Indigestion (Dyspepsia, Upset Stomach Pain)


It is not clear, however, how these non-GI diseases might cause indigestion
Another important cause of indigestion is drugs Many drugs are frequently associated with indigestion, for example, nonsteroidal anti-inflammatory drugs ( NSAIDs such as ibuprofen ), antibiotics, and estrogens ) In fact, most drugs are reported to cause indigestion in at least some people with functional symptoms

Antidepressants for indigestion
Patients with functional disorders, including indigestion, are frequently found to be suffering from depression and/or anxiety It is unclear, however, if the depression and anxiety are the cause or the result of the functional disorders or are unrelated to these disorders ( Depression and anxiety are common and, therefore, their occurrence together with functional disorders may be coincidental) Several clinical trials have shown that antidepressants are effective in IBS in relieving abdominal pain Antidepressants also have been shown to be effective in unexplained (non-cardiac) chest pain, a condition thought to represent a dysfunction of the esophagus Antidepressants have not been studied adequately in other types of functional disorders, including indigestion It probably is reasonable to treat patients with indigestion with psychotropic drugs if they have moderate or severe depression or anxiety
The antidepressants work in functional disorders at relatively low doses that have little or no effect on depression It is believed, therefore, that these drugs work not by combating depression, but in different ways (through different mechanisms) For example, these drugs have been shown to adjust (modulate) the activity of the nerves and to have analgesic (pain-relieving) effects as well

Commonly used psychotropic drugs include the tricyclic antidepressants , desipramine (Norpramine) and trimipramine ( Surmontil ).

Although studies are encouraging, it is not yet clear whether the newer class of antidepressants, the serotonin-reuptake inhibitors such as fluoxetine ( Prozac ), sertraline ( Zoloft ), and paroxetine ( Paxil ), are effective in functional disorders, including indigestion Diet and indigestion
Dietary factors have not been well-studied in the treatment of indigestion Nevertheless, people often associate their symptoms with specific foods (such as salads and fats ) Although specific foods might worsen the symptoms of indigestion, they usually are not the cause of indigestion (Intolerance to specific foods, for example, lactose intolerance [milk] and allergies to wheat, eggs, soy , and milk protein are not considered functional diseases like indigestion) The common placebo response in functional disorders such as indigestion also may explain the improvement of symptoms in some people with the elimination of specific foods
Dietary fiber often is recommended for patients with IBS, but fiber has not been studied in the treatment of indigestion Nevertheless, it probably is reasonable to treat patients with indigestion with fiber if they also have constipation
Intolerance to lactose (the sugar in milk) often is blamed for indigestion Since indigestion and lactose intolerance both are common, the two conditions may coexist In this situation, restricting lactose will improve the symptoms of lactose intolerance, but will not affect the symptoms of indigestion Lactose intolerance is easily determined by a milk challenge testing the effects of lactose (hydrogen breath testing) or trying a strict lactose elimination diet If lactose is determined to be responsible for some or all of the symptoms, elimination of lactose-containing foods is appropriate Unfortunately, many patients stop drinking milk or eating milk-containing foods without good evidence that it improves their symptoms This often is detrimental to their intake of calcium which may contribute to osteoporosis
One of the food substances most commonly associated with the symptoms of indigestion is fat The scientific evidence that fat causes indigestion is weak Most of the support is anecdotal (not based on carefully done, scientific studies) Nevertheless, fat is one of the most potent influences on gastrointestinal function (It tends to slow down the gastrointestinal muscles while it causes the muscles of the gallbladder to contract) Therefore, it is possible that fat may worsen indigestion even though it doesn’t cause it Moreover, reducing the ingestion of fat might relieve symptoms A strict low fat diet can be accomplished fairly easily and is worth trying Additionally, there are other health-related reasons for reducing dietary fat
Other dietary factors, fructose, and other sugar -related foods (fermentable, oligo- di- and mono-saccharides and polyols or FODMAPs ), have been suggested as a cause of indigestion since many people do not fully digest and absorb them before they reach the distal intestine Fructose intolerance and perhaps also FODMAP intolerance can be diagnosed with a hydrogen breath test using fructose and treated by elimination of fructose and/or FODMAP containing foods from the diet Unfortunately, fructose and FODMAPs are widespread among fruits and vegetables, and fructose is found in high concentrations in many food products sweetened with corn syrup Thus, an elimination diet can be difficult to maintain Pro-motility medication for indigestion
One of the leading theories for the cause of indigestion is abnormalities in the way gastrointestinal muscles function The function of muscles may be abnormally increased, abnormally decreased, or it may by uncoordinated There are medications, called smooth muscle relaxants that can reduce the activity of the muscles and other drugs that can increase the activity of the muscles, called promotility drugs
Many of the symptoms of indigestion can be explained on the basis of reduced activity of the gastrointestinal muscles that results in slowed transport (transit) of food through the stomach and intestine

