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What is dyspepsia

Dyspepsia also called indigestion or an upset stomach — is a general term that describes discomfort or pain in your upper middle part of abdomen (mid upper abdomen). Heartburn and acid reflux are the same thing – when acid from your stomach comes up your throat. You’ll have a burning feeling when this happens. This can be a symptom of indigestion. The pain might come and go, but it’s usually there most of the time. Dyspepsia can be associated with any other upper gastrointestinal symptom such as epigastric fullness, nausea, vomiting, or heartburn, provided epigastric pain is the patient’s primary concern 1). The pain typically worsens when you are lying down or bending over. Functional dyspepsia refers to patients with dyspepsia where endoscopy (and other tests where relevant) has ruled out organic pathology that explains the patient’s symptoms.

People of any age can get dyspepsia. Both men and women get it. About 1 of every 4 persons gets dyspepsia at some time.

Indigestion is not a disease, but rather some symptoms you experience, including abdominal pain and a feeling of fullness soon after you start eating. Although indigestion is common, each person may experience indigestion in a slightly different way. Symptoms of indigestion may be felt occasionally or as often as daily.

How to tell if you have indigestion (dyspepsia)

You can have the following symptoms after eating or drinking:

  • Heartburn – a painful burning feeling in the chest, often after eating
  • Feeling full and bloated
  • Feeling sick
  • Belching and farting
  • Bringing up food or bitter tasting fluids
  • A gnawing or burning stomach pain
  • Bloating
  • Nausea (upset stomach)
  • Vomiting
  • Burping

Indigestion can be a symptom of another digestive disease. Indigestion that isn’t caused by an underlying disease may be eased with lifestyle changes and medication. Dyspepsia that is mild and occasional can usually be managed with lifestyle changes and over-the-counter medications. In more serious cases, other treatment may be needed.

A systematic review 2) reported that ~20% of the population has symptoms of dyspepsia globally. Dyspepsia is more common in women, smokers, and those taking non-steroidal anti-inflammatory drugs 3). Patients with dyspepsia have a normal life expectancy 4), however, symptoms negatively impact on quality of life 5) and there is a significant economic impact to the health service and society 6). Dyspepsia is estimated to cost the US health care service over $18 billion per annum 7) and societal costs are likely to be double this 8) with 2–5% 9) having time off work because of symptoms.

When to see a doctor

Mild indigestion is usually nothing to worry about. Consult your doctor if discomfort persists for more than two weeks.

Contact your doctor right away if pain is severe or accompanied by:

  • If you are 55 or over
  • Unintentional weight loss or loss of appetite
  • Difficulty swallowing (dysphagia)
  • Repeated vomiting or vomiting with blood
  • Black, tarry stools
  • Trouble swallowing that gets progressively worse
  • Fatigue or weakness, which may indicate anemia

Seek immediate medical attention if you have:

  • Shortness of breath, sweating or chest pain radiating to the jaw, neck or arm
  • Chest pain on exertion or with stress

These symptoms can be a sign of something more serious.

What causes indigestion

Indigestion has many possible causes. Often, indigestion is related to lifestyle and may be triggered by food, drink or medication.

Often, dyspepsia is caused by a stomach ulcer or acid reflux disease. If you have acid reflux disease, stomach acid backs up into your esophagus (the tube leading from your mouth to your stomach). This causes pain in your chest. Your doctor may do some tests to find out if you have an ulcer or acid reflux disease. Some medicines, like anti-inflammatory medicines, can cause dyspepsia. Sometimes no cause of dyspepsia can be found.

Table 1. Differential Diagnosis of Dyspepsia

Diagnostic categoryApproximate prevalence*

Functional (nonulcer) dyspepsia

Up to 70 percent

Peptic ulcer disease

15 to 25 percent

Reflux esophagitis

5 to 15 percent

Gastric or esophageal cancer

< 2 percent

Abdominal cancer, especially pancreatic cancer

Rare

Biliary tract disease

Rare

Carbohydrate malabsorption (lactose, sorbitol, fructose, mannitol)

Rare

Gastroparesis

Rare

Hepatoma

Rare

Infiltrative diseases of the stomach (Crohn disease, sarcoidosis)

Rare

Intestinal parasites (Giardia species, Strongyloides species)

Rare

Ischemic bowel disease

Rare

Medication effects

Rare

Metabolic disturbances (hypercalcemia, hyperkalemia)

Rare

Pancreatitis

Rare

Systemic disorders (diabetes mellitus, thyroid and parathyroid disorders, connective tissue disease)

Rare


*—Based on the occurrence of the disorders in patients with dyspepsia who are evaluated with endoscopy.

