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Dyspepsia (Indigestion)

dyspepsia

Dyspepsia (indigestion) is a term which describes pain and sometimes other symptoms which come from your upper gut (the stomach, oesophagus or duodenum). There are various causes (described below). Treatment depends on the likely cause.

Understanding digestion

Food passes down the oesophagus (food pipe) into the stomach. The stomach makes acid , which helps to digest food. Food then passes gradually into the duodenum (the first part of the small intestine).In the duodenum and the rest of the small intestine, food mixes with enzymes (chemicals). 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.

What are symptoms of dyspepsia?

 The main symptom is usually pain or discomfort in the upper abdomen.

  • Heartburn (a burning sensation felt in the lower chest area),
  • Bloating, belching, quickly feeling full after eating, feeling sick (nausea) or vomiting
  • 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. However, some people have frequent bouts of dyspepsia, which affects their quality of life.

What causes dyspepsia?

Common causes

Most cases of 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.It is the most common cause of dyspepsia. The cause is not clear, although infection with a bacterium (germ) called Helicobacter pylori (commonly just called H. pylori) may account for some cases (see below).

Duodenal and stomach (gastric) ulcers. An ulcer is where the lining of the gut is damaged and the underlying tissue is exposed. I. These are sometimes called peptic ulcers. See separate leaflets called 'Duodenal Ulcer' and 'Stomach (Gastric) Ulcer' for more detail.

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

Acid reflux, oesophagitis and GORD. Acid reflux is when some acid leaks up (refluxes) into the oesophagus from the stomach. 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 is where 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 abdomen. It helps us to breathe. A hiatus hernia commonly causes GORD. See separate leaflet called 'Hiatus Hernia' for more detail.

Infection with H. pylori - see below.

Some medicines may cause dyspepsia as a side-effect. Anti-inflammatory medicines are the most common culprits. For example: aspirin, ibuprofen, and diclofenac - but there are others. Anti-inflammatory medicines sometimes affect the lining of the stomach and allow acid to cause inflammation and ulcers.

Various other medicines sometimes cause dyspepsia, or make dyspepsia worse. They include: digoxin, antibiotics, steroids, iron, calcium antagonists, nitrates, theophyllines, bisphosphonates.

(Note: this is not a full list. Check with the leaflet that comes with your medication for a list of possible side-effects.)

H. pylori and dyspepsia

The bacterium (germ) H. pylori can infect the lining of the stomach and duodenum.. Once you are infected, unless treated, the infection usually stays for the rest of your life.Most people with H. pylori have no symptoms and do not know that they are infected. 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.. Other uncommon causes of dyspepsia.

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

What is normally done if you develop dyspepsia?

Your doctor is likely to do an initial assessment by asking you about your symptoms and examining your abdomen. Following the initial assessment, depending on your circumstances, such as the severity and frequency of symptoms, your doctor may suggest one or more of the following plans of action.

Antacids taken as required-Antacids are alkali liquids or tablets that can neutralise the stomach acid. A dose may give quick relief.

A change or alteration in your current medication.

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

Test for H. pylori infection and treat if it is present.

A test to detect H. pylori is commonly done if you have frequent bouts of dyspepsia. As mentioned, 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 you have a current H. pylori infection.

An alternative test is the stool antigen test.

A blood test can detect antibodies to H. pylori.

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

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

Note: after combination therapy, a test may be advised to check that H. pylori has gone (has been eradicated). This test will usually be a breath test or a stool antigen test (described earlier). it has not gone, and you still have symptoms, then a repeat course of combination therapy with a different set of antibiotics may be advised.

Acid-suppressing medication

Reducing acid in the stomach can help in many cases of dyspepsia, whatever the underlying cause. If acid-suppressing medication works, then symptoms should go. If symptoms return at a later date, once the medication is stopped, then further courses may be advised.

There are two groups of medicines which reduce stomach acid - proton pump inhibitors (PPIs) and H2-receptor antagonists. They work in different ways to block the cells in the stomach lining from making acid. There are several brands in each group. A PPI (such as omeprazole, lansoprazole, pantoprazole, rabeprazole, or esomeprazole) is usually better and is normally tried first.

Further tests

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:

  • Pass blood with your faeces (blood can turn your faeces black).
  • Vomit blood.
  • Lose weight unintentionally.
  • Feel generally unwell.
  • Have difficulty swallowing (dysphagia).
  • Vomit persistently.
  • Develop anaemia.
  • Have an abnormality when you are examined by a doctor, such as a lump in the abdomen.
  • 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.
  • If the symptoms are severe and do not respond to treatment.
  • 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.

Tests advised may include:

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

A blood test to check for 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 faeces (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.

Lifestyle changes

  • Make sure you eat regular meals.
  • Lose weight if you are obese.
  • Stop smoking
  • Don't drink 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:
  • Don’t eat in the last three hours before bedtime, and don't drink in the last two hours before bedtime.
  • If you are able, try raising the head of the bed by 10-20 cms (for example, with books or bricks under the bed's legs). This helps gravity to keep acid from refluxing into the oesophagus. If you do this, do not use additional pillows, because this may increase abdominal pressure.

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