(It is clear, as discussed previously, that there are other causes of these symptoms in addition to slowed transit.

) Such symptoms include nausea, vomiting, and abdominal bloating When transit is severely affected, abdominal distention (swelling) also may occur and can result in abdominal pain (Early satiety is unlikely to be a function of slowed transit because it occurs too early for slowed transit to have consequences) Theoretically, drugs that speed up the transit of food should, in at least some patients, relieve symptoms of indigestion that are due to slow transit
The number of promotility drugs that are available for use clinically is limited Studies of their effectiveness in indigestion are even more limited The most studied drug is cisapride ( Propulsid ), a promotility drug that was withdrawn from the market because of serious cardiac side effects (Newer drugs that have similar effects but lack the toxicity are being developed) The few studies with cisapride for indigestion were inconsistent in their results Some studies demonstrated benefits whereas others showed no benefit Cisapride was effective in patients with severe emptying problems of the stomach ( gastroparesis ) or severely slowed transit of food through the small intestine (chronic intestinal pseudo-obstruction) These two diseases may or may not be related to indigestion
Another promotility drug that is available is erythromycin , an antibiotic that stimulates gastrointestinal smooth muscle as one of its side effects Erythromycin is used to stimulate smooth muscles of the gastrointestinal tract at doses that are lower than those used for treating infections There are no studies of erythromycin in indigestion, but erythromycin is effective in gastroparesis and probably also in chronic intestinal pseudo-obstruction
Metoclopramide ( Reglan ) is another promotility drug that is available It has not been studied, however, in indigestion Moreover, it is associated with some troubling side effects Therefore, it may not be a good drug to undergo further testing in indigestion
Domperidone (Motilium) is a promotility drug that is available in the US, but requires a special permit from the US Food and Drug administration As a result, it is not very commonly prescribed It is an effective drug with minimal side effects How do you know if you have indigestion (diagnosis)?
Indigestion is diagnosed primarily based on typical symptoms and the exclusion of non-functional gastrointestinal diseases (including acid-related diseases), non-gastrointestinal diseases, and psychiatric illness There are tests for identifying abnormal gastrointestinal function directly, but they are limited in their ability to do so What natural or home remedies are used to treat dyspepsia (indigestion)?
Studies of natural and home remedies for indigestion are few Most recommendations for natural and home remedies have little evidence to support their use Several potential remedies, however, deserve mention including: Acid-suppressing remedies: The most common cause of dyspepsia is probably gastrointestinal reflux disease (acid reflux or GERD ) That may be why remedies such as baking soda, which neutralizes stomach acid, have been recommended Even if baking soda works, it is more effective (and probably safer) to use antacids in liquid or pill form for this purpose Ginger: Ginger has been demonstrated to relieve nausea One small study showed it to be ineffective in relieving dyspepsia, but ginger is harmless and worth a try if nausea is a component of the dyspepsia Peppermint: Peppermint has been demonstrated to have effects on the function of the gastrointestinal tract; it is among the most potent inhibitors of intestinal muscles It is effective in another functional disease, irritable bowel syndrome , but there is minimal evidence that it is effective in dyspepsia Nevertheless, like ginger, it is harmless and worth a try Meals: Eating smaller, more frequent meals Lifestyle changes: Stay away from specific foods and drinks , smoking , and alcohol if they provoke symptoms What treatments relieve and cure indigestion (dyspepsia)?
