Indigestion

Definition

Indigestion, which is sometimes called dyspepsia, is a general term covering a group of nonspecific symptoms in the digestive tract. It is often described as a feeling of fullness, bloating, nausea, heartburn , or gassy discomfort in the chest or abdomen. The symptoms develop during meals or shortly afterward. In most cases, indigestion is a minor problem that often clears up without professional treatment.

Description

Indigestion or dyspepsia is a widespread condition, estimated to occur in 25% of the adult population of the United States. Most people with indigestion do not feel sick enough to see a doctor; nonetheless, it is a common reason for office visits. About 3% of visits to primary care doctors are for indigestion.

Causes & symptoms

Physical causes

The symptoms associated with indigestion have a variety of possible physical causes, ranging from commonplace food items to serious systemic disorders:

• Diet. Milk, milk products, alcoholic beverages, tea, and coffee cause indigestion in some people because they stimulate the stomach's production of acid.

• Medications. Certain prescription drugs as well as over-the-counter medications can irritate the stomach lining. These medications include nonsteroidal anti-inflammatory drugs (NSAIDs, or over-the-counter pain killers like aspirin), some antibiotics, digoxin, theophylline, corticosteroids, iron (ferrous sulfate), oral contraceptives, and tricyclic antidepressants.
• Disorders of the pancreas and gallbladder. These include inflammation of the gallbladder or pancreas, cancer of the pancreas, and gallstones.
• Intestinal parasites. Parasitic infections that cause indigestion include amebiasis, fluke and tapeworm infections , giardiasis, and strongyloidiasis.
• Systemic disorders, including diabetes, thyroid disease, and collagen vascular disease.
• Cancers of the digestive tract.
• Conditions associated with women's reproductive organs. These conditions include menstrual cramps, pregnancy , and pelvic inflammatory disease.

Psychologic & emotional causes

Indigestion often accompanies an emotional upset, because the part of the nervous system involved in the so-called "fight-or-flight" response also affects the digestive tract. People diagnosed with anxiety or somato-form disorders frequently have problems with indigestion. Many people in the general population, however, will also experience heartburn, "butterflies in the stomach," or stomach cramps when they are in upsetting situations—such as school examinations, arguments with family members, crises in their workplace, and so on. Some people's digestive systems appear to react more intensely to emotional stress due to hypersensitive nerve endings in their intestinal tract.

Specific gastrointestinal disorders

In some cases, the patient's description of the symptoms suggests a specific digestive disorder as the cause of the indigestion. Some doctors classify these cases into three groups:

ESOPHAGITIS TYPE. Esophagitis is an inflammation of the tube that carries food from the throat to the stomach (the esophagus). The tissues of the esophagus can become irritated by the flow (reflux) of stomach acid backward into the lower part of the esophagus. If the patient describes the indigestion in terms of frequent or intense heartburn, the doctor will consider gastroesophageal reflux disease (GERD) as a possible cause. GERD is a common disorder in the general population, affecting about 30% of adults. In 2001, a study showed that obesity impairs the antireflux action. Those that are overweight have more severe reflux than most patients. Nighttime GERD affects 79% of adults with heartburn and is potentially more destructive to the esophagus than daytime indigestion. Another study found that acid reflux leads to cough and wheezing problems, particularly in people with asthma .

GERD also affects some infants and children, and is a common cause of babies spitting up formula. In most cases, the condition resolves itself, but children older than one year with regularly occurring pain in the lower chest or upper abdomen should cause concern. If a child is bothered by these symptoms during sleep or activities, a physician should be consulted.

PEPTIC ULCER TYPE. Patients who smoke and are over 45 are more likely to have indigestion of the peptic ulcer type. This group also includes people who find that their indigestion is relieved by taking antacids or eating a small amount of food. Patients in this category are often found to have Helicobacter pylori infections. H. pylori is a rod-shaped bacterium that lives in the tissues of the stomach and causes irritation of the mucous lining of the stomach walls. Most people with H. pylori infections do not develop chronic indigestion, but the organism appears to cause peptic ulcer disease (PUD) in a vulnerable segment of the population.