[Source 10)]

Table 2. Agents Commonly Associated with Dyspepsia

Acarbose (Precose)

Alcohol

Antibiotics, oral (e.g., erythromycin)

Bisphosphonates

Corticosteroids (e.g., prednisone)

Herbs (e.g., garlic, ginkgo, saw palmetto, feverfew, chaste tree berry, white willow)

Iron

Metformin (Glucophage)

Miglitol (Glyset)

Nonsteroidal anti-inflammatory drugs, including cyclooxygenase-2 inhibitors

Opiates

Orlistat (Xenical)

Potassium chloride

Theophylline

[Source 11)]

Common causes of indigestion include:

  • Overeating or eating too quickly
  • Fatty, greasy or spicy foods
  • Too much caffeine, alcohol, chocolate or carbonated beverages
  • Smoking
  • Anxiety
  • Certain antibiotics, pain relievers and iron supplements

Sometimes indigestion is caused by other digestive conditions, including:

  • Gastritis
  • Peptic ulcers
  • Celiac disease
  • Gallstones
  • Constipation
  • Pancreas inflammation (pancreatitis)
  • Stomach cancer
  • Intestinal blockage
  • Reduced blood flow in the intestine (intestinal ischemia)

Indigestion with no obvious cause is known as functional or nonulcer dyspepsia.

Common triggers for dyspepsia

Some people experience dyspepsia regardless of what they eat. Others find they only get it after eating certain foods or meals. Common triggers for indigestion include:

  • large meals
  • fatty or spicy foods
  • coffee and cola drinks
  • citrus foods
  • alcohol
  • chocolate
  • cigarettes
  • peppermints.

Other things that can increase your risk of dyspepsia are:

  • being overweight or obese
  • being pregnant
  • taking certain medications (check with your doctor).
  • eating a large meal
  • exercising too soon after eating

Indigestion complications

Although indigestion doesn’t usually have serious complications, it can affect your quality of life by making you feel uncomfortable and causing you to eat less. You might miss work or school because of your symptoms. When indigestion is caused by an underlying condition, that condition can also have its own complications.

Sometimes dyspepsia can be the sign of a serious problem–for example, a deep stomach ulcer. Rarely, dyspepsia is caused by stomach cancer. If you have dyspepsia, talk to your family doctor. This is especially important if any one of the following is true for you:

  • You’re older than 50 years of age
  • You recently lost weight without trying to
  • You have trouble swallowing
  • You have severe vomiting
  • You have black, tarry bowel movements

Indigestion symptoms

People with indigestion may have one or more of the following symptoms:

  • Early fullness during a meal. You haven’t eaten much of your meal, but you already feel full and may not be able to finish eating.
  • Uncomfortable fullness after a meal. Fullness lasts longer than it should.
  • Discomfort in the upper abdomen. You feel a mild to severe pain in the area between the bottom of your breastbone and your navel.
  • Burning in the upper abdomen. You feel an uncomfortable heat or burning sensation between the bottom of your breastbone and your navel.
  • Bloating in the upper abdomen. You feel an uncomfortable sensation of tightness.
  • Nausea. You feel as though you want to vomit.

Less frequent symptoms include vomiting and belching.

Sometimes people with indigestion also experience heartburn, but heartburn and indigestion are two separate conditions. Heartburn is a pain or burning feeling in the center of your chest that may radiate into your neck or back during or after eating.

Dyspepsia diagnosis

Your doctor is likely to start with a health history and a thorough physical exam. Those evaluations may be sufficient if your indigestion is mild and you’re not experiencing certain symptoms, such as weight loss and repeated vomiting.

But if your indigestion began suddenly, and you are experiencing severe symptoms or are older than age 55, your doctor may recommend:

  • Laboratory tests, to check for thyroid problems or other metabolic disorders.
  • Breath and stool tests, to check for Helicobacter pylori (H. pylori), the bacterium associated with peptic ulcers, which can cause indigestion. H. pylori testing is controversial because studies suggest limited benefit from treating the bacterium.
  • Endoscopy, to check for abnormalities in your upper digestive tract. A tissue sample (biopsy) may be taken for analysis.
  • Imaging tests (X-ray or CT scan), to check for intestinal obstruction.

In an endoscopy, a small tube with a camera inside it is put into your mouth and down into your stomach. Then your doctor can look inside your stomach to try to find a cause for your pain.

  • You still have stomach pain after you take a dyspepsia medicine for 8 weeks.
  • The pain goes away for a while but comes back again.