The treatment of indigestion is a difficult and unsatisfying topic because so few drugs have been studied and have been shown to be effective Moreover, the drugs that have been shown to be effective have not been shown to be very effective This difficult situation exists for many reasons including: Life-threatening illnesses (for example, cancer , heart disease , and high blood pressure ) are the illnesses that capture the public’s interest and, more importantly, research funding Indigestion is not a life-threatening illness and has received little research funding Because of the lack of research, an understanding of the physiologic processes (mechanisms) that are responsible for indigestion has been slow to develop Effective drugs cannot be developed until there is an understanding of these mechanisms Research in indigestion is difficult Indigestion is defined by subjective symptoms (such as pain) rather than objective signs (for example, the presence of an ulcer) Subjective symptoms are more unreliable than objective signs in identifying homogenous groups of patients As a result, groups of patients with indigestion who are undergoing treatment are likely to contain some patients who do not have indigestion, which may dilute (negatively affect) the results of the treatment Moreover, the results of treatment must be evaluated on the basis of subjective responses (such as improvement of pain) In addition to being more unreliable, subjective responses are more difficult to measure than objective responses (for example, healing of an ulcer) Different subtypes of indigestion (for example, abdominal pain and abdominal bloating) are likely to be caused by different physiologic processes (mechanisms) It also is possible, however, that the same subtype of indigestion may be caused by different mechanisms in different people What’s more, any drug is likely to affect only one mechanism Therefore, it is unlikely that any one medication can be effective in all-even most-patients with indigestion, even patients with similar symptoms This inconsistent effectiveness makes the testing of drugs particularly difficult Indeed, it can easily result in drug trials that demonstrate no efficacy (usefulness) when, in fact, the drug is helping a subgroup of patients Subjective symptoms are particularly prone to responding to placebos (inactive drugs) In fact, in most studies, 20% to 40% of patients with indigestion will improve if they receive placebo drugs Now, all clinical trials of drugs for indigestion require a placebo-treated group for comparison with the drug-treated group The large placebo response means that these clinical trials must utilize large numbers of patients to detect meaningful (significant) differences in improvement between the placebo and drug groups Therefore, these trials are expensive to conduct
The lack of understanding of the physiologic processes (mechanisms) that cause indigestion has meant that treatment usually cannot be directed at the mechanisms Instead, treatment usually is directed at the symptoms For example, nausea is treated with medications that suppress nausea but do not affect the cause of the nausea On the other hand, the psychotropic drugs ( antidepressants ) and psychological treatments (such as cognitive behavioral therapy) treat hypothetical causes of indigestion (for example, abnormal function of sensory nerves and the psyche) rather than causes or even the symptoms Treatment for indigestion often is similar to that for irritable bowel syndrome (IBS) even though the causes of IBS and indigestion are likely to be different Education
It is important to educate patients with indigestion about their illness, particularly by reassuring them that the illness is not a serious threat to their physical health (though it may be to their emotional health) Patients need to understand the potential causes for the symptoms

Most importantly, they need to understand the medical approach to the problem and the reasons for each test or treatment.

Education prepares patients for a potentially prolonged course of diagnosis and trials of treatment.

Education also may prevent patients from falling prey to the charlatans who offer unproven and possibly dangerous treatments for indigestion Many symptoms are tolerable if patients’ anxieties about the seriousness of their symptoms can be relieved It also helps patients deal with symptoms when they feel that everything that should be done to diagnose and treat, in fact, is being done The truth is that psychologically healthy people can tolerate a good deal of discomfort and continue to lead happy and productive lives

Smooth muscle relaxants for indigestion
The most widely studied drugs for the treatment of abdominal pain in functional disorders are a group of drugs called smooth-muscle relaxants.

