of the to to the of food to a of without any to food to this Patients often it to what they by bloating, and many different may be to of symptoms in some and abdominal in FGIDs has a in the in the and is diagnostic of an FGID. However, when it is it should be regarded as an example, for or The is and may a of abnormal and the patient’s abdominal is it may or may not be although the patient it is and is that it At other the or have to be there is Abdominal can be and a in and is an when it occurs In the upper GI tract, usually from or in in the tract, results from and Diagnostic/Symptoms Remarks Imaging are of value for the diagnosis of may help out an or a that could the patient to Health care may be that symptoms of and are of and may for the of in this is usually but can cause significant in to the to and in or It is also related to in and medication to be may Rome III criteria for functional must A recurrent of or visible on 3 during the previous 3 criteria for a diagnosis of functional dyspepsia, IBS, or other FGID. The criteria must be fulfilled for the previous 3 months, with symptom the diagnosis. GI or with in related to for example, may to and Functional Dietary or of or other Celiac disease. constipation. motility diseases associated with or example, of to may be a normal of the Abdominal fluid or visible GI food by taking 3 a with 2 It is to the of food and the rather than having large should be of such as and such as and of foods and such as or should be into the rather than to the to with on such as and of foods high in and or do not and food and a to foods that in the to as well as and in that any should be a based on protein and with a in and and and are being used for and symptoms, but their is of such as and have in and should be with and dietary medications with are but without any evidence of to the or other symptoms are such as or abdominal pain, may more if accompanied by abdominal pain, food as well as when there is an abdominal A absence of of and accompanied by abdominal pain, when no cause is trial of then challenge with lactose, of food However, only a should be has been to in patients with may be useful in patients with disease by symptoms. treatment. if the patient is a Definition and Description This focuses on functional rather than pain accompanied by In clinical practice, the “functional and are often used the chronic of the symptoms and The presence of abdominal pain is usually thought to distinguish between and although the may be to in practice. is an or chronic in bowel occur frequently than or are or to or associated with a of or constipation. Fecal is a of in the or Symptoms of discomfort during a bowel than bowel or than or or pain in the or of Diagnostic/Symptoms Remarks The Rome III criteria or more must be for functional are: during of or in of of for of of for of to of of the than 3 are without the of criteria for Criteria fulfilled for the previous 3 months, with symptom diagnosis. should be considered in of chronic with abdominal constipation. A of have been to such as and they are usually rather than in bowel Age 50 history of to and but an who has no bowel in 3 or 4 for a is considered However, is often an of a may more to with the of or a of a in the bowel if aged above bowel are or and to 2 to 3 or occurs in with or Symptoms of for with no or from the Patients with should be not to when the is its foods in in the and and the of in the to and patients that their symptoms (as it may in and they should in in such as or to and with for constipation. 2 of of and of foods high in and of example, and and food and to a for and to a and from to and management not the to a bowel The can affect bowel well with a and with a bowel to 2 a for a medical or constipation. to the of medication and in the on and such as to be taken with of Stool are that are used and can be for but there is evidence on of with for medicines or available are the treatment, but are associated with high such as and such as may cause abdominal pain and in followed by with no bowel and to and can be without drugs most of the In the absence of routine diagnostic testing is not in all or more is there is an for history and Description of Stool taken to and Complete blood to occult blood or and for GI if to to the WGO guideline on WGO The WGO of the and