Dyspepsia (Indigestion)

Comprehending digestion

Food passes down the gullet (oesophagus) into the stomach. The stomach makes acid which is not essential but helps to digest food. Food then passes gradually into the first part of the small intestine (the duodenum).

Food mixes with chemicals called enzymes in the duodenum and the rest of the small intestine. The enzymes come from the pancreas and from cells lining the intestine. The enzymes break down (digest) the food. Digested food is then absorbed into the body from the small intestine.

Knowing dyspepsia

Dyspepsia is a term which includes a group of symptoms that come from a problem in our upper gut. The gut (gastrointestinal tract) is the tube that starts at the mouth and ends at the anus. The upper gut includes the oesophagus, stomach and duodenum.

Various conditions cause dyspepsia. The main symptom is usually pain or discomfort in the upper tummy (abdomen). In addition, other symptoms that may develop include:

Belching.

Being sick (vomiting).

Quickly feeling full after eating.

Feeling sick (nausea).

Bloating.

Patients often get confused with symptoms of dypepsia abd GERD. Heartburn (a burning sensation felt in the lower chest area) and bitter-tasting liquid coming up into the back of the throat (sometimes called ‘waterbrash’) as symptoms of dyspepsia. However, these are now considered to be features of a condition called gastro-oesophageal reflux disease (GERD)

Symptoms tend to occur in bouts which come and go, rather than being present all the time. Most people have a bout of dyspepsia, often called indigestion, from time to time. For example, after a large spicy meal. In most cases it soon goes away and is of little concern. Some people however have frequent bouts of dyspepsia, which affects their quality of life.

Elements triggering dyspepsia

Common grounds

Most cases of repeated (recurring) dyspepsia are due to one of the following:

Non-ulcer dyspepsia. This is sometimes called functional dyspepsia. It means that no known cause can be found for the symptoms. That is, other causes for dyspepsia, such as duodenal or stomach ulcer, acid reflux, inflamed oesophagus (oesophagitis), gastritis, etc, are not the cause. Endoscopy has been done and the inside of our gut looks normal (if you have a test called an gastroscopy (endoscopy) – It is the most common cause of dyspepsia. About 6 in 10 people who have recurring bouts of dyspepsia have non-ulcer dyspepsia. The cause is not clear, although infection with a germ (bacterium) called Helicobacter pylori (commonly just called H. pylori) may account for some cases.

Duodenal and stomach (gastric) ulcers. An ulcer occurs when the lining of the gut is damaged and the underlying tissue is exposed. If we could see inside our gut, an ulcer looks like a small, red crater on the inside lining of the gut. These are sometimes called peptic ulcers.

Duodenitis and gastritis (inflammation of the duodenum and/or stomach) – which may be mild, or more severe and may lead to an ulcer.

Acid reflux, oesophagitis and GORD. When some acid leaks up (refluxes) into the oesophagus from the stomach, Acid reflux occurs. Acid reflux may cause oesophagitis (inflammation of the lining of the oesophagus). The general term gastro-oesophageal reflux disease (GORD) means acid reflux, with or without oesophagitis.

Hiatus hernia. This occurs when the top part of the stomach pushes up into the lower chest through a defect in the diaphragm. The diaphragm is a large flat muscle that separates the lungs from the tummy (abdomen). It helps us to breathe. A hiatus hernia commonly causes GORD.

Infection with H. pylori

ALL of above can be ruled out by simple Endoscopy

Medication. Some medicines may cause dyspepsia as a side-effect , or make dyspepsia worse. They include digoxin, steroids, iron, nitrates, bisphosphonates, theophyllines and antibiotics.

Anti – inflammatory medicines are the most common culprits. These are medicines tha tmany people take for arthritis, muscular pains, sprains, period pains, etc. For example: Ibuprofen, aspirin, & dicofenac. Anti-inflammatory medicines sometimes affect the lining of the stomach and allow acid to cause inflammation and ulcers.