The gastrointestinal tract is primarily composed of a type of muscle called smooth muscle (By contrast, skeletal muscles such as the biceps are composed of a type of muscle called striated muscle) Smooth muscle relaxant drugs reduce the strength of contraction of the smooth muscles but do not affect the contraction of other types of muscles They are used in functional disorders, particularly IBS, with the assumption (not proven) that strong or prolonged contractions of smooth muscles in the intestine-spasms-are the cause of the pain in functional disorders There are even smooth muscle relaxants that are placed under the tongue, as is nitroglycerin for angina, so that they may be absorbed rapidly
There are not enough studies of smooth muscle relaxants in indigestion to conclude that they are effective at reducing pain Since their side effects are few, these drugs probably are worth trying As with all drugs that are given to control symptoms, patients should carefully evaluate whether or not the smooth muscle relaxant they are using is effective at controlling the symptoms If it is not clearly effective, the option of discontinuing the relaxant should be discussed with a physician
Commonly used smooth muscle relaxants are hyoscyamine ( Levsin , Anaspaz , Cystospaz , Donnamar ) and methscopolamine ( Pamine , Pamine Forte ) Other drugs combine smooth muscle relaxants with a sedative chlordiazepoxide hydrochloride and clidinium bromide ( Donnatal , Librax ), but there is no evidence that the addition of sedatives adds to the effectiveness of the treatment Psychological treatments for indigestion
Psychological treatments include cognitive-behavioral therapy, hypnosis, psychodynamic or interpersonal psychotherapy , and relaxation/ stress management Few studies of psychological treatments have been conducted in indigestion, although more studies have been done in IBS Thus, there is little scientific evidence that they are effective in indigestion, although there is some evidence that they are effective in IBS
Hypnosis has been proposed as an effective treatment for IBS It is unclear exactly how effective hypnosis is, or how it works Which specialties of doctors treat indigestion (dyspepsia)?
Since indigestion is very common, almost all doctors see and treat patients with indigestion, especially family practitioners, internists and even pediatricians If these generalists are unable to provide adequate treatment, the patient usually is referred to a gastroenterologist, an internist or pediatrician with specialty training in gastrointestinal diseases What are the complications of indigestion (dyspepsia)? Share Your Story
The complications of functional diseases of the gastrointestinal tract are relatively limited Since symptoms are most often provoked by eating, patients who alter their diets and reduce their intake of calories may lose weight However, loss of weight is unusual in functional diseases In fact, loss of weight should suggest the presence of non-functional diseases Symptoms that awaken patients from sleep also are more likely to be due to non-functional than functional disease
Most commonly, functional diseases interfere with patients’ comfort and daily activities Individuals who develop nausea or pain after eating may skip breakfast or lunch because of the symptoms they experience Patients also commonly associate symptoms with specific foods (for example, milk, fat, vegetables) Whether or not the associations are real, these patients will restrict their diets accordingly Milk is the most common food that is eliminated, often unnecessarily, and this can lead to inadequate intake of calcium and osteoporosis The interference with daily activities also can lead to problems with interpersonal relationships, especially with spouses Most patients with functional disease live with their symptoms and infrequently visit physicians for diagnosis and treatment What can a person expect during the diagnosis and treatment of indigestion (prognosis)?
The initial approach to dyspepsia, whether it be treatment or testing, depends on the patient’s age, symptoms and the duration of the symptoms If the patient is younger than 50 years of age and serious disease, particularly cancer , is not likely, testing is less important If the symptoms are typical for dyspepsia and have been present for many years without change, then there is less need for testing, or at least extensive testing, to exclude other gastrointestinal and non-gastrointestinal diseases
