Food passes down the oesophagus (gullet) into the stomach. The stomach
makes acid which is not essential, but 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 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 (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. 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. 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 non-ulcer dyspepsia. The cause is not
clear, although infection with a bacterium (germ) called H. pylori may account for some cases (see below). See separate leaflet called 'Dyspepsia - Non-ulcer (Functional)' for more detail.
-
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. 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. See separate leaflet
called 'Acid Reflux & Oesophagitis' for more detail.
-
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.
-
Medication. Some drugs may cause dyspepsia as a side-effect.
-
Anti-inflammatory drugs
are the most common culprits. These are drugs that many people take for
arthritis, muscular pains, sprains, period pains, etc. For example:
aspirin, ibuprofen, and diclofenac - but there are others.
Anti-inflammatory drugs sometimes affect the lining of the stomach and
allow acid to cause inflammation and ulcers.
-
Various other drugs 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
Helicobacter pylori (commonly just called H. pylori)
is a bacterium (germ). 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 most common cause of duodenal and stomach ulcers. 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. The exact way H. pylori causes
problems in some infected people is not totally clear. In some people
this bacterium causes inflammation in the lining of the stomach or
duodenum. This causes the defence mucus barrier to be disrupted in some
way (and in some cases the amount of acid to be increased) which seems
to allow the acid to cause inflammation and ulcers. See separate
leaflet called 'Helicobacter Pylori & Stomach Pain' for more detail.
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 abdomen. The examination is usually normal
if you have one of the common causes of dyspepsia. Your doctor will
want to review any drugs 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
This may be possible if a drug 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.
A sample of your breath is analysed after you take a special drink.
Note: prior to this test you should not have taken any antibiotics for
at least four weeks. Also, you should not have taken a proton pump
inhibitor or H2 blocker drug for at least two weeks. (These are acid
suppressing drugs - discussed further below.) Also, you should not eat
anything for six hours before the test. The reason for these rules is
because they can affect the test result.
- An alternative test is the 'stool antigen test'. In this test you
give a pea-sized sample of your faeces (stools) which is tested for H. Pylori.
Note: prior to this test you should not have taken any antibiotics for
at least four weeks. Also, you should not have taken a proton pump
inhibitor or H2 blocker drug for at least two weeks. (These are acid
suppressing drugs.)
- A blood test can detect antibodies to H. pylori. This is sometimes used to confirm that you are, or have been, infected with H. pylori.
However, it takes six months or more for this test to become negative
once the infection has cleared. So, it is no use to confirm whether
treatment has cleared the infection (if this needs to be known). If
needed, the breath test or stool antigen test are usually used to check
if an infection has cleared following treatment.
- 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 drug 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 drugs exactly as directed, and to take the full course. (See
separate leaflet called 'Helicobacter Pylori & Stomach Pain' which deals with the treatment of H. pylori in more detail.)
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). If a test is done it needs
to be done at least four weeks after the course of combination therapy
has finished. In most cases, the test is 'negative' meaning that the
infection has gone. If 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.
Some doctors say that for most
situations, this 'confirmation of eradication' test is not necessary if
symptoms have gone. The logic is that if symptoms have gone it usually
indicates that whatever was causing the dyspepsia has gone. But, some
doctors say it is needed to play safe. Your own doctor will advise if
you should have this test following treatment to clear H. pylori.
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 drugs which reduce stomach acid -
'proton pump inhibitors (PPIs)' and 'H2 blockers'. 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) is usually better and is usually tried first.
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. Many people take acid
suppressing medication 'as required'. That is, waiting for symptoms to
develop, and then taking a short course of treatment to clear the
symptoms. Some people take them regularly if symptoms occur each day.
If this is the situation, you should aim to find the lowest dose of
medication that keeps symptoms away.
Prokinetic drugs
These are drugs that speed
up the passage of food through the stomach. They include domperidone
and metoclopramide. They are not commonly used but help in some cases,
particularly if you have marked bloating or belching symptoms. They
tend to be used only if acid suppressing medication has not helped much.
Further tests
Further tests are not needed
in most cases. One or more of 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 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 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. See separate leavlet called 'Gastroscopy (Endoscopy)' for 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, 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 all types of dyspepsia:
-
Some foods and drinks
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 dyspepsia or making symptoms worse, 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.
-
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.
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:
- 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 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.
Disclaimer: This article is for information only and should not
be used for the diagnosis or treatment of medical conditions. EMIS and
PiP have used all reasonable care in compiling the information but make
no warranty as to its accuracy. Consult a doctor or other health care
professional for diagnosis and treatment of medical conditions.
© EMIS and PiP 2008 Reviewed: 23 Aug 2008