NONULCER TYPE. Most cases of chronic indigestion—as many as 65%—fall into this third category. Nonulcer dyspepsia is sometimes called functional dyspepsia because it appears to be related to abnormalities in the way that the stomach empties its contents into the intestine. In some people, the stomach empties either too slowly or too rapidly. In others, the stomach's muscular contractions are irregular and uncoordinated. These disorders of stomach movement (motility) may be caused by hypersensitive nerve endings in the stomach tissues. Patients in this group are likely to be younger than 45 and have a history of taking medications for anxiety or depression .

Diagnosis

Patient history

Because indigestion is a nonspecific set of symptoms, patients who feel sick enough to seek medical attention are likely to go to their primary care doctor. The history does not always point to an obvious diagnosis. The doctor can, however, use the process of history-taking to evaluate the patient's mood or emotional state in order to assess the possibility of a psychiatric disturbance. In addition, asking about the location, intensity, timing, and recurrence of the indigestion can help the doctor weigh the different diagnostic possibilities.

An important part of the history-taking is asking about symptoms that may indicate a serious illness. These warning symptoms include:

• weight loss
• persistent vomiting
• difficulty or pain in swallowing
• vomiting blood or passing blood in the stools
• anemia

Imaging studies

If the doctor thinks that the indigestion should be investigated further, he or she will order an endoscopic examination of the stomach. An endoscope is a slender tube-shaped instrument that allows the doctor to look at the lining of the patient's stomach. If the patient has indigestion of the esophagitis type or nonulcer type, the stomach lining will appear normal. If the patient has PUD, the doctor will be able to see breaks or ulcerated areas in the tissue. He or she may also order ultrasound imaging of the abdomen, or a radionuclide scan to evaluate the motility of the stomach.

Laboratory tests

BLOOD TESTS. If the patient is over 45, the doctor will have the patient's blood analyzed for a complete blood cell count, measurements of liver enzyme levels, electrolyte and serum calcium levels, and thyroid function.

TESTS FOR HELICOBACTER PYLORI. Doctors can now test patients for the presence of H. pylori without having to take a tissue sample from the stomach. One of these noninvasive tests is a blood test and the other is a breath test.

Treatment

Nutritional supplements

Nutritionists or naturopaths may recommend the following to improve digestion:

• Stay away from foods that may cause an upset stomach. These include spicy, fried, cured, or junk foods, cucumbers, onions, peppers, tomatoes, beans, soda pop, or beverages containing caffeine .
• Eat lighter but more frequent meals.
• Avoid smoking.
• Adopt a high-fiber diet to improve regularity and treat such digestive problems as constipation, hemorrhoids , irritable bowel disease, and colon cancer. A high-fiber diet provides such additional health benefits as boosting the immune system function and preventing heart disease , cancer, and other diseases.
• Increase water intake. Proper hydration helps the digestive system work better.
• Improve poor digestive enzyme function with hydrochloric acid and pancreatic enzyme supplements such as lipase, amylase, and protease.
• Thickening a baby's food can help with reflux (add one tablespoon of dry rice cereal to each ounce of formula or breast milk). Hold babies upright after feedings rather than putting them down right away.

Herbal medicine

Practitioners of Chinese traditional herbal medicine might recommend medicines derived from peony (Paeonia lactiflora ), hibiscus (Hibiscus sabdariffa ), or hare's ear (Bupleurum chinense ) to treat indigestion. Western herbalists are likely to prescribe fennel (Foeniculum vulgare ), lemon balm (Melissa officinalis ), or peppermint (Mentha piperita ) to relieve stomach cramps and heartburn.

Homeopathy

Homeopaths tailor their remedies to the patient's overall personality profile as well as the specific symptoms. Depending on the patient's reaction to the indigestion and some of its likely causes, the homeopath might choose Lycopodium, Carbo vegetalis, Nux vomica, or Pulsatilla.

Diet and stress management

Many patients benefit from the doctor's reassurance that they do not have a serious or fatal disorder. Cutting out alcoholic beverages and drinks containing caffeine often helps. The patient may also be asked to keep a record of food intake, daily schedule, and symptom severity. Food diaries sometimes reveal psychological or dietary factors that influence indigestion.