On the other hand, if the symptoms are of recent onset (weeks or months), progressively worsening, severe, or associated with “warning” signs, then early, more extensive testing is appropriate Warning signs include loss of weight, nighttime awakening, blood in the stool or the material that is vomited (vomitus), and signs of inflammation, such as fever or abdominal tenderness Testing also is appropriate if, in addition to symptoms of dyspepsia, there are other prominent symptoms that are not commonly associated with dyspepsia
If there are symptoms that suggest conditions other than dyspepsia, tests that are specific for these diseases should be done first The reason is that if these other tests disclose other diseases, it may not be necessary to do additional testing Examples of such symptoms and possible testing include: Vomiting: upper gastrointestinal endoscopy to diagnose inflammatory or obstructing diseases; gastric emptying studies and/or electrogastrography to diagnose impaired emptying of the stomach Abdominal distention with or without increased flatulence: upper gastrointestinal and small intestinal x-rays to diagnose obstructing diseases; hydrogen breath testing to diagnose bacterial overgrowth of the small intestine
For a patient with typical symptoms of dyspepsia who requires testing to exclude other diseases, a standard screening panel of blood tests would reasonably be included These tests might reveal clues to non-gastrointestinal diseases Sensitive stool testing (antigen/antibody) for Giardia lamblia would be reasonable because this parasitic infection is common and can be acute or chronic Some physicians do blood testing for celiac disease (sprue), but the value of doing this is unclear Moreover, if an EGD is planned, biopsies of the duodenum usually will make the diagnosis of celiac disease A plain X-ray of the abdomen might be done during an episode of abdominal pain (to look for intestinal blockage or obstruction) Testing for lactose intolerance or a trial of a strict lactose-free diet should be considered The physician’s clinical judgment should determine the extent to which initial testing is appropriate
Once testing has been done to an extent that is appropriate for the clinical situation, it is reasonable to first try a therapeutic trial of stomach acid suppression to see if symptoms improve Such a trial probably should involve a PPI (proton pump inhibitor) for 8 to 12 weeks If there is no clear response of symptoms, the options then are to discontinue the PPI or confirm its effectiveness in suppressing acid with 24 hour acid testing If there is a clear and substantial decrease in symptoms with the PPI, then decisions need to be made about continuing acid suppression and which drugs to use
Another therapeutic approach is to test for Helicobacter pylori infection of the stomach (with blood, breath or stool tests) and to treat patients with infection to eradicate the infection It may be necessary to retest patients after treatment to prove that treatment has effectively eradicated the infection, particularly if dyspeptic symptoms persist after treatment
If treatment with a PPI has satisfactorily suppressed acid according to acid testing (or acid suppression has not been measured) and yet the symptoms have not improved, it is reasonable to conduct further testing as described above Esophago-gastro-duodenoscopy, or EGD, (and, possibly, colonoscopy ) would be the next consideration, probably with multiple biopsies of the stomach and duodenum (and colon if colonoscopy is done) Finally, small intestinal x-rays and an ultrasound examination of the gallbladder might be done An abdominal ultrasound examination, CT scan , or MRI scan can exclude non-gastrointestinal diseases Once appropriate testing has been completed, empiric trials of other drugs (for example, smooth muscle relaxants, psychotropic drugs, and promotility drugs) can be done (An empiric trial of a drug is a trial that is not based on an understanding of the exact cause of the symptoms)
If all of the appropriate testing reveals no disease that could be causing the symptoms and the dyspeptic symptoms have not responded to empiric treatments, other, more specialized tests should be considered These tests include hydrogen breath testing to diagnose bacterial overgrowth of the small intestine, gastric emptying studies, EGG , small intestinal transit studies, antro-duodenal motility and barostatic studies, and possibly capsule endoscopy These specialized studies probably should be done at centers that have experience and expertise in diagnosing and treating functional diseases What research is ongoing for treatments to cure indigestion (dyspepsia)?
The future of dyspepsia will depend on our increasing knowledge of the processes (mechanisms) that cause dyspepsia

