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

The upper gut

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).

In the duodenum and the rest of the small intestine, food mixes with chemicals called enzymes. 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 (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:

  • Quickly feeling full after eating.
  • Feeling sick (nausea).
  • Being sick (vomiting).

Symptoms are often related to eating. Doctors used to include 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 (GORD) – see below.

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 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.
  • Duodenal and stomach (gastric) ulcers. An ulcer occurs when the lining of the gut is damaged and the underlying tissue is exposed. See the separate leaflets called Duodenal Ulcerand Stomach Ulcer (Gastric Ulcer) for more detail.
  • 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. Acid reflux occurs when some acid leaks up (refluxes) into the oesophagus from the stomach.
  • Hiatus hernia. This occurs when the top part of the stomach pushes up into the lower chest through a defect in the diaphragmInfection with Helicobacter pylori (H. pylori)– see below.
  • Medication. Some medicines may cause dyspepsia as a side-effect:
    • Anti-inflammatory medicinesare the most common culprits. These are medicines that 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 medicinessometimes cause dyspepsia, or make dyspepsia worse. They include: digoxin, antibiotics, steroids, iron, calcium antagonists, nitrates and bisphosphonates.
      (Note: this is not a full list. Check with the leaflet that comes with your medication for a list of possible side-effects.)
  1. pyloriand dyspepsia

The germ (bacterium) H. pylori 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 lives. 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 most common cause of duodenal and stomach ulcers.

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.

There are separate leaflets which describe 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 tummy (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 have taken 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.

Lifestyle changes

For all types of dyspepsia, the National Institute for Health and Care Excellence (NICE) recommends the following lifestyle changes:

  • Make sure you eat regular meals.
  • Lose weight if you are obese.
  • If you are a smoker, consider giving up.
  • 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 return most nights, the following may help:
    • 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 are able, try raising the head of the bed by 10-20 cm (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.

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 obtain 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

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.

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.  pyloridoes not cause these problems.
  • Infection with  pylorihas been ruled out.
  • pylorihas been treated but symptoms persist.

Further tests

Further tests are not needed in most cases. One or more of the above options will often sort out 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 stools (blood can turn your stools black).
    • Bring up (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 or nurse looks inside your oesophagus, stomach and duodenum. They do this by passing a thin, flexible telescope down your oesophagus.
  • 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 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.

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