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Indigestion -jes(h)-chən

(Dyspepsia)

by Norton J. Greenberger, MD

Indigestion is pain or discomfort in the upper abdomen. People may also describe the sensation as gassiness, a sense of fullness, or gnawing or burning. The sense of fullness may occur after a small meal (early satiety), be a feeling of excessive fullness after a normal meal (postprandial fullness), or be unrelated to meals. For more about severe abdominal discomfort, see Acute Abdominal Pain.

Because dyspepsia is usually a vague, mild discomfort, many people do not seek medical care until it has been present (or coming and going) for a long time. Sometimes, dyspepsia is a more sudden, noticeable (acute) sensation.

Depending on the cause of the dyspepsia, people may have other symptoms such as a poor appetite, nausea, constipation, diarrhea, flatulence, and belching. For some people, eating makes symptoms worse. For others, eating relieves symptoms.

Causes

Dyspepsia has many causes, which, despite common use of the term indigestion, do not involve a problem digesting food.

Acute dyspepsia may occur briefly after ingestion of

  • A large meal

  • Alcohol

  • Certain irritating drugs (such as bisphosphonates, erythromycin, iron, or nonsteroidal anti-inflammatory drugs [NSAIDs])

    Also, some people having a heart attack or unstable angina (coronary artery ischemia) may feel only a sensation of dyspepsia, rather than chest pain (see Chest or Back Pain).

For recurrent dyspepsia, common causes include

  • Achalasia

  • Cancer (of the stomach or esophagus)

  • Delayed gastric (stomach) emptying

  • Drugs

  • Gastroesophageal reflux disease (GERD)

  • Gastritis or peptic ulcer disease

  • Unknown (nonulcer dyspepsia)

Achalasia (see Achalasia) is a disorder in which the rhythmic contractions of the esophagus greatly decrease and the lower esophageal muscle does not relax normally.

Delayed gastric emptying is a situation in which food remains in the stomach for an abnormally long period of time. Delayed emptying is usually caused by a disorder (such as diabetes, a connective tissue disorder, or a neurologic disorder) that affects the nerves to the digestive tract.

Anxiety by itself does not cause dyspepsia. However, anxiety can sometimes worsen dyspepsia by increasing the person’s concern about unusual or unpleasant sensations, so that minor discomfort becomes very distressing.

In many people, doctors find no abnormality during a physical examination or after looking in the esophagus and stomach with a flexible viewing tube (upper endoscopy). In such cases, called nonulcer (functional) dyspepsia, the person's symptoms may be due to an increased sensitivity to sensations in the stomach or to intestinal contractions.

Evaluation

Not every episode of dyspepsia requires immediate evaluation by a doctor. The following information can help people decide when a doctor’s evaluation is needed and help them know what to expect during the evaluation.

Warning signs

In people with dyspepsia, certain symptoms and characteristics are cause for concern. They include

  • Shortness of breath, sweating, or fast heart rate accompanying an episode of dyspepsia

  • Loss of appetite (anorexia)

  • Nausea or vomiting

  • Weight loss

  • Blood in the stool

  • Difficulty swallowing (dysphagia) or pain with swallowing (odynophagia)

  • Dyspepsia that persists despite treatment with drugs such as proton pump inhibitors (PPIs)

When to see a doctor

People who have a single, sudden episode of dyspepsia should see a doctor right away, especially if their symptoms are accompanied by shortness of breath, sweating, or a fast heart rate. Such people may have acute coronary ischemia. People with chronic dyspepsia that occurs when they exert themselves but that goes away when they rest may have angina (see Angina) and should see a doctor within a few days.

People with dyspepsia and one or more of the other warning signs should see a doctor within a few days to a week. Those with recurrent dyspepsia and no warning signs should see a doctor at some point, but a delay of a week or so is not harmful.

What the doctor does

Doctors first ask questions about the person's symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause of the dyspepsia and the tests that may need to be done (see Table: Some Causes and Features of Indigestion).

The history is focused on obtaining a clear description of the symptoms, including whether they are sudden or chronic. Doctors need to know the timing and frequency of recurrence, any difficulty swallowing, and whether the symptoms occur only after eating, drinking alcohol, or taking certain drugs. Doctors also need to know what factors make the symptoms worse (particularly exertion, certain foods, or alcohol) or relieve them (particularly eating or taking antacids).

Doctors also ask the person about gastrointestinal symptoms such as anorexia, nausea, vomiting, vomiting of blood (hematemesis), weight loss, and bloody or black stools. Other symptoms include shortness of breath and sweating.

Doctors need to know whether the person has been diagnosed with a gastrointestinal and/or heart disorder, has any heart risk factors (such as high blood pressure [hypertension] or an excessive amount of cholesterol in the blood [hypercholesterolemia]), and the results of previous tests that have been done and treatments that have been tried.

The physical examination usually does not give doctors clues to a specific diagnosis. However, doctors look for signs of chronic disease, such as very pale skin, wasting away of muscle or fat tissue (cachexia), or yellowing of the eyes and skin (jaundice). They also do a rectal examination to detect any blood. Doctors are more likely to recommend testing for people with such abnormal findings.