Acquiring this knowledge, in turn, depends on research funding.

Because of the difficulties in conducting research in dyspepsia, this knowledge will not come quickly Until we have an understanding of the mechanisms of dyspepsia, newer treatments will be based on our developing a better understanding of the normal control of gastrointestinal function, which is proceeding more rapidly Specifically, there is intense interest in intestinal neurotransmitters, which are chemicals that the nerves of the intestine use to communicate with each other The interactions of these neurotransmitters are responsible for adjusting (modulating) the functions of the intestines, such as contraction of muscles and secretion of fluid and mucus
5-hydroxytriptamine (5-HT or serotonin) is a neurotransmitter that stimulates several different receptors on nerves in the intestine Examples of experimental drugs for intestinal neurotransmission are sumatriptan ( Imitrex ) and buspirone (Buspar) These drugs are believed to reduce the responsiveness (sensitivity) of the sensory nerves to what’s happening in the intestine by attaching to a particular 5-HT receptor, the 5-HT1 receptor The 5-HT1 receptor drugs, however, have received only minimal study so far and their role in the treatment of dyspepsia, if any, is unclear
Promotility drugs similar to cisapride, as previously discussed, are being pursued actively
Another area of active research is relaxation of the muscles of the stomach for the treatment of dyspepsia Normally when food enters the stomach, the stomach relaxes to accommodate the food and the secretions it stimulates Many patients with dyspepsia have been found to have reduced relaxation of the stomach when food enters, and it is possible that this results in discomfort Drugs that specifically relax the muscles of the stomach are being developed, but more clinical trials showing their benefit are needed What is small intestinal bacterial overgrowth (SIBO)? Small intestinal bacterial overgrowth (SIBO): A potential cause of indigestion is bacterial overgrowth of the small intestine (small intestinal bacterial overgrowth or SIBO), although the frequency with which this condition causes indigestion has not been determined, and there is little research in the area The relationship between overgrowth and indigestion needs to be pursued, however, since many of the symptoms of indigestion are also symptoms of bacterial overgrowth Overgrowth can be diagnosed by hydrogen breath testing and is treated primarily with antibiotics
Other diseases and conditions can aggravate indigestion and other functional diseases Anxiety and/or depression are probably the most commonly-recognized exacerbating factors for patients with functional diseases The menstrual cycle: During their periods, women often note that their functional symptoms are worse This corresponds to the time during which the female hormones, estrogen and progesterone, are at their highest levels Furthermore, it has been observed that treating women who have indigestion with leuprolide (Lupron), an injectable drug that shuts off the body’s production of estrogen and progesterone, is effective at reducing symptoms of indigestion in premenopausal women These observations support a role for hormones in the intensification of fun What endoscopy tests help exclude other diseases?
The endoscopic tests include: Upper gastrointestinal endoscopy (esophago-gastro-duodenoscopy or EGD) to examine the esophagus, stomach and duodenum Colonoscopy to examine the colon and terminal ileum Endoscopy also is available to examine the small intestine, but this type of endoscopy is complex, not widely available, and of unproven value in indigestion To examen the small intestine , a capsule containing a tiny camera and transmitter that can be swallowed (capsule endoscopy) As the capsule travels through the intestines, it transmits pictures of the inside of the intestines to an external recorder for later review The capsule is not widely available and its value, particularly in indigestion, has not yet been proven Newer endoscopes, similar to those used for EGD and colonoscopy are available that allow the entire small intestine to be examined Unlike the capsule, however, the endoscope has channels in it that allow instruments to be passed into the intestine to collect samples of tissue (biopsies) and to treat abnormal findings such as polyps

X-rays are easier to perform and less costly than endoscopies.


The skills necessary to perform gastrointestinal X-rays, however, are becoming rare among radiologists because they are doing them less often Therefore, the quality of the X-rays often is not as high as it used to be, and, as a result, CT scans of the small intestine are replacing small intestinal X-rays

As noted previously, endoscopies have an advantage over X-rays since at the time of endoscopies, biopsies can be taken to diagnose or exclude histological diseases, something that X-rays cannot do.

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