H. pylori and dyspepsia

The germ (bacterium) H. pylori can infect the lining of the stomach and duodenum. It is one of the most common infections. More than a quarter of people become infected with H. pylori at some stage in their lives. Once we are infected, unless treated, the infection usually stays for the rest of our life.

Most people with H. pylori have no symptoms and do not know that they are infected. However, H. pylori is the most common cause of duodenal and stomach ulcers. About 3 in 20 people who are infected with H. pylori develop an ulcer. It is also thought to cause some cases of non-ulcer dyspepsia, duodenitis and gastritis. The exact way H. pylori causes problems in some infected people is not totally clear. In some people this bacterium causes inflammation in the lining of the stomach or duodenum. This causes the defence mucous barrier to be disrupted in some way (and in some cases the amount of acid to be increased) which seems to allow the acid to cause inflammation and ulcers.

Other uncommon elements of dyspepsia

Other problems of the upper gut such as stomach cancer and oesophageal cancer can cause dyspepsia when they first develop.

Wellness program in dyspepsia

The examination is usually normal if we have one of the common causes of dyspepsia. Review of any medicines that we have taken in case one may be causing the symptoms or making them worse. Following the initial assessment, depending on our circumstances, such as the severity and frequency of symptoms, follwing steps may be taken

Antacids taken as required

Antacids are alkali liquids or tablets that can neutralise the stomach acid. A dose may give quick relief. If we have mild or infrequent bouts of dyspepsia we may find that antacids used as required are all that we need.

A change or alteration in one’s current medication

This may be possible if a medicine that we are taking is thought to be causing the symptoms or making them worse.

Investigation for H. pylori infection and cure

A test to detect H. pylori is commonly done if we have frequent bouts of dyspepsia. As stated earlier, it is the underlying cause of most duodenal and stomach ulcers and some cases of gastritis, duodenitis and non-ulcer dyspepsia. Various tests can detect H. pylori and your doctor may suggest one:

A breath test can confirm that we have a current H. pylori infection. A sample of our breath is analysed after we have taken a special drink. We need to keep in mind that prior to this test we should not take any antibiotics for at least four weeks. Also, we should not have taken a proton pump inhibitor (PPI) or H2-receptor antagonist (also known as an H2 blocker medicine) for at least two weeks. (These are acid-suppressing medicines) Also, we should not eat anything for six hours before the test. The reason for these rules is because they can affect the test result.

An alternative test is the stool antigen test. In this test you give a pea-sized sample of the stools (faeces) which is tested for H. pylori. Here again it is important to keep in mind that prior to this test we should not have taken any antibiotics for at least four weeks. Also, we should not have taken a PPI or H2-receptor antagonist medicine for at least two weeks. (These are acid-suppressing medicines.)

A blood test can detect antibodies to H. pylori. This is sometimes used to confirm that you are, or have been, infected with H. pylori. However, it takes six months or more for this test to become negative once the infection has cleared. So, it is no use to confirm whether treatment has cleared the infection. If needed, the breath test or stool antigen test are usually used to check if an infection has cleared following treatment.

Sometimes a small sample (biopsy) of the lining of the stomach is taken if you have a gastroscopy (endoscopy). The sample can be tested for H. pylori.

If we are found to be infected with H. pylori then treatment may cure the symptoms. Briefly, to clear H. pylori infection we need to take two antibiotics at the same time. In addition, we need to take a medicine to reduce the acid in the stomach. This allows the antibiotics to work well in the stomach. We need to take this combination therapy for upto two weeks. It is important to take all the medicines exactly as directed and to take the full course.

Acid-burking medication

A one-month trial of full-dose medication which reduces stomach acid may be considered – in particular, if:

Symptoms are more suggestive of acid reflux or oesophagitis.

Infection with H. pylori has been ruled out.

