These guidelines have been adapted from advice issued by the British Society of Gastroenterology and the British Digestive Foundation. Everyone experiences occasional digestive upsets such as indigestion, flatulence or a disturbance of bowel habit. These can be regarded as normal and are often caused by diet, lifestyle or a change in routine. If symptoms of this sort persist or worsen, or if you develop new digestive symptoms that you have not previously experienced, you may be suffering from a digestive disorder that needs treatment.

You should see your doctor if you experience the following symptoms, particularly if they are unexpected or persistent. It is impossible in this leaflet to give a full list of the causes of these symptoms, but your doctor will make a judgement after taking a further history and examining you. In most people these symptoms are due to conditions that are not serious, but in some cases there may be more serious diseases such as bowel inflammation or cancer. Your doctor will advise you on what to do.

• Abdominal pain before or after meals, or indigestion. This may be due to an ulcer in your stomach or duodenum with or without the bug known as Helicobacter pylori. Other causes include gallstones, but rarely it may be caused by cancer of the stomach.
• Persistent feeling of fullness, bloating or flatulence. Gallstones are a common cause of these symptoms but the symptoms may occur after heavy meals.
• Nausea or vomiting. Nausea and vomiting can occur in a wide variety of illnesses and after a heavy meal and excessive alcohol intake. They are not specific to any disease state.
• Your eyes, skin or urine turning yellow. This suggests that you are jaundiced and the problem may be in your blood or may be due to a blockage of your liver or bile ducts. Common causes are hepatitis, gallstones, cirrhosis of the liver and blood infections.
• Heartburn, regurgitation or waterbrash. These suggest that food, acid or bile is passing back into the gullet and causing irritation of the lining of this organ. Waterbrash is the taste of stomach contents in your mouth.
• Pain or difficulty in swallowing. You may get this if you have a throat infection, for instance due to a simple virus. More serious causes include narrowing of the gullet or the upper part of the stomach from repeated acid damage or from cancer.
• Loss of appetite. Appetite may be lost owing to a large number of illnesses including depression and an under-active thyroid. It too is not specific to any particular diseases but if it does not settle, it may be due to cancer.
• Continuing or unexplained weight loss. Again a number of conditions can cause this, including diabetes, an over-active thyroid, infections, depression and cancer.
• Indigestion developing for the first time in mid or later life. This may be an early sign of cancer of the stomach or pancreas and must be reported to your doctor. It may also be due to non-cancerous ulcers in the stomach.
• Persisting diarrhoea, constipation or any change in bowel habit. There is a host of causes of these symptoms. Most are not serious and settle without any specific treatment. They should cause concern if they do not settle after a week or two.
• Change in your stools (bowel motions), especially if they become black, dark red, pale or contain mucus or slime. Black stools may be due to iron tablets but may also be due to bleeding from somewhere high up in the bowel. The red blood that is shed is changed to a black colour by the digestive juices in the bowel. Dark red stools may be due to eating beetroot but again there may be blood, coming from somewhere in your large bowel or higher. Diseases that cause dark red bleeding include diverticular disease, inflammatory bowel disease and polyps, but cancer must also be considered.
• Bleeding from your back passage. Often bright red blood is due to piles or haemorrhoids but depending on your age and the presence of other symptoms, cancer may be a possibility.
• Feeling that your stools are emptying incompletely. There may be a lump in the back passage such as piles or even hard stools. Another cause is cancer of the rectum or back passage.
• Generally feeling tired, lethargic or unwell, and also having abdominal symptoms. This may be due to overwork, lack of sleep, irregular eating or depression. If abdominal symptoms such as pain or backache are present, there may be concern about cancer in the stomach or bowel or in the pancreas.

Indigestion is persistent or recurring pain or discomfort felt in the centre of the upper part of your tummy. The medical term for this is dyspepsia. The pain or discomfort may be related to meals: it may be made worse by food or may be relieved by food. Sometimes the sufferer feels too full after a small amount of food and cannot finish a full meal. In some cases, there may be no relation to food. When discomfort of a burning nature is felt behind the breastbone, it is known as heartburn. Some people get a combination of these two symptoms.