Other treatments

Some alternative treatments are aimed at lowering the patient's stress level or changing attitudes and beliefs that contribute to indigestion. These therapies and practices include Reiki, reflexology , hydrotherapy, therapeutic massage, yoga , and meditation .

Allopathic treatment

Since most cases of indigestion are not caused by serious disorders, many doctors prefer to try medications and other treatment measures before ordering an endoscopy. Many patients with acid reflux treat themselves with over-the-counter remedies. For nighttime GERD, a 2001 study recommends a dose of a proton pump inhibitor before breakfast and another dose before dinner. Some medicines are also approved for use in infants and children with indigestion that doesn't resolve itself.

Medications

Patients with the esophagitis type of indigestion are often treated with H₂ antagonists. H₂ antagonists are drugs that block the secretion of stomach acid. They include ranitidine (Zantac) and famotidine (Pepcid).

Patients with motility disorders may be given prokinetic drugs. Prokinetic medications such as metoclopramide (Reglan) and cisapride (Propulsid) speed up the emptying of the stomach and increase intestinal motility.

Removal of H. pylori

Antibiotic therapy may be given to wipe out H. pylori bacteria from the gastrointestinal tract.

Expected results

Most cases of mild indigestion do not need medical treatment. For patients who consult a doctor and are given an endoscopic examination, 5–15% are diagnosed with GERD and 15–25% with PUD. About 1% of patients who are endoscoped have stomach cancer. Most patients with functional dyspepsia do well on either H₂ antagonists or prokinetic drugs, depending on the cause of their indigestion.

Prevention

Indigestion can often be prevented by attention to one's diet, general stress level, and ways of managing stress. Specific preventive measures include:

• stopping smoking
• cutting down on or eliminating alcohol, tea, or coffee
• avoiding foods that are highly spiced or loaded with fat
• eating slowly and keeping mealtimes relaxed
• practicing yoga or meditation
• not taking aspirin or other medications on an empty stomach
• keeping one's weight within normal limits

Resources

BOOKS

Cummings, Stephen, MD, and Dana Ullman, MPH. Everybody's Guide to Homeopathic Medicines. New York: G. P. Putnam's Sons, 1991.

Gach, Michael Reed, and Carolyn Marco. Acu-Yoga: Self-Help Techniques to Relieve Tension. Tokyo and New York: Japan Publications, Inc., 1998.

Murray, Michael, and Joseph Pizzorno. Encyclopedia of Natural Medicine. Rocklin, CA: Prima Health, 1998.

PERIODICALS

Avidan, B., et al. "Temporal Associations Between Coughing or Wheezing and Acid Reflux in Asthmatics." Gut 49, no. 6 (December 2001): 767.

"Fast Lives Bring on the Burn." Chemist and Druggist (November 10, 2001): 37.

Wajed, Shahjehan A. "Elevated Body Mass Disrupts the Barrier to Gastroesophageal Reflux." JAMA—The Journal of the American Medical Association (December 5, 2001): 2650.

"What You Should Know about Gastroesophageal Reflux (GER) in Infants and Children." American Family Physician (December 1, 2001).

Zoler, Mitchell L. "Nighttime GERD Affects 79% of Adults with Heartburn." Internal Medicine News (October 15, 2001).

Mai Tran

Teresa Norris

Indigestion

Definition

Indigestion, which is sometimes called dyspepsia, is a general term covering a group of nonspecific symptoms in the digestive tract. It is often described as a feeling of fullness, bloating, nausea, heartburn, or gassy discomfort in the chest or abdomen. The symptoms develop during meals or shortly afterward. In most cases, indigestion is a minor problem that often clears up without professional treatment.

Description

Indigestion or dyspepsia is a widespread condition, estimated to occur in 25% of the adult population of the United States. Most people with indigestion do not feel sick enough to see a doctor; nonetheless, it is a common reason for office visits. About 3% of visits to primary care doctors are for indigestion.