If initial testing fails to provide a cause, your doctor may diagnose functional dyspepsia.

Figure 1. Evaluation and Management of Dyspepsia

How to get rid of indigestion

Your treatment will depend on what is causing your dyspepsia, but medicine is the most common treatment. If you have a stomach ulcer, it can be cured. You may need to take an acid-blocking medicine. If you have an infection in your stomach, you may also need to take an antibiotic. If your doctor thinks that a medicine you’re taking causes your dyspepsia, you might take another medicine. A medicine that cuts down on the amount of acid in your stomach might help your pain. This medicine can also help if you have acid reflux disease. Your doctor might want you to have an endoscopy if:

 

Lifestyle changes may help ease indigestion. Your doctor may recommend:

  • Avoiding foods that trigger indigestion
  • Eating five or six small meals a day instead of three large meals
  • Reducing or eliminating the use of alcohol and caffeine
  • Avoiding certain pain relievers, such as aspirin, ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve)
  • Finding alternatives for medications that trigger indigestion
  • Controlling stress and anxiety
  • Cut down on tea, coffee, cola or alcohol.

If your indigestion persists, medications may help. Over-the-counter antacids are generally the first choice. If you are pregnant, check with your doctor or pharmacist if these medications are safe for you to take.

Pregnant women often get indigestion. It’s very common from 27 weeks onwards.

It can be caused by hormonal changes and the growing baby pressing against the stomach.

A pharmacist can help with uncomfortable feelings or pain. They can recommend the best medicines to use when you’re pregnant.

Other options include:

  • Proton pump inhibitors (PPIs), which can reduce stomach acid. PPIs may be recommended if you experience heartburn along with indigestion.
  • H-2-receptor antagonists (H2RAs), which can also reduce stomach acid.
  • Prokinetics, which may be helpful if your stomach empties slowly.
  • Antibiotics, if H. pylori bacteria are causing your indigestion.
  • Antidepressants or anti-anxiety medications, which may ease the discomfort from indigestion by decreasing your sensation of pain.

The medicines for dyspepsia most often have only minor side effects that go away on their own. Some medicines can make your tongue or stools black. Some may cause headaches, nausea or diarrhea. If you have side effects that make it hard for you to take medicine for dyspepsia, talk to your family doctor. Your doctor may have you take a different medicine or may suggest something you can do to make the side effects less bothersome. Remember to take medicines just the way your doctor tells you. If you need to take an antibiotic, take all of the pills, even when you start feeling better.

Home remedies for indigestion

You can do quite a bit to help yourself feel better:

  • If you smoke, stop smoking.
  • Losing weight, if you are overweight.
  • If some foods bother your stomach, try to avoid eating them.
  • Try to reduce the stress in your life.
  • If you have acid reflux, don’t eat right before bedtime.
  • Raising the head of your bed with blocks under two legs may also help.
  • Unless your doctor tells you otherwise, don’t take a lot of anti-inflammatory medicines like ibuprofen (one brand: Motrin), aspirin, naproxen (brand name: Aleve) and ketoprofen (brand name: Orudis). Acetaminophen (brand name: Tylenol) is a better choice for pain, because it doesn’t hurt your stomach.

Mild indigestion can often be helped with lifestyle changes, including:

  • Eating smaller, more-frequent meals. Chew your food slowly and thoroughly.
  • Avoiding triggers. Fatty and spicy foods, processed foods, carbonated beverages, caffeine, alcohol, and smoking can trigger indigestion.
  • Maintaining a healthy weight. Excess pounds put pressure on your abdomen, pushing up your stomach and causing acid to back up into your esophagus.
  • Exercising regularly. Exercise helps you keep off extra weight and promotes better digestion.
  • Managing stress. Create a calm environment at mealtime. Practice relaxation techniques, such as deep breathing, meditation or yoga. Spend time doing things you enjoy. Get plenty of sleep.
  • Changing your medications. With your doctor’s approval, stop or cut back on pain relievers or other medications that may irritate your stomach lining. If that’s not an option, be sure to take these medications with food.

Alternative medicine

Alternative and complementary treatments may help ease indigestion, although none of these treatments has been well-studied. These treatments include:

  • Herbal therapies such as peppermint and caraway.
  • Psychological treatment, including behavior modification, relaxation techniques, cognitive behavioral therapy and hypnotherapy.
  • Acupuncture, which may work by blocking the pathways of nerves that carry sensations of pain to the brain.
  • Mindfulness meditation.
  • STW 5 (Iberogast), a liquid supplement that contains extracts of herbs including bitter candytuft, peppermint leaves, caraway and licorice root. STW 5 may work by reducing the production of gastric acid.