Heartburn is a burning discomfort in the lower and middle part of the chest. It appears to start from the stomach and goes up to the throat. Heartburn occurs when digestive juices, usually containing acid, but sometimes bile, pass back into the oesophagus (gullet). The passing back of juices in the opposite direction is referred to as reflux. The gullet was not designed to come in contact with acid, unlike the stomach, and when such exposure occurs, the lining of the gullet becomes inflamed and painful. The main cause of reflux is a hiatus hernia, a condition in which the valve between the gullet and the stomach does not work well and the contents of the stomach pass upwards into the gullet. Inflammation of the gullet is referred to as oesophagitis; when due to reflux, the term reflux oesophagitis is used to describe it. Indigestion and heartburn often occur together and it is difficult to distinguish one from the other. The two will therefore be described together in the rest of this leaflet. Symptoms common between the two are bloating of the upper part of the tummy, a feeling of sickness, actual vomiting and retching. Is heartburn (or indigestion) anything to do with the heart? The word heartburn implies that the pain arises from the heart, but in fact this is not the case. However, the symptoms of heartburn and indigestion can sometimes be confused with pain from the heart. Heart pain or angina is felt in the chest and sometimes in the upper part of the tummy, often after exercise, and is relieved by rest. Pain from a heart attack is more severe and prolonged. If in doubt, consult your doctor.

Causes include ulcers in the stomach and/or the duodenum; inflammation of the lining of the gullet due to reflux, inflammation of the lining of the stomach or duodenum caused by the bug known as Helicobacter pylori; abnormal contractions of the stomach; stones in the gallbladder; and sometimes cancer of the stomach. Indigestion and heartburn are often aggravated by the following:

• Pregnancy
• Smoking, drinking alcohol, eating fatty foods; being overweight
• Bending down or lying flat too much
• Wearing tight clothing around the waist
• Medications such as aspirin and other drugs for rheumatism and arthritis How do I avoid indigestion and heartburn? Measures to avoid indigestion and heartburn include the following:
• Avoiding or giving up smoking
• Eating meals at regular times, not rushing meals, avoiding meals before bed time and avoiding heavy and fatty meals
• Avoiding foods that aggravate symptoms
• Avoiding agents that irritate the lining of the stomach, including aspirin; other drugs for arthritis such as ibuprofen and steroids; alcohol; and coffee
• Losing weight if you are overweight
• Avoiding wearing tight belts; avoiding lying flat and bending down; raising the head end of the bed to reduce acid working upwards to the gullet When should I consult my doctor? Most people suffer indigestion at some point in life and will take medicines to ease the symptoms. In most the symptoms will subside but if you have one or more of the following, you must consult your GP:
• Regular indigestion or heartburn (occurring every week or more often)
• Symptoms persisting for more than 2 weeks and not responding to antacids
• Symptoms interfering with work, leisure and sleep
• If you are aged 50 years or over
• If you vomit, especially if blood is present in the vomit; if you have difficulty swallowing; if the pain goes through to your back; and if you are losing weight Do not continue to treat yourself if symptoms do not get better. See your doctor. What tests might the doctor do and where do I get information on these? If the doctor feels you need tests, he or she may request an ultrasound of your tummy or upper GI endoscopy or both.

Bleeding from the back passage is a common symptom and will be experienced by about a third of people in their lifetime. There are many reasons for bleeding from the anus and the most common causes are listed below.

• Haemorrhoids or piles
• Fissures or tears in the anus
• Cancer of the anus, rectum or large bowel
• Medicines such as warfarin, which thin the blood
• Diverticular disease
• Inflammatory bowel disease
• Vigorous wiping of the back passage and other injury to this area Is my bleeding due to cancer? Naturally, this is one of the commonest concerns of people who see blood in their back passage. While this symptom should be taken seriously whenever it occurs, I should point out that in most cases it is not due to cancer. By far the most common cause is piles, but this diagnosis must not be assumed until you are examined and the back passage carefully inspected. Make a note of the following features, which your doctor will be interested to know.

Blood from piles is generally bright red in colour or fresh, whereas that from cancer is darker in colour or stale. What the colour of the blood tells us is simply that the blood is coming from low down in the rectum or from the anus and that the blood vessels that are leaking are directly connected to the arteries. The arteries pump red blood containing oxygen, whereas veins carry blood which, deprived of most of its oxygen, is darker in colour. Piles or haemorrhoids are located in the anus and are fed by oxygen rich blood. However, other more serious conditions such as cancer of the anus and the lower rectum can produce bleeding of a similar character, but they are much less common than piles. Blood that has been shed higher up in the bowel is broken down by the bowel and therefore tends to be darker in colour. More serious disorders occur higher in the bowel than lower down.