Causes and symptoms

Physical causes

The symptoms associated with indigestion have a variety of possible physical causes, ranging from commonplace food items to serious systemic disorders:

• Diet. Milk, milk products, alcoholic beverages, tea, and coffee cause indigestion in some people because they stimulate the stomach's production of acid.
• Medications. Certain prescription drugs as well as over-the-counter medications can irritate the stomach lining. These medications include aspirin, NSAIDs, some antibiotics, digoxin, theophylline, corticosteroids, iron (ferrous sulfate), oral contraceptives, and tricyclic antidepressants.
• Disorders of the pancreas and gallbladder. These include inflammation of the gallbladder or pancreas, cancer of the pancreas, and gallstones.
• Intestinal parasites. Parasitic infections that cause indigestion include amebiasis, fluke and tapeworm infections, giardiasis, and strongyloidiasis.
• Systemic disorders, including diabetes, thyroid disease, collagen vascular disease.
• Cancers of the digestive tract.
• Conditions associated with women's reproductive organs. These conditions include menstrual cramps, pregnancy, and pelvic inflammatory disease.

Psychologic and emotional causes

Indigestion often accompanies an emotional upset, because the part of the nervous system involved in the so-called "fight-or-flight" response also affects the digestive tract. People diagnosed with anxiety or somatoform disorders frequently have problems with indigestion. Many people in the general population, however, will also experience heartburn, "butterflies in the stomach," or stomach cramps when they are in upsetting situations-such as school examinations, arguments with family members, crises in their workplace, and so on. Some people's digestive systems appear to react more intensely to emotional stress due to hypersensitive nerve endings in their intestinal tract.

Specific gastrointestinal disorders

In some cases, the patient's description of the symptoms suggests a specific digestive disorder as the cause of the indigestion. Some doctors classify these cases into three groups:

ESOPHAGITIS TYPE. Esophagitis is an inflammation of the tube that carries food from the throat to the stomach (the esophagus). The tissues of the esophagus can become irritated by the flow (reflux) of stomach acid backward into the lower part of the esophagus. If the patient describes the indigestion in terms of frequent or intense heartburn, the doctor will consider gastroesophageal reflux disease (GERD) as a possible cause. GERD is a common disorder in the general population, affecting about 30% of adults.

PEPTIC ULCER TYPE. Patients who smoke and are over 45 are more likely to have indigestion of the peptic ulcer type. This group also includes people who find that their indigestion is relieved by taking antacids or eating a small amount of food. Patients in this category are often found to have Helicobacter pylori infections. H. pylori is a rod-shaped bacterium that lives in the tissues of the stomach and causes irritation of the mucous lining of the stomach walls. Most people with H. pylori infections do not develop chronic indigestion, but the organism appears to cause peptic ulcer disease (PUD) in a vulnerable segment of the population.

NONULCER TYPE. Most cases of chronic indigestion—as many as 65%—fall into this third category. Nonulcer dyspepsia is sometimes called functional dyspepsia because it appears to be related to abnormalities in the way that the stomach empties its contents into the intestine. In some people, the stomach empties either too slowly or too rapidly. In others, the stomach's muscular contractions are irregular and uncoordinated. These disorders of stomach movement (motility) may be caused by hypersensitive nerve endings in the stomach tissues. Patients in this group are likely to be younger than 45 and have a history of taking medications for anxiety or depression.

Diagnosis

Patient history

Because indigestion is a nonspecific set of symptoms, patients who feel sick enough to seek medical attention are likely to go to their primary care doctor. The history does not always point to an obvious diagnosis. The doctor can, however, use the process of history-taking to evaluate the patient's mood or emotional state in order to assess the possibility of a psychiatric disturbance. In addition, asking about the location, intensity, timing, and recurrence of the indigestion can help the doctor weigh the different diagnostic possibilities.

An important part of the history-taking is asking about symptoms that may indicate a serious illness. These warning symptoms include:

• Weight loss
• Persistent vomiting
• Difficulty or pain in swallowing
• Vomiting blood or passing blood in the stools
• Anemia.

