Introduction
In this second of 4 posts on Gut Matters we discuss dyspepsia (indigestion) and gastric pain. The feature image shows us a meal that is well planned and right sized. This will prevent indigestion, bloating, and gastric pain.
Dyspepsia as a disease label refers to four conditions:
- (1) Indigestion or dyspepsia which is a sensation familiar to each of us when we overeat;
- (2) Functional dyspepsia (or non-ulcer dyspepsia (NUD)) which is recurrent dyspepsia with no abnormality detected on investigations;
- (3) Gastroesophageal reflux disease (GERD) which is indigestion due to acid reflux and characterized by a taste of sourness coming up the food passage into the mouth; and
- (4) Indigestion and upper abdominal pain due to infection by a bacterium called Helicobacter pylori (H pylori) in the stomach and duodenum.
Investigations
Apart from dyspepsia from overeating, investigations may be needed to determine the cause of dyspepsia. These can be:
Laboratory tests to check for anaemia. (Ref [2])
Endoscopy to check for abnormalities in the esophageal and stomach lining particularly in older people with symptoms that are persistent for two weeks or more. A tube (endoscope) is passed down the esophagus all the way down to the stomach and duodenum to examine the mucosa lining to look for inflammation and ulcer(s). A biopsy of the gastric mucosa lining can also be obtained via the endoscope to examine for the presence of H. pylori bacteria. (Ref [2])
Urea breath test to check for presence of H. pylori bacteria in the stomach and duodenum. To do this a pill, or liquid containing tagged carbon molecules is swallowed. If you have H. pylori infection, carbon is released when the pill or liquid comes in contact with H. pylori bacteria in your stomach. And because your body absorbs the carbon, the carbon is released as tagged carbon dioxide when you breathe out. To measure the released carbon molecules, you blow into a bag and the released carbon molecules are detected and measured. Medications that may interfere with the accuracy of the test e.g., proton pump inhibitors (PPI) or bismuth are stopped for up to 2 weeks before the test. (Ref [3])
Urea breath test to check for cure. The same test used for diagnosis is used to tell if H. pylori infection is eradicated. Generally, you will wait for at least 4 weeks after you have completed the course of antibiotics before repeat testing. (Ref [3])
Treatment pointers
Dyspepsia from overeating. We know what to do. Lifestyle factors may help to ease indigestion. Avoid foods that trigger indigestion. Reduce or eliminate the use of alcohol, smoking. Avoid or reduce use of pain relievers like ibuprofen, or naproxen for joint pains. Control stress and anxiety. Ref 2 (treatment of indigestion).
Functional dyspepsia. Symptoms include pain or burning in the stomach, bloating, or excessive belching. Risk factors are smoking, anxiety or depression. Initial investigations are normal. If symptoms are not controlled by lifestyle changes, further assessment may be needed. Presence of red flags like weight loss, or appetite loss needs investigations too. (Ref 3 and 4)
Gastroesophageal reflux disease (GERD). Pay attention to reduction of risk factors — obesity, smoking, eating large meals or eating late at night, drinking alcohol or coffee. Investigations like endoscopy may be needed to assess inflammation, erosion, and biopsy to assess the extent of inflammatory changes will be needed if symptoms of pain and heart burn are severe. Treatment with proton pump inhibitors like omeprazole, esomemprazole, or lansoparazole, and monitoring progress will be needed. (Ref 5 and 6)
Helicobactor pylori (H pylori) infection. Once confirmed treatment a 7-day triple therapy of proton pump inhibitor, and two kinds of antibiotics are needed for cure. See details in Ref 7.
Take home messages
- 1- Dyspepsia as a disease label has 4 groups of causes.
- 2- Lifestyle improvement may correct some of the causes.
- 3- Treatment of GERD and H. pylori infection require more intensive treatment and follow through.
Acknowledgements
Grateful thanks are due to Maddi-Bazzocco for the feature image of a healthy meal.
References and further reading
- 1-Mayo Clinic. Indigestion. Symptoms & causes. URL: https://www.mayoclinic.org/diseases-conditions/indigestion/symptoms-causes/syc-20352211 Accessed 22 Sep 2022.
- 2-Mayo Clinic. Indigestion. Diagnosis & treatment. URL: https://www.mayoclinic.org/diseases-conditions/indigestion/diagnosis-treatment/drc-20352215 . Accessed 22 Sep 2022.
- 3-Mayo Clinic. Functional dyspepsia. Symptoms & causes. https://www.mayoclinic.org/diseases-conditions/functional-dyspepsia/symptoms-causes/syc-20375709 . Accessed 22 Sep 2022.
- 4-Mayo Clinic. Functional dyspepsia. Diagnosis & treatment. https://www.mayoclinic.org/diseases-conditions/functional-dyspepsia/diagnosis-treatment/drc-20375715 . Accessed 22 Sep 2022.
- 5-Mayo Clinic. Gastroesophageal reflux disease (GERD). Symptoms & causes. https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940 . Accessed 22 Sep 2022.
- 6-Mayo Clinic. Gastroesophageal reflux disease (GERD). Diagnosis & treatment. https://www.mayoclinic.org/diseases-conditions/gerd/diagnosis-treatment/drc-20361959 . Accessed 22 Sep 2022.
- 7-NHS. Derbyshire Joint Area Prescribing Committee. Management of dyspepsia and gastro-esophageal reflux disease. Jul 2022. http://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical_Guidelines/Formulary_by_BNF_chapter_prescribing_guidelines/BNF_chapter_1/Dyspepsia_&_GORD.pdf
Dr LG Goh
Dr GOH Lee Gan is a retired Associate Professor in the Department of Family Medicine, National University Health System. He has an interest in learning and teaching how we can age well everyday (AWE).