Blood from piles is usually small in quantity and is seen either on the outside of the stool or on the toilet paper. Sometimes the blood drips into the toilet pan but occasionally there can be a lot of it. Of course, torrential bleeding from the back passage, whatever its cause, should be reported immediately, as if unchecked, it may be life threatening. If blood is inside the stools, the bleeding source is likely to be high up in the bowel and the blood has time to mix with the stools. Have you noticed other problems around the anus? The doctor will ask you about other symptoms: pain (sometimes due to piles but more often due to a fissure or a tear in the anus), itching, soreness, discomfort, and a lump or lumps that drop out of the back passage or hang permanently out of the anus (all also suggesting piles). What should I do if I see blood? The first point to make is that in general you should not become anxious about the cause of your bleeding, as it is usually not due to serious disease. However, you must report to your doctor within the next week or two so that you can be examined. The following features should prompt you to take bleeding from the back passage seriously, as the chances of cancer or other serious disease are higher: If you are over 60 years: - Any bleeding from the back passage, especially if it is not associated with other problems around the anus (discussed two paragraphs above).

Bleeding from the back passage and bowel symptoms such as a change in your bowel habit. Changes in bowels include going more often, the stools getting looser, or the stools getting harder and more difficult to push out. In any case, the symptoms described in the last sentence, if they persist for longer 2 or 3 weeks, whether or not they occur with bleeding, should be reported to your GP. Your GP will go over the history with you, examine you and decide whether or not to refer you to a specialist. If the nature of your bleeding is such that the GP considers your case to be urgent (because you fall into one of the categories in the above two paragraphs), he or she will refer you immediately to see a specialist in hospital. The specialist will arrange to see you within two weeks of receiving your GP's referral letter if you fall in the urgent category.

This leaflet is for adult constipation. The causes of constipation and their treatment are different in children. People vary in how often they open their bowels and surveys have shown that this is from three times a day to three times a week in the UK. The stools are solid but are soft and are easy to pass without straining. No one's bowels are absolutely regular- patients who can set Big Ben by the bowels are few and far between!

There is no absolute dividing line between normal bowels and constipation. A significant change from your normal bowel habit to one where you are going much less often, where your stools are harder than usual, or you strain to open your bowels should be considered as constipation and reported to your GP. Other symptoms that accompany constipation are a feeling of the tummy being bloated and uncomfortable and sometimes pain and bleeding when the bowels are open after straining. There may be no underlying disease to explain constipation, but diseases such as cancer should be considered. Some people are concerned when they do not open their bowels regularly that the stools could poison their body. This is not true. What are the causes of constipation not due to disease? Lack of fibre in the diet. A low fibre diet fails to provide the bulk necessary for a comfortable bowel action. Bad bowel habits. People are sometimes too busy or find it inconvenient to go to the toilet when their body tells them to go. This happens when people do shift work or do not have adequate toilet facilities. Ignoring this urge causes constipation. Poor use of the muscles that help evacuate the bowels: Bowel evacuation is a complex process requiring the coordinated use of several muscles. Some muscles contract, while other relax to help expel stools, and in some people the actions of these muscles are reversed. Problems around the anus such as painful piles and fissures can cause incoordination of the muscles of the back passage. People who are emotionally upset also tend to get constipated. Poor fluid intake: Fluids taken by mouth are important to keep the stools soft. People who do not drink much, risk becoming constipated. Inactivity: This is an important cause of constipation. Stroke, admission to hospital and a debilitating illness are some of the many factors leading to inactivity.

The most important are:

Diseases that obstruct the bowel: These include cancer, diverticular disease and inflammation due for instance to Crohn's disease. Under-active thyroid: The thyroid's secretion helps bowel muscles to work normally to expel stools. An over-active thyroid causes the opposite, namely, diarrhoea. Late stage diabetes: The persistently high levels of sugar in the blood stream lead to damage of the nerves supplying the bowel. Constipation must however not be attributed to this in a diabetic patient without further investigations. Irritable bowel syndrome: This is a disturbance of the muscles of the bowels or the nerves supplying these muscles . Pregnancy: The hormones produced during pregnancy slow down the bowels. Constipation improves in most women once the baby is delivered. Prescribed medications: A large number of medicines cause constipation. The list is too long to give here but the most common include

• Iron tablets
• Some antacids
• Some painkillers, especially those containing codeine
• Antidepressants and tranquillisers
• Some opening medicines. Paradoxically, some opening medicines, especially those containing senna, taken over a long period, cause damage to the bowel muscles and cause constipation. What should I do to keep my bowels working normally?
• Eat a high fibre diet (Information Leaflet 28) and eat regular meals.
• Always go to the toilet as soon as you feel the urge to go. Alternatively, develop a routine time when it is convenient, for instance, first thing in the morning or last thing at night.
• Increase your fluid intake. Drink 8-10 cupfuls of fluid a day.
• Be as active as possible at all times. At least 20 minutes of strenuous exercise or fast walking a day is helpful.
• Avoid laxatives.
• Make sure that there are good toilet facilities at home and at work.
• Where possible avoid medicines that cause constipation or make it worse.