Imaging studies

If the doctor thinks that the indigestion should be investigated further, he or she will order an endoscopic examination of the stomach. An endoscope is a slender tube-shaped instrument that allows the doctor to look at the lining of the patient's stomach. If the patient has indigestion of the esophagitis type or nonulcer type, the stomach lining will appear normal. If the patient has PUD, the doctor will be able to see breaks or ulcerated areas in the tissue. He or she may also order ultrasound imaging of the abdomen, or a radio-nuclide scan to evaluate the motility of the stomach.

Laboratory tests

BLOOD TESTS. If the patient is over 45, the doctor will have the patient's blood analyzed for a complete blood cell count, measurements of liver enzyme levels, electrolyte and serum calcium levels, and thyroid function.

TESTS FOR HELICOBACTER PYLORI. Doctors can now test patients for the presence of H. pylori without having to take a tissue sample from the stomach. One of these noninvasive tests is a blood test and the other is a breath test.

Treatment

Since most cases of indigestion are not caused by serious disorders, many doctors prefer to try medications and other treatment measures before ordering an endoscopy.

Diet and stress management

Many patients benefit from the doctor's reassurance that they do not have a serious or fatal disorder. Cutting out alcoholic beverages and drinks containing caffeine often helps. The patient may also be asked to keep a record of food intake, daily schedule, and symptom severity. Food diaries sometimes reveal psychologic or dietary factors that influence indigestion.

Medications

Patients with the esophagitis type of indigestion are often treated with H₂ antagonists. H₂ antagonists are drugs that block the secretion of stomach acid. They include ranitidine (Zantac) and famotidine (Pepcid).

Patients with motility disorders may be given pro-kinetic drugs. Prokinetic medications speed up the emptying of the stomach and increase intestinal motility. They include metoclopramide (Reglan) and cisapride (Propulsid). These drugs relieve symptoms in 60-80% of patients.

Removal of H. pylori

It is not clear that patients with H. pylori infections who have not developed gastric ulcers need to have the bacterium removed. Some studies indicate, however, that these patients may benefit from antibiotic therapy.

Alternative treatment

Herbal medicine

Practitioners of Chinese traditional herbal medicine might recommend medicines derived from peony (Paeonia lactiflora ), hibiscus (Hibiscus sabdariffa ), or hare's ear (Bupleurum chinense ) to treat indigestion. Western herbalists are likely to prescribe fennel (Foeniculum vulgare ), lemon balm (Melissa officinalis ), or peppermint (Mentha piperita ) to relieve stomach cramps and heartburn.

Homeopathy

Homeopaths tailor their remedies to the patient's overall personality profile as well as the specific symptoms. Depending on the patient's reaction to the indigestion and some of its likely causes, the homeopath might choose Gelsemium (Gelsemium sempervirens), Carbo vegetalis, Nux vomica, or Pulsatilla (Pulsatilla nigricans).

Other treatments

Some alternative treatments are aimed at lowering the patient's stress level or changing attitudes and beliefs that contribute to indigestion. These therapies and practices include Reiki, reflexology, hydrotherapy, therapeutic massage, yoga, and meditation.

Prognosis

Most cases of mild indigestion do not need medical treatment. For patients who consult a doctor and are given an endoscopic examination, 5-15% are diagnosed with GERD and 15-25% with PUD. About 1% of patients who are endoscoped have stomach cancer. Most patients with functional dyspepsia do well on either H₂ antagonists or prokinetic drugs, depending on the cause of their indigestion.

Prevention

Indigestion can often be prevented by attention to one's diet, general stress level, and ways of managing stress. Specific preventive measures include:

• Stop smoking.
• Cutting down on or eliminating alcohol, tea, or coffee.
• Avoiding foods that are highly spiced or loaded with fat.
• Eating slowly and keeping mealtimes relaxed.
• Practicing yoga or meditation.
• Not taking aspirin or other medications on an empty stomach.
• Keeping one's weight within normal limits.

Resources

OTHER

"Indigestion." ThriveOnline. April 6, 1998. 〈http://thriveonline.oxygen.com〉.

KEY TERMS

Dyspepsia— Another name for indigestion.

