What is Indigestion?

Indigestion or an “upset stomach” is a general term that describes discomfort in your upper abdomen. It is characterised by symptoms you experience, including abdominal pain and a feeling of fullness soon after you start eating.

It’s normal for your stomach to produce acid, it is required to maintain a suitable environment for digesting enzymes to function and for a sterilising action on the gastric contents but sometimes this acid together with digestive enzymes in the stomach namely pepsin can irritate the lining of your stomach, the top part of your bowel (duodenum) or your gullet (oesophagus) resulting in symptoms of indigestion.

Digestive System

Indigestion may also be due to the lining of your digestive system being overly sensitive to acid, or the “stretching” caused by eating.

Although indigestion is common, how you experience indigestion may differ from other people. Not only can there be irritation but also ulceration which is the erosion of the stomach, duodenal or oesophageal lining by stomach acid. Medically indigestion is termed dyspepsia. Dyspepsia is a collective term for all of the above. Symptoms of dyspepsia may be felt occasionally or as often as daily.

Dyspepsia is often accompanied by gastroesophageal reflux disease (GERD/GORD). This is when control is lost over the closure between the oesophagus and the stomach resulting in a leakage of the stomach contents into the oesophagus resulting in a burning feeling in the chest (heartburn) that occurs after eating. Gastro-oesophageal reflux disease is also associated sometimes with difficulty in swallowing (dysphagia); oesophageal inflammation (oesophagitis), ulceration, and a loss of elasticity and function of the oesophagus. Other symptoms that may accompany GORD are shown in the following figure.

GORD symptoms

It is interesting to note that in all industrial countries dyspepsia affects more than one fourth of the general population and is a frequent reason for medical consultation having a significant impact upon quality of life. Therefore it is no surprise that lifestyle is one of the main culprits for dyspepsia.

Causes or symptoms

  • Drinks with high acidity (citrus) or low pH (soft drinks), coffee, wine, and other alcoholic beverages. Spicy foods may cause acute mucosal injury and acute epigastric pain. Fatty foods. All should be avoided.

  • Smoking, stress, obesity.

  • Lactose malabsorption may underlie dyspepsia with cramps, flatulence, and diarrhea, as well.

  • The following medications commonly cause dyspepsia:

    • Pain killers called non-steroidal anti-inflammatory drugs or NSAIDs.

    • Potassium, iron, niacin supplements.

    • Certain antibiotics, corticosteroids, estrogens, theophylline, treatment for osteoporosis

  • Lying down after having a main meal. Meals should be taken well before going to bed and raising the head of the bed helps.

  • Recurrence and ulceration is common when a bacterium called Helicobacter pylori is present in the stomach lining. H. pylori also increases acid secretion, therefore it is important to seek medical advice if symptoms are recurring.

  • The usual cause of pain and symptoms is ulceration or gastroesophageal reflux disease although ulcers are not always present in patients with dyspepsia. Presence of H. pylori infection dramatically increases chances of peptic ulceration. Diagnosis of H pylori is therefore very important.

  • Nearly all ulcers not associated with NSAIDs are caused by H. pylori. NSAID use and H. pylori are therefore independent risk factors for gastric ulcers.

Urgent endoscopic investigation is required if dyspepsia is accompanied by ‘alarm features’ e.g. bleeding, difficulty in swallowing, recurrent vomiting, or weight loss. Urgent investigation should also be considered for patients over 55 years with unexplained, recent-onset dyspepsia that has not responded to treatment.

Treatment strategy for dyspepsia

Patients with dyspepsia should be advised about lifestyle changes. Some medications may cause dyspepsia—these should be stopped, if possible. Antacids may provide some symptomatic relief. A stepwise approach to treatment is usually reasonable unless urgent investigation is required and/or if symptoms are severe. The pharmacist can suggest over the counter medications for a short duration as a trial or else refer to a doctor depending on the severity. If symptoms persist in uninvestigated dyspepsia, treatment involves a proton pump inhibitor or a histamine H2-receptor antagonist for up to 4 weeks. Treatment can then be used intermittently to control symptoms long term. Patients with uninvestigated dyspepsia, who do not respond to an initial trial with a proton pump inhibitor, should be tested for Helicobacter pylori and given eradication therapy if H. pylori is present.

Treatment with histamine H2-receptor antagonists for ulcers has been largely replaced by proton pump inhibitors due to their efficacy but histamine H2-receptor antagonist remain useful for dyspepsia without alarm features or without ulcers.

Treatments

Antacids Histamine2 Receptor Antagonists Proton pump inhibitors
Available in liquid or chewable tablet form without prescription. Act by neutralising excess gastric acid that has been already secreted in the stomach. To be taken after meals to relieve symptoms for a quick, short lived effect. They are not used to heal ulcers. Available as tablets with prescription. Significantly reduce gastric acid secretion and lower the acid and pepsin concentration. Heal gastric and duodenal ulcers; they are also used to relieve symptoms of gastroesophageal reflux disease. Have a rapid onset of action and a long duration of action. Available as capsules with or without prescription for short courses. Almost completely stop stomach acid secretion to allow healing. Used in severe chronic symptoms. PPIs have a delayed onset but are of a long action.

Safety profile of treatment options

In patients with fluid retention avoid antacids with large amounts of sodium. A proton pump inhibitor should be prescribed for appropriate indications at the lowest effective dose for the shortest period; the need for long-term treatment should be reviewed periodically. By decreasing gastric acidity changes occur in intestinal flora therefore proton pump inhibitors may increase the risk of gastro-intestinal infections (including Clostridium difficile infection). Proton pump inhibitors can increase the risk of fractures, when used at high doses for over a year in the elderly and can decrease serum magnesium concentration with prolonged use.

H. Pylori eradication

Eradication of Helicobacter pylori reduces recurrence of gastric and duodenal ulcers and the risk of re-bleeding. Acid inhibition combined with antibacterial treatment is highly effective in the eradication of H. pylori; reinfection is rare. Initial treatment consists of a one or two week triple-therapy regimen that comprises a proton pump inhibitor and the antibiotics clarithromycin, and either amoxicillin or metronidazole. Treatment failure usually indicates antibacterial resistance or poor compliance.

GORD Treatment

For mild symptoms of gastro-oesophageal reflux disease, initial management may include the use of antacids and alginates. Alginate-containing antacids can form a ‘raft’ that floats on the surface of the stomach contents to reduce reflux and protect the oesophageal mucosa. Histamine H2-receptor antagonists may relieve symptoms and permit reduction in antacid consumption. However, proton pump inhibitors provide more effective relief of symptoms than H2-receptor antagonists. When symptoms abate, treatment is titrated down to a level which maintains remission (e.g. by giving treatment intermittently).

For severe symptoms of gastro-oesophageal reflux disease or for patients with a proven or severe pathology specialist advice is required treatment with a proton pump inhibitor usually needs to be maintained at the minimum effective dose.

In conclusion one who may be suffering from indigestion and may be ignoring it or treating it with over the counter medications might benefit from specifying what treatment is best targeted at his/her problem. Symptoms may seem as generalised pain in the upper abdomen but can be properly recognised if described to a healthcare professional.

This article is not intended to replace a one-on-one relationship with a qualified health care professional and is not intended as medical advice. It is intended as a sharing of knowledge and information.

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