Some Causes and Features of Indigestion

Cause

Common Features*

Tests

Achalasia (rhythmic contractions of the esophagus are greatly decreased, and the lower esophageal muscle does not relax normally)

Difficulty swallowing (dysphagia) that worsens over months to years

Sometimes spitting up (regurgitation) of undigested food while sleeping

Discomfort in the chest

Fullness after a small meal (early satiety), nausea, vomiting, bloating, and symptoms that are worsened by food

X-rays of the upper digestive tract after barium is given by mouth (barium swallow)

Measurements of pressure produced during contractions of the esophagus (esophageal manometry)

Cancer (such as cancer of the esophagus or stomach)

Chronic, vague discomfort

Later, dysphagia with esophageal cancer or early satiety with stomach cancer

Weight loss

Upper digestive tract endoscopy (examination of the esophagus, stomach, and duodenum using a flexible viewing tube called an endoscope)

Coronary ischemia (inadequate blood flow to the coronary arteries)

Sometimes in people who have symptoms when exerting themselves

Risk factors for heart disorders (such as high blood pressure, diabetes, and/or high cholesterol levels)

Electrocardiography (ECG)

Blood tests

Sometimes stress testing

Drugs (such as bisphosphonates, erythromycin and other macrolide antibiotics, estrogens, iron, nonsteroidal anti-inflammatory drugs [NSAIDs], and potassium)

In people who are taking a drug that can cause indigestion

Symptoms occur shortly after taking the drug

A doctor’s examination

Esophageal spasm

Sometimes difficulty swallowing liquids and solids

Barium swallow

Esophageal manometry

Gastroesophageal reflux disease (GERD)

Heartburn and/or sometimes reflux of acid or stomach contents into mouth

Symptoms sometimes triggered by lying down

Relief with antacids

A doctor's examination

Sometimes trying treatment with drugs to suppress acid production

Sometimes endoscopy of the upper digestive tract

Peptic ulcer disease

Burning or gnawing pain occurring before meals and partially relieved by eating food or taking antacids, histamine-2 (H 2 ) blockers, or proton pump inhibitors (PPIs)

May awaken people at night

Endoscopy of the upper digestive tract

Poor stomach emptying (gastroparesis)—usually due to other disorders such as diabetes, connective tissue disorders, and/or neurologic disorders

Nausea, abdominal pain, and sometimes vomiting

Early satiety

Sometimes in people who are known to have a causative disorder

Endoscopy of the upper digestive tract and/or nuclear scanning to evaluate stomach emptying

*Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. Features overlap between causes.

CT = computed tomography; MRI = magnetic resonance imaging.

Testing

Possible tests include

  • Upper endoscopy

  • Blood tests

Because of the risk of cancer, doctors typically look in the esophagus and stomach with a flexible tube (upper endoscopy) in people who are over age 45 and in younger people with warning signs. Those who are younger and have no symptoms other than dyspepsia are often treated with acid-blocking drugs. If this treatment is unsuccessful, doctors usually do an endoscopy.

People with symptoms of acute coronary ischemia, particularly those with risk factors, should go to the emergency department for an immediate evaluation, including electrocardiography (ECG) and blood tests for damage to heart muscle cells.

People with chronic, nonspecific symptoms should undergo blood tests. If results of the blood tests are abnormal, doctors consider additional tests (such as imaging studies or endoscopy). Some doctors recommend screening for Helicobacter pylori infection with a breath test or a test of a stool sample.

Doctors do esophageal manometry (see Manometry) and pH (acidity) studies for people who still have reflux symptoms after they have undergone an upper endoscopy and have been taking a proton pump inhibitor (PPI) for 2 to 4 weeks.

Sometimes an abnormality found during testing (such as gastritis or gastroesophageal reflux) is not the cause of the person's dyspepsia. Doctors know this only when the disorder clears up but symptoms of dyspepsia do not.

Treatment

The best way to treat dyspepsia is to treat any underlying disorders. People with no identifiable disorders are observed over time and reassured.

For people who do not appear to have a specific disorder, doctors often try treatment with acid-blocking drugs (such as proton pump inhibitors or histamine-2 [H 2 ] blockers) or drugs that combat ulcers by increasing the amount of mucus in the stomach (cytoprotective agents). Alternatively, doctors may give a drug that helps stimulate movement of the digestive tract muscles (prokinetic drugs—such as metoclopramide and erythromycin). Doctors may prescribe an antidepressant for some people.

Key Points

  • People with severe “gas” discomfort in the upper abdomen or chest may have acute coronary ischemia.

  • People who have warning signs and who are over age 45 require an endoscopy.

  • People who have no warning signs and who are under age 45 are treated with an acid-blocking drug.

  • People whose symptoms do not lessen in 2 to 4 weeks require further evaluation.

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Drugs Mentioned In This Article

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    Select Brand Names
  • ERY-TAB, ERYTHROCIN
  • REGLAN