Always check with your doctor before taking any supplements to be sure you’re taking a safe dose and that the supplement won’t adversely interact with any other medications you’re taking.

What is functional dyspepsia

There is no definitive pathophysiologic mechanism for functional dyspepsia, which suggests that it is a heterogeneous group of disorders. Patients with functional dyspepsia commonly have coexisting symptoms of irritable bowel syndrome or other functional gastrointestinal tract disorders 12). In one 10-year follow-up study of patients with dyspepsia or irritable bowel syndrome, 40 percent of symptomatic patients switched subgroups over the study period 13).

Several studies implicate gastric dysmotility in the pathophysiology of functional dyspepsia 14). Many patients experience motility-related symptoms, such as bloating, early satiation, nausea, and vomiting. Studies have documented altered gastric motility (e.g., gastroparesis, gastric dysrhythmias, abnormal fundus accumulation, pyloric sphincter dysfunction) in up to 80 percent of patients with functional dyspepsia 15). However, the degree of dysmotility does not correlate with symptoms 16).

Because many patients with functional dyspepsia have burning pain that is indistinguishable from ulcer-related dyspepsia, the relationship between functional dyspepsia and acid secretion is unclear. One study demonstrated a lower pH level in the duodenum of patients with functional dyspepsia compared with those in the control group, although the pH level did not correlate with symptoms 17). The role of Helicobacter pylori infection in functional dyspepsia has also been investigated. Large population studies have shown an increased incidence of H. pylori infection in patients with functional dyspepsia; however, given the high incidence of both conditions in the general population and the minimal response to treatment, the significance of the association is unclear 18). In spite of this uncertainty, testing for and treating H. pylori infection have become integral to the diagnostic management of functional dyspepsia.

Diagnostic Criteria for Functional Dyspepsia

Presence of at least one of the following:

  • Bothersome postprandial fullness
  • Early satiation
  • Epigastric pain
  • Epigastric burning

and

  • No evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms.

Functional dyspepsia diagnosis

Functional dyspepsia is a diagnosis of exclusion; therefore, physicians should focus on excluding serious or specifically treatable diseases, without spending too much time investigating symptoms. Dyspepsia has a broad and diverse differential diagnosis (Table 1 above), including functional dyspepsia, peptic ulcer disease, reflux esophagitis, and gastric or esophageal malignancy. Functional dyspepsia is the most prevalent diagnosis, making up 70 percent of dyspepsia cases 19).

The physician should perform a detailed history and physical examination at the initial presentation, noting any findings that point to a diagnosis other than functional dyspepsia (e.g., right upper-quadrant pain with cholelithiasis, exercise association with coronary artery disease, radiation to the back with pancreatitis). Table 2 includes medications and other agents commonly associated with dyspepsia 20). Because the differential diagnosis is broad, the workup can range from empiric therapy to extensive laboratory and imaging studies. Figure 1 is an algorithm for the evaluation and treatment of patients with dyspepsia 21).

Several strategies have been suggested for initial management of uninvestigated dyspepsia, including a trial of acid suppressants, a test-and-treat approach (for H. pylori infection), and early endoscopy. A Cochrane review found that in the absence of warning signs for serious disease, a test-and-treat strategy is effective and cheaper than initial endoscopy 22). Initial endoscopy has been shown to provide a small reduction in the risk of recurrent dyspepsia symptoms; however, physicians need to weigh the cost of endoscopy against patient preference for early reassurance and symptom reduction 23). The Cochrane review showed the test-and-treat strategy to be slightly more effective than empiric acid suppressants, although the comparative cost-effectiveness of these strategies has not been established 24). Physicians can diagnose H. pylori infection with noninvasive tests, such as serologic, stool antigen, or urea breath tests. Serologic testing is the most common because of its wide availability and low cost, although urea breath testing is more accurate 25).

In patients 55 years or younger, the American Gastroenterological Association 26) identifies several warning signs that should trigger an early, aggressive workup (e.g., unintended weight loss, progressive dysphagia, persistent vomiting, evidence of GI bleeding, family history of cancer). The American Gastroenterological Association recommends proceeding directly to endoscopy in patients with warning signs and in those older than 55 years 27); however, there has been debate about a lower cutoff age of 35 to 45 years in men 28). Although it is not addressed in the American Gastroenterological Association guidelines, an initial complete blood count may be appropriate to screen for anemia. The American Gastroenterological Association guidelines do not address laboratory testing and imaging; however, it is reasonable to consider these approaches in patients with negative esophagogastroduodenoscopy findings and warning signs, or if the treatment course is unsuccessful.

