Common stomach pains that comes to the community pharmacy and how to identify them
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Common Stomach Pains Presenting to Community Pharmacy
In a community pharmacy setting, the term "stomach pain" covers a wide range of GI complaints. Below are the most common presentations, how to identify them, and pharmacy-relevant points for each.
1. Dyspepsia (Functional / Non-Ulcer)
What it is: The most common upper GI complaint. Dyspepsia literally means "difficult digestion" - a heterogeneous group of upper abdominal symptoms with no clearly identified organic cause in the majority of patients (>70% will have no findings on endoscopy).
How to identify it:
- Epigastric pain or burning (Rome IV: the core symptom)
- Postprandial fullness (uncomfortable sensation of food lingering after meals)
- Early satiation (feeling full before finishing a normal-sized meal)
- Upper abdominal bloating, belching, nausea
- Symptoms originate from the gastroduodenal region, NOT the chest
- Heartburn can coexist, but if heartburn is the predominant symptom, the diagnosis shifts to GERD
Key differentiator: When heartburn and regurgitation dominate, think GERD. When upper abdominal fullness, early satiety, and nausea dominate after meals, think functional dyspepsia.
- Sleisenger and Fordtran's Gastrointestinal and Liver Disease
- Yamada's Textbook of Gastroenterology
2. Gastroesophageal Reflux Disease (GERD) / Heartburn
What it is: Reflux of stomach acid into the esophagus, causing characteristic symptoms. Very common in the community - patients often self-present for OTC antacids or PPIs.
How to identify it:
- Substernal (retrosternal) burning - "heartburn" - that may radiate toward the throat
- Water brash (sudden mouth filling with saliva)
- Regurgitation of sour/bitter fluid
- Worse after meals, lying down, bending forward, or large meals
- Symptoms of heartburn + regurgitation carry 70% sensitivity and specificity for GERD
- Atypical presentations: chronic cough, hoarseness, laryngitis
Red flags requiring referral: Dysphagia, weight loss, GI bleeding, symptoms >4 weeks not responding to OTC therapy (possible Barrett's esophagus risk).
- Harrison's Principles of Internal Medicine 22E
- Goldman-Cecil Medicine
3. Peptic Ulcer Disease (PUD) - Gastric and Duodenal Ulcers
What it is: Mucosal ulceration in the stomach or duodenum, most commonly caused by H. pylori infection or NSAID use.
How to identify it:
- Classic symptom: Burning epigastric pain - described as sharp, dull, an ache, or an "empty/hungry feeling"
- Pain relieved by food, milk, or antacids (buffers the acid)
- Pain recurs as the stomach empties - may classically wake the patient at night
- Pattern: daily pain for weeks, then remission, then recurrence weeks to months later
- Gastric ulcer: Postprandial pain and nausea; food may worsen it
- Duodenal ulcer: Pain relieved by eating, worsens 2-3 hours after meals, night pain more common
Warning signs requiring urgent referral:
- Sudden severe/generalized pain (perforation)
- Mid-back radiation (pancreatic penetration/pancreatitis)
- Vomiting blood (haematemesis), coffee-ground vomit, black tarry stools (melaena) - all indicate bleeding
Important history: Ask about regular NSAID/aspirin use and any recent H. pylori testing.
- Tintinalli's Emergency Medicine
4. Irritable Bowel Syndrome (IBS)
What it is: A functional gut-brain disorder. The hallmark is recurrent abdominal pain linked to altered bowel habits, without structural disease. Very common - patients often present for antispasmodics, laxatives, or antidiarrhoeals.
How to identify it (Rome IV Criteria):
- Recurrent abdominal pain at least 1 day per week on average, for the last 3 months (with onset ≥6 months ago)
- AND two or more of:
- Pain related to defecation (better or worse after a bowel movement)
- Associated with change in stool frequency
- Associated with change in stool form/appearance
Subtypes:
| Subtype | Dominant Stool Pattern |
|---|---|
| IBS-C | Constipation |
| IBS-D | Diarrhoea |
| IBS-M | Mixed |
Supporting features: Bloating, flatulence, postprandial cramping triggered by fatty/spicy foods or caffeine. Women more often have IBS-C; more common under 50 years old. Stress and anxiety are key triggers.
- Goldman-Cecil Medicine
5. Gastritis (Acute and Chronic)
What it is: Inflammation of the gastric mucosa. Often related to H. pylori, NSAIDs, alcohol, or stress.
How to identify it:
- Epigastric pain, nausea, and vomiting
- Can mimic PUD but tends to be less well-defined
- Most common presentation of chronic gastritis is GI bleeding (from occult blood in stool to massive haemorrhage), rather than just pain
- Often asymptomatic for years, even up to perforation
Note for pharmacy: Patients on chronic NSAIDs presenting with new epigastric discomfort should be suspected of NSAID-induced gastritis/ulceration. Always check if a gastroprotective PPI has been co-prescribed.
- Sherris & Ryan's Medical Microbiology
- Tintinalli's Emergency Medicine
6. Constipation-Related Abdominal Pain
What it is: Infrequent bowel movements with hard stools causing lower abdominal cramping and bloating. Extremely common community pharmacy presentation.
How to identify it:
- Lower abdominal cramping, heaviness, or bloating
- Infrequent defecation (≤3 bowel movements per week)
- Hard, lumpy stools (Bristol Stool Scale types 1-2)
- Sensation of incomplete evacuation
- Often associated with poor fluid/fibre intake, sedentary lifestyle, or medications (opioids, iron supplements, calcium channel blockers)
- Can overlap with IBS-C
Quick Identification Summary Table
| Condition | Pain Location | Character | Key Feature | Triggers / Relief |
|---|---|---|---|---|
| Functional Dyspepsia | Epigastric | Burning / fullness | Postprandial fullness, early satiety | Meals |
| GERD | Retrosternal / throat | Burning | Heartburn + regurgitation | Lying down; relieved by antacids |
| Peptic Ulcer | Epigastric | Burning / "hungry" ache | Night pain, relieved by food | Food/antacids relieve; NSAIDs/H. pylori |
| IBS | Lower / diffuse abdomen | Cramping | Pain linked to bowel habit change | Stress, food; relieved by defecation |
| Gastritis | Epigastric | Dull / burning | Nausea/vomiting; GI bleeding risk | NSAIDs, alcohol, H. pylori |
| Constipation | Lower abdomen | Cramping / pressure | Hard stools, infrequent BMs | Low fibre/fluids, medications |
Red Flag Symptoms: When to REFER Immediately
These warrant same-day GP or ED referral - do NOT manage in pharmacy:
- Haematemesis or melaena (upper GI bleed)
- Sudden severe/generalised abdominal pain (possible perforation)
- Unintentional weight loss
- Progressive dysphagia
- Persistent vomiting
- First presentation of symptoms in a patient >55 years
- Palpable abdominal mass
- Pain radiating to the back (pancreatitis or aortic aneurysm)
- Iron-deficiency anaemia with GI symptoms
These red flags are key discriminators in community pharmacy triage - any of the above should override attempts to manage symptoms with OTC products.
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