Endoscope— A slender tubular instrument used to examine the inside of the stomach.

Gastroesophageal reflux disease (GERD)— A disorder of the lower end of the esophagus, caused by stomach acid flowing backward into the esophagus and irritating the tissues.

H₂ antagonist— A type of drug that relieves indigestion by reducing the production of stomach acid.

Heartburn— A popular term for an uncomfortable burning sensation in the stomach and lower esophagus, sometimes caused by the reflux of small amounts of stomach acid.

Helicobacter pylori — A gramnegative rod-shaped bacterium that lives in the tissues of the stomach and causes inflammation of the stomach lining.

Motility— The movement or capacity for movement of an organism or body organ. Indigestion is sometimes caused by abnormal patterns in the motility of the stomach.

Peptic ulcer disease (PUD)— A stomach disorder marked by corrosion of the stomach lining due to the acid in the digestive juices.

Prokinetic— A drug that works to speed up the emptying of the stomach and the motility of the intestines.

Reflux— The backward flow of a body fluid or secretion. Indigestion is sometimes caused by the reflux of stomach acid into the esophagus.

indigestion a commonly used term which encompasses a wide variety of gastrointestinal symptoms, including abdominal pain, heartburn, acid regurgitation, belching, bloating, bad breath, and even excessive passage of flatus. Each of these symptoms may have one of many causes when present as an isolated symptom and indicator of a specific disease; or many of them may occur together and be indicative of one or more disorders. Doctors may discern from the detailed history of the symptoms of ‘indigestion’ whether they are likely to represent a disorder of either the upper or the lower gastrointestinal tract.

The term indigestion however, is most often used to describe the symptom consortium often referred to as ‘dyspepsia’ — commonly defined as upper abdominal or epigastric pain which may or may not be related to eating. Associated symptoms may include heartburn, upper abdominal bloating, or belching. This is an extremely common condition occurring at one time or another in 25% of the adult population. Dyspepsia may be categorized as ‘organic dyspepsia’, when there is a clearly definable cause and disease entity, or as ‘functional dyspepsia’ when the pathophysiology has not been defined.

Organic dyspepsia

Common causes include chronic peptic ulcer, gastro–oesophageal reflux with or without oesophagitis, symptomatic gallstones, chronic pancreatitis; and intra-abdominal malignancy. Rarer causes include metabolic disorders, such as the uraemia of renal failure and hypercalcaemia, and conditions such as diabetes mellitus which disturb the function of the autonomic nervous system and hence impair gastric emptying.

Functional dyspepsia

Many now regard this as part of a wider spectrum of functional abdominal disorders which includes irritable bowel syndrome. In many instances the symptom pattern resembles that of an organic dyspepsia, although ‘alarm’ symptoms and signs such as weight loss, gastrointestinal bleeding, enlarged lymph glands, or an abdominal mass are absent. The cause of functional dyspepsia has not been clearly defined but is thought to relate to disturbances of motor function of the upper gastrointestinal tract, possibly associated with abnormalities of visceral sensation. Psychosocial factors such as stress, life events, and disturbance of affect are thought by some to be permissive for symptom production, even though they may not be the primary cause of the problem.

People under middle age who have no ‘alarm’ symptoms are not routinely investigated and are likely to be offered symptomatic treatment, with a variety of approaches including dietary modification, antacids, cognitive therapy, and possibly anti-depressant medication when appropriate. For those with symptoms that suggest the presence of organic disease, and for older people in whom such disease is in any case more likely, further investigation is required, such as upper gastrointestinal endoscopy, abdominal ultrasound scan; and possibly abdominal CT scan. Specific therapy can then be directed towards the identified cause.

Michael Farthing, and Anne Ballinger

in·di·ges·tion / ˌindiˈjeschən; -dī-/ • n. pain or discomfort in the stomach associated with difficulty in digesting food.DERIVATIVES: in·di·ges·tive / -tiv/ adj.

indigestion Discomfort and distension of the stomach after a meal, also known as dyspepsia, including heartburn. Persistent indigestion may be a symptom of a digestive disorder such as hiatus hernia or peptic ulcer.