Dyspepsia (Indigestion)

Understanding digestion

Food passes down the oesophagus (gullet) into the stomach. The stomach makes acid which is not essential, but helps to digest food. After being mixed in the stomach, food passes 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 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. Various conditions cause dyspepsia.

The main symptom of dyspepsia is usually pain or discomfort in the upper abdomen. In addition, other symptoms that may also develop include: heartburn, 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.

What causes dyspepsia?

Common causes
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 recurring bouts of dyspepsia which may be due to a condition of the gut. Most cases of recurring dyspepsia are due to one of the following:

• Functional dyspepsia. This is sometimes called 'non-ulcer' 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, acid reflux, inflamed oesophagus (oesophagitis), gastritis, 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 functional dyspepsia. The cause is not clear, although infection with 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. If you could see inside your gut, an ulcer looks like a small, red crater on the inside lining of the gut. These are sometimes called peptic ulcers.
• Duodenitis (inflammation of the duodenum) - which may be mild or more severe and a precursor to an ulcer.
• Gastritis (inflammation of the 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 term gastro-oesophageal reflux disease (GORD) is a general term which 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. It commonly (but not always) causes GORD.
• Medication. Some medicines may cause dyspepsia as a side-effect.
  • Anti-inflammatory medicines are the most common culprits. These are medicines which many people take for arthritis, muscular pains, sprains, period pains, etc. 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 which sometimes cause dyspepsia, or make dyspepsia worse, include: digoxin, some 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.)
• Infection with H. pylori - see below.

H. pylori and dyspepsia
Helicobacter pylori (commonly just called H. pylori) is a bacterium (bug). It can infect the lining of the stomach and duodenum. It is one of the most common infections in the UK. More than a quarter of people in the UK become infected with H. pylori at some stage in their life. 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. However, H. pylori is the usual cause of duodenal ulcers, and a common cause of stomach ulcers. It is also thought to cause some cases of functional dyspepsia, duodenitis and gastritis. The exact way H. pylori causes ulcers and inflammation is not clear. In some way it seems to alter the protective layer of mucus that lines the stomach and duodenum which protects the underlying cells. This may allow acid to 'burn' the cells to cause inflammation and ulcers.

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

There are separate leaflets which describe most of the above conditions in more detail. The rest of this leaflet gives an overview of what might happen if you see your doctor about dyspepsia.

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. The examination is usually normal if you have one of the common causes of dyspepsia. Your doctor will want to review any medicines that you take in case one may be causing the symptoms or making them worse.

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. There are many brands which you can buy. You can also get some on prescription. If you have mild or infrequent bouts of dyspepsia you may find that antacids used 'as required' are all that you need.

A change or alteration in your current medication
If a medicine 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 functional dyspepsia.

A common test for H. Pylori is the 'stool antigen test'. In this test you give a pea-sized sample of your faeces (stools) which is tested for H. pylori. An alternative test is a 'breath test'. (A sample of your breath is analysed to detect the H. pylori bacterium after you take a special drink.)

If you are found to be infected with H. pylori then treatment may cure the symptoms. Briefly, to clear H. pylori infection it involves a short course of two antibiotics plus an acid suppressing medicine. (Another leaflet deals with the treatment of H. pylori in more detail.) It is important to take the full course exactly as prescribed for the best chance of clearing H. pylori from the gut.

If symptoms go after treating for H. pylori, then that is the end of the matter. (As no other tests are done if symptoms go, you will not know exactly what caused the symptoms - that is if you had an ulcer, or gastritis, or functional dyspepsia. But it does not matter if symptoms go as whatever was causing the symptoms will have gone!)

Trial of acid suppressing 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. H. pylori does not cause these problems.
• If infection with H. pylori has been ruled out.
• If H. pylori has been treated but symptoms persist.

There are two groups of medicines which reduce stomach acid - 'proton pump inhibitors' and 'H2 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 proton pump inhibitor (such as omeprazole, lansoprazole, pantoprazole, rabeprazole, or esomeprazole) tends to be tried first.

Reducing acid in the stomach can help in many cases of dyspepsia, whatever the underlying cause. If medication helps, then further courses may be advised if symptoms persist. Some people take acid suppressing medication 'on-demand' (that is, waiting for symptoms to develop before taking treatment). Some people take them regularly if symptoms occur each day.

Further tests
Further tests are not needed in most cases. The above options 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 the symptoms are not typical and may be coming from outside the gut. For example, to rule out problems of the gall-bladder, pancreas, liver, etc.
• If the symptoms are severe and do not respond to treatment.
• If you have a known 'risk-factor' for stomach cancer. For example, if you have Barrett's oesophagus, dysplasia, atrophic gastritis, or had ulcer surgery over 20 years ago.

Tests advised may include:

• Endoscopy (gastroscopy). In this test a doctor or nurse looks inside your oesophagus, stomach and duodenum. They do this by passing a thin, flexible telescope down your oesophagus. A separate leaflet describes endoscopy in more detail.
• 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). However, it may be enough to make you anaemic.
• Tests of the gall bladder, liver, 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
There is no clear evidence that lifestyle factors affect dyspepsia. However, some people find that some things seem to make a difference. For example:

• For dyspepsia which is likely to be due to functional dyspepsia - some people say that cutting out caffeine (found in tea, coffee, cola, etc), or spicy foods, or fatty foods seems to help. If you suspect that something is making symptoms worse, it is sensible to cut it out for a while to see if it makes any difference.
• For dyspepsia which is likely to be due to acid reflux - (when heartburn is a major symptom), the following may be worth considering.
  • Smoking. The chemicals from cigarettes relax the sphincter (the muscle that acts like a valve at the bottom of the oesophagus). This may make acid reflux more likely. If you are a smoker, symptoms may ease if you stop smoking.
  • Some foods and drinks may make reflux worse in some people. (It is thought that some foods may relax the sphincter and allow more acid to reflux.) 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 and drinks that have been suspected of making symptoms worse in some people include: peppermint, tomatoes, chocolate, spicy foods, hot drinks, coffee, and alcoholic drinks.
  • Weight. If you are overweight it puts extra pressure on the stomach and encourages acid reflux. Losing some weight may ease the symptoms.
  • 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, it may help to go 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 you raise the head of the bed by 10-15 cms (with books under the bed's legs), this will help gravity to keep acid from refluxing into the oesophagus.

© EMIS and PIP 2005   Updated: June 2005   PRODIGY Validated