You must let your GP know if despite the above measures, constipation persists for more than 2 weeks. This is particularly important if you are aged over 40 and you have symptoms such as intermittent diarrhoea, abdominal pain and bloating of the tummy. Do not resort to taking laxatives or opening medicines without advice and supervision from your doctor.

People vary in how often they open their bowels and surveys have shown that this is from three times a day to three times a week in the UK. The stools are solid but are soft and are easy to pass without straining. No one's bowels are absolutely regularpatients who can set Big Ben by the bowels are few and far between!

There is no absolute dividing line between normal bowels and diarrhoea. A significant change from your normal bowel habit to one where you are going much more often, where your stools are looser than usual or are liquid should be considered as diarrhoea and reported to your GP. A common symptom that accompanies diarrhoea is gripey abdominal pain (called colic, or a feeling of 'green apples going through').
There may be no underlying disease to explain diarrhoea, but diseases such as cancer and inflammatory bowel disease should be considered.

It is useful to divide diarrhoea into acute and chronic, as the causes are different. Acute diarrhoea comes on suddenly and lasts a short time, usually a few days. Chronic diarrhoea occurs over a long period, usually months and even years. Causes of acute diarrhoea: The main ones are

• Food poisoning.
• Gastroenteritis
• Anxiety
• Treatment with antibiotics
• Alcohol
• Travel to a new place, for instance on holiday. Causes of chronic diarrhoea
• Irritable bowel syndrome (see Information Leaflet 7).
• Inflammatory bowel disease (see Information Leaflet 15).
• Poor absorption of food: this may be due to lack of the enzymes that aid in the digestion of food, notably from the pancreas, as in chronic pancreatitis; also celiac disease, where there is an abnormality of the lining of the small bowel.
• An over-active thyroid: the hormones produced by the thyroid normally help in regulating the muscles of the bowel. An excess of these hormones leads to diarrhoea, as the bowels are pushed too hard.
• Long-standing diabetes.
• Some types of bowel cancer. Cancer high up in the large bowel can cause diarrhoea. Cancer low down in the bowel usually causes constipation. The stools held up above the obstruction are turned into liquid by bacteria, and this liquid stool leaks down to the rectum from where it is passed. This liquid stool, resulting from diarrhoea, is referred to as spurious diarrhoea.
• Following stomach operations: food goes through too quickly into the intestines when the valve at the bottom end of the stomach is removed, and does not get digested as thoroughly.
• Some drugs such as antibiotics, magnesium-containing antacids, laxatives and some medicines for blood pressure.

You must consult your GP if your diarrhoea does not settle by the end of a week. You must consult the GP earlier than this if the diarrhoea is severe and so much fluid is being lost that you are likely to be dehydrated. Dehydration is especially likely in children under the age of 2 years and in elderly people. If the liquid stools contain blood, you must consult your GP, whatever the duration of the diarrhoea. In the meantime observe the following:

• Drink plenty of fluids to ensure that you do not become dehydrated and ask your chemist about rehydration solutions. However, you must not continue to treat yourself without medical advice.
• Observe good hygiene to avoid passing infection from your stools to others Wash your hands well after using the toilet.
• Avoid preparing food for others, especially babies and old people.
• Avoid taking tablet or medicines to control diarrhoea until you have consulted your GP

Doctors now recommend high fibre diets for a variety of conditions including the following:

• Diverticular disease
• Constipation
• Some patients with irritable bowel syndrome
• Haemorrhoids or piles
• Patients recovering from major bowel surgery
• Those believed to be at risk of developing bowel cancer
• As an aid to losing weight

Fibre is quite simply that portion of food that cannot be digested. Dietary fibre is the term used to describe the amount of indigestible material in the food we eat, and this portion passes through the bowel practically unaltered.

Because fibre is not digested, it passes unchanged into the large bowel. There it absorbs water, which softens the fibre and increases its bulk. The presence of this bulk stimulates the muscles of the large bowel to push the fibre along the lower alimentary canal more smoothly and to help in its expulsion along with other food residue. Fibre also reduces the time food takes to pass through the bowel, thus reducing the time harmful substances in the food come in contact with the lining of the bowel. It reduces the pressure within the inside of the bowel, thus minimising the development of diverticular disease

The following are good sources of fibre:<

• Wholegrain cereals, for instance wholemeal bread, wholewheat pasta, brown rice, rye crispbread and wholemeal flour
• Breakfast cereals such as Branflakes, Allbran, puffed and shredded wheat and Weetabix
• Fruit - fresh (apples, pears, etc, which are best eaten with their skin), or dried (eg dates, figs, apricots and sultanas)
• Vegetables - cook so that they are still crisp
• Beans and pulses eg haricot, kidney, chickpeas, lentils