H. pylori has been treated but symptoms persist.

A 4- to 8-week course of a medicine that greatly reduces the amount of acid our stomach makes is usually advised. Proton pump inhibitors (PPI) are the most commonly used medicine. These are a group (class) of medicines that work on the cells that line the stomach, reducing the production of acid. Ex: Omeprazole, Lansaprozole, Pantaprazole, Rabiprazole, Esmoprazole, Iloprazole but there lot of brand names containing same medicines.

Another calss of medicines that are used are H2 blockers.They are also called histamine H2-receptor antagonists but are commonly called H2 blockers. H2 blockers work in a different way on the cells that line the stomach, reducing the production of acid. They include Ranitidine, famotidine, cimetidine, nizatidine and they also come various brand names. As the amount of acid is greatly reduced, the ulcer usually heals.

Reducing acid in the stomach can help in many cases of dyspepsia, whatever the underlying cause may persist. If acid-suppressing medication works then symptoms should go. If symptoms return at a later date, once the medication is stopped, further courses may be advised. Many people take acid-suppressing medication as required. That is, waiting for symptoms to develop and then taking a short course of treatment to clear the symptoms. Some people take them regularly if symptoms occur each day. If this is the situation, we should aim to find the lowest dose of medication that keeps symptoms away.

Additional Investigations

Further tests are not needed in most cases. One or more of the above options will often sort the problem. Reasons why further tests may be advised include:

If additional symptoms suggest that your dyspepsia may be caused by a serious disorder such as stomach or oesophageal cancer, or a complication from an ulcer such as bleeding. For example, if you:

Feel generally unwell.

Lose weight unintentionally.

Pass blood with your stools (blood can turn your stools black)

If you have a risk factor for stomach cancer, such as Barrett’s oesophagus, dysplasia, atrophic gastritis, or had ulcer surgery over 20 years earlier.

Have difficulty swallowing (dysphagia).

Bring up (vomit) blood.

Vomit persistently.

Develop anaemia.

Have an abnormality when you are examined by a doctor, such as a lump in the abdomen.

If the symptoms are severe and do not respond to treatment.

If you are aged over 55 and develop persistent or unexplained dyspepsia.

If the symptoms are not typical and may be coming from outside the gut. For example, to rule out problems of the gallbladder, pancreas, liver, etc.

Investigations may include:

Gastroscopy (endoscopy). In this test a doctor looks inside your oesophagus, stomach and duodenum. They do this by passing a thin, flexible telescope down your oesophagus. See separate leaflet called Gastroscopy (Endoscopy) for more detail.

A blood test to check anaemia. If you are anaemic, it may be due to a bleeding ulcer, or to a bleeding stomach cancer. You may not notice the bleeding if it is not heavy, as the blood is passed out unnoticed in your stools.

Tests of the gallbladder, pancreas, etc, if the cause of the symptoms is not clear.

Treatment depends on what is found or ruled out by the tests.

A relook at Lifestyle

For all types of dyspepsia, following lifestyle changes are recommended-

Making sure of eating regular meals.

Losing weight if we are obese.

Considering giving up smoking if one is a smoker

Not drinking too much alcohol.

For dyspepsia which is likely to be due to acid reflux – when heartburn is a major symptom – the following may also be worth considering:

Posture. Lying down or bending forward a lot during the day encourages reflux. Sitting hunched or wearing tight belts may put extra pressure on the stomach, which may make any reflux worse.

Bedtime. If symptoms recur most nights, the following may help:

Going to bed with an empty, dry stomach. To do this, don’t eat in the last three hours before bedtime and don’t drink in the last two hours before bedtime.

If one is able, one should try raising the head of the bed by 10-20 cms (for example, withbooks or bricks under the bed’s legs). This helps gravity to keep acid from refluxing into the oesophagus. If we do this, we should not use additional pillows, because this may increase abdominal pressure.​

CONCLUSION:

Pain and sometimes other symptoms which come from one’s upper gut (the stomach, oesophagus or duodenum) is termed as Dyspepsia (indigestion). Majority of times symtoms settlle with medications. Depending on age, symptoms and response to treatment further tests will be necessary.