Indigestion remedies

Treatment of functional dyspepsia can be frustrating for physicians and patients because few treatment options have proven effective. Patients will need continued reassurance and support from their physicians. Treatment is generally aimed at one of the presumed underlying etiologies of functional dyspepsia.

Gastric acid suppression

Gastric acid suppressants have been studied extensively in the treatment of functional dyspepsia. Although their benefit in patients with ulcer-related dyspepsia or gastroesophageal reflux disease is considerable, the benefit in patients with functional dyspepsia is less clear. Antacids, sucralfate (Carafate), and misoprostol (Cytotec) have been evaluated in limited studies without evidence of benefit 29). Bismuth salts showed some benefit compared with placebo in a meta-analysis; however, the studies that showed benefit were not well designed and involved only patients with H. pylori infection, with intent to eradicate the infection. Because of the questionable benefit and long-term risk of neurotoxicity, bismuth salts cannot be recommended as first-line agents for functional dyspepsia 30).

Histamine H2 blockers are more promising agents for treating functional dyspepsia and have been evaluated in multiple trials. A meta-analysis concluded that H2 blockers significantly improve symptoms; however, there was evidence of some publication bias, and the effect may have been overestimated, especially in comparison with proton pump inhibitors 31). Studies of proton pump inhibitors have shown a statistically significant improvement in symptoms of functional dyspepsia compared with placebo. These studies were of better quality than those investigating H2 blockers, making it difficult to compare relative effectiveness 32). Given the small benefit of gastric acid suppressants and the commonly chronic nature of functional dyspepsia symptoms, physicians must consider the cost and long-term safety profile of the medication chosen for initial treatment.

Prokinetics

Many patients with functional dyspepsia report predominant symptoms of bloating, early satiation, nausea, and vomiting. As a result, physicians have tried targeting treatment at improving GI motility. Multiple randomized controlled trials have demonstrated that prokinetic agents are effective in treating functional dyspepsia 33). One study has shown that domperidone is effective for functional dyspepsia 34). Domperidone is relatively safe, but has not been approved for use in the United States.

The only available prokinetic agents in the United States are metoclopramide (Reglan) and erythromycin, for which the evidence is sparse. Metoclopramide may cause tardive dyskinesia and parkinsonian symptoms in older persons, limiting its use 35). Erythromycin has some prokinetic effects and is used to treat gastroparesis. However, erythromycin has not been studied as a treatment for functional dyspepsia, so its effectiveness is unknown. There is some initial evidence to suggest that herbal formulations containing peppermint improve functional dyspepsia symptoms, possibly through effects on the smooth muscle of the intestines 36). However, peppermint formulations available in the United States have not been well studied, and more research is needed.

H. pylori eradication

H. pylori eradication may be beneficial as an initial strategy for management of uninvestigated dyspepsia before endoscopy. Several meta-analyses have examined eradication therapy in patients with endoscopically confirmed functional dyspepsia.19 Although there have been some discrepancies between studies, the most recent meta-analysis showed a small but statistically significant improvement in functional dyspepsia symptoms with H. pylori eradication 37). The number needed to treat for one patient to have relief of symptoms is 15. It is not known whether this strategy is cost-effective 38).

Psychotropic and Psyhological Interventions

Because of the high rate of coexisting depression and psychiatric illness in patients with refractory functional dyspepsia, many physicians prescribe antidepressants. However, there are only limited studies with a lack of randomized controlled trials supporting this strategy. A meta-analysis showed that tricyclic antidepressants significantly improved functional GI disorders, but the review did not isolate functional dyspepsia from other functional GI disorders, such as irritable bowel syndrome and heartburn 39). A small crossover study found that low-dose amitriptyline improved functional dyspepsia symptoms; however, it included only 14 patients and lasted only one month 40). A larger study of children with irritable bowel syndrome, functional abdominal pain, or functional dyspepsia showed no improvement with amitriptyline versus placebo 41). More trials are underway that may elucidate the use of tricyclic antidepressants in patients with functional dyspepsia 42).

Four randomized controlled trials investigated the use of psychological interventions in patients with dyspepsia symptoms 43). Because each trial evaluated a different intervention (i.e., psychotherapy, psychodrama, cognitive behavior therapy, relaxation therapy, and hypnosis), no meta-analysis was possible. Additionally, because of the poor quality of these trials, there was insufficient evidence to recommend these interventions for treatment of dyspepsia. However, these methods can still be used to treat common psychiatric comorbidities.

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