Non-ulcer (Functional) Dyspepsia

Understanding digestion

What is dyspepsia?

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

The main symptom of dyspepsia is usually pain or discomfort in the upper abdomen. In addition, other symptoms that may also develop include: heartburn (a burning sensation felt in the lower chest area), bloating, belching, quickly feeling 'full' after eating, feeling sick (nausea) or vomiting. Symptoms are often related to eating. Symptoms tend to occur in 'bouts' which come and go, rather than being present all the time. However, some people have frequent bouts of dyspepsia which affects quality of life.

What is non-ulcer dyspepsia?

Non-ulcer dyspepsia 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 ulcer, stomach ulcer, oesophagitis (inflamed oesophagus), gastritis (inflammed stomach), etc, are not the cause. The inside of your gut looks normal (if you have an endoscopy - see below). It is the most common cause of dyspepsia. About 6 in 10 people who have recurring bouts of dyspepsia have non-ulcer dyspepsia.

What causes non-ulcer dyspepsia?

The symptoms seem to come from the upper gut, but the cause is not known. If you have tests, nothing abnormal is found inside your gut. The lining inside your gut looks normal and is not inflamed. The amount of acid in the stomach is normal.

The following are some theories as to possible causes:

• Sensation in the stomach or duodenum may be altered in some way - an 'irritable stomach'. About 1 in 3 people with non-ulcer dyspepsia also have 'irritable bowel syndrome' and have additional symptoms of lower abdominal pains, erratic bowel movements, etc. The cause of irritable bowel syndrome is not known.
• A delay in emptying the stomach contents into the duodenum may be a factor in some cases. The muscles in the stomach wall may not work as well as they should.
• Infection with a bacterium (germ) called H. pylori may cause some cases. This bacterium is found in the stomach in some people with non-ulcer dyspepsia. However, many people are 'carriers' of this bacterium, and it causes no symptoms in most people. The role of H. pylori is controversial in non-ulcer dyspepsia (although it is the main cause of duodenal and stomach ulcers). However, getting rid of H. pylori infection helps in some cases.
• Some people feel that certain foods and drinks may cause the symptoms or make them worse. It is difficult to prove this. Foods and drinks that have been suspected of causing symptoms or making symptoms worse in some people include: peppermint, tomatoes, chocolate, spicy foods, hot drinks, coffee, and alcoholic drinks. However, food is not thought to be a major factor in most cases.
• Anxiety, depression, or stress are thought to make symptoms worse in some cases.
• A side-effect of some drugs can cause dyspepsia. The most common culprits are anti-inflammatory drugs such as ibuprofen and aspirin. Various other drugs which sometimes cause dyspepsia, or make dyspepsia worse, include: antibiotics, steroids, iron, calcium antagonists, nitrates, theophyllines, bisphosphonates. (Note: this is not an exhaustive list. Check with the leaflet that comes with your medication for a list of possible side-effects.) If you suspect a prescribed drug is causing the symptoms, or making them worse, then see your doctor to discuss possible alternatives.

What tests may be done?

Strictly speaking, non-ulcer dyspepsia is a diagnosis that is made only when no other cause can be found for the symptoms (such as an ulcer). Therefore, prior to the diagnosis being made you may have had an endoscopy. In this test a doctor looks inside your stomach and duodenum by passing a thin, flexible telescope down your oesophagus. If you have non-ulcer dyspepsia, the inside of your gut looks normal. However, most people with dyspepsia do not have an endoscopy. See separate leaflet called 'Dyspepsia (Indigestion)' for an overview of dyspepsia, and when tests are advised.

A test to detect the H. pylori bacterium may be done. If H. pylori is found then it may be causing the symptoms. See separate leaflet called 'Helicobacter Pylori & Stomach Pain' for more details about H. pylori and how it can be diagnosed. Briefly, it can be detected in a sample of faeces, or in a 'breath test', or from a blood test, or from a biopsy sample taken during an endoscopy.

What are the treatment options for non-ulcer dyspepsia?

Reassurance and explanation

This is often helpful. Some people worry that they may have a serious disease such as stomach cancer. Worry and anxiety can make symptoms worse. It may be useful to know that you have non-ulcer dyspepsia, and not some other disease. However, you will have to accept that pain, discomfort and other 'dyspeptic' symptoms are likely to 'come and go'.

Clearing H. pylori infection

If you are infected with H. pylori, the first treatment usually tried is to clear the H. pylori infection. However, as mentioned, infection with H. pylori is probably a coincidence rather than a cause in most cases of non-ulcer dyspepsia. For example, one study found that only about 1 in 15 people with non-ulcer dyspepsia who were infected with H. pylori were cured by clearing H. pylori. Another leaflet deals with the treatment of H. pylori. Briefly, it involves a one week course of two antibiotics plus an acid suppressing drug.

Acid suppressing drugs

A one month trial of medication that reduces stomach acid is often advised. This helps in some cases, but not all. It may work because the lining of your stomach may be extra sensitive to the acid. Or, it may work because you may have very mild inflammation in your stomach that 'comes and goes', but is never found if you have an endoscopy test to look into your stomach.

There are two groups of drugs that reduce stomach acid - 'proton pump inhibitors (PPIs)' and 'H2 blockers'. They work in different ways but both reduce (suppress) the amount of acid that the stomach makes. Proton pump inhibitors include: omeprazole, lansoprazole, pantoprazole, rabeprazole, and esomeprazole. H2 blockers include: cimetidine, famotidine, nizatidine, and ranitidine. There are several brands in each group.

If medication helps, then further courses may be advised if symptoms persist. Many people take acid suppressing medication 'as required'. That is, waiting for symptoms to develop before taking a short course of treatment. Some people take acid suppressing medication regularly if symptoms occur each day.

Prokinetic medicines

These include drugs called domperidone and metoclopramide. They help to speed up the passage of food through the stomach and may help with symptoms of bloating and feeling sick. There has been little research done to prove how effective these drugs are for non-ulcer dyspepsia, but one may be worth a try if other treatments do not help.

Lifestyle changes

There is no clear evidence that lifestyle factors affect dyspepsia. However, some people find that some things seem to make a difference. For example:

• Some foods may make symptoms worse in some people. It is difficult to be certain how much foods contribute. Let common sense be your guide. If it seems that a food is causing symptoms, then try avoiding it for a while to see if symptoms improve. Foods that have been suspected of making symptoms worse are listed earlier.
• Smoking. Some smokers find that symptoms improve if they give up smoking.
• Weight. If you are overweight then losing some weight may ease the symptoms.

What is the outlook (prognosis)?

Symptoms of non-ulcer dyspepsia tend to come and go. You are likely to have times when symptoms go completely, and times where they are troublesome. Non-ulcer dyspepsia does not lead to cancer or other serious illnesses.