getting to grips with indigestion
by Jenny Bryan
Each year, about four out of ten people suffer from indigestion. But look inside their digestive system, and most will have no obvious signs that there's anything wrong.
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Some will have an inflamed oesophagus and a few will have an ulcer in their stomach or upper intestine. About 30% of people over 50 have a hiatus hernia (see abc of body under 'hiatus hernia') though many of these will have no symptoms at all.
'There are three types of indigestion,' explains Professor Roy Pounder from the Royal Free Hospital, London. 'Reflux type when stuff comes up from the stomach into the chest because of a weak valve into the stomach, indigestion pain which may be improved by eating if it's an ulcer, and dysmotility pain which makes you feel full, bloated and sick.'
Clearly, the pain and discomfort of indigestion is just as real to someone with definite signs of gastric disease as someone whose digestive system looks healthy. And both need help to get rid of their symptoms. As Dr Brendan Delaney, reader in primary care and general practice at Birmingham University points out, persistent reflux can be just as disruptive to sleep and other daily activities as the chest pain of angina.
sorting out the symptoms
The most common symptoms of digestive problems are:
- heartburn – burning feeling starting in the stomach or lower chest and moving up towards the throat
- pain – beneath the breastbone, in the stomach or upper abdomen, with or without other symptoms (eg, heartburn, nausea, vomiting, a feeling of fullness). It can sometimes be confused with the pain of a heart attack or angina, but this is more likely to be crushing and gripping, often spreading down the left arm (see chest pain needs a rapid response)
- bloating – feeling uncomfortably full, with a lot of internal gas and the need to burp, belch or pass wind.
Many people complain of a mixture of heartburn, pain and bloating and it's the doctor's job to work out which is causing them the most trouble so he or she can decide the most likely cause. Another term you may hear is 'dyspepsia'. Doctors keep changing what they mean by dyspepsia but, at present, they use it as a way of grouping all of the core symptoms of ulcer-type indigestion together, ie, epigastric pain, heartburn and bloating.
Heartburn is usually a symptom of gastro-oesophageal reflux disease (GORD) in which the acid contents of the stomach move up into the oesophagus where they may cause irritation and inflammation (see abc of body under 'gastro-oesophageal reflux disease').
While heartburn is reflux-related, pain may or may not be due to an ulcer in the stomach or the top part of the intestine – the duodenum. An ulcer is a patch of severely inflamed tissue, often fried-egg like in appearance, which penetrates into the underlying layers of the stomach or duodenum. Left untreated it may rupture and cause potentially life threatening internal bleeding.
The good news is that gastric and duodenal ulcers have become less common in recent years. The bad news is that more people are getting non-ulcer dyspepsia – they have all the symptoms of an ulcer but, when they have tests to look for one, there's no sign of an ulcer.
do I need tests?
Most people under 55 who go to their doctor for the first time complaining of indigestion, heartburn or pain won't be offered any tests. This is partly because symptoms often occur without any clear signs of gastric disease. So doctors tend to reserve investigations for older people who may have additional worrying symptoms, such as swallowing difficulties, loss of appetite, weight loss or anaemia, or who do not respond to treatment for indigestion.
Where it is considered necessary, the most likely investigation is endoscopy. This means putting a miniature telescope down your oesophagus into your stomach and duodenum to look for signs of disease and, if necessary, to snip off small pieces of tissue for examination in the laboratory.
what's the best treatment?
Doctors have more guidelines on how to treat indigestion than virtually any other health problem. But in July 2000 the National Institute for Clinical Excellence (NICE) issued guidance aimed at cutting £50 million off the cost of treating dyspepsia. Doctors were urged to use cheaper antacids and acid-suppressing drugs to reduce the acid in the stomach and relieve symptoms of indigestion, rather than a more expensive and more powerful group of drugs, called proton pump inhibitors (PPIs) (see abc of body under 'proton pump inhibitor').
For people with mild symptoms of dyspepsia or GORD, the guidance recommended a 'step up' approach:
- start with a low-dose antacid which relieves symptoms by reducing the effects of acids in the stomach
- if this doesn't help, switch to a histamine (H2) antagonist which suppresses acid production (see abc of body under 'histamine antagonist')
- if symptoms remain uncontrolled, move to a PPI which has a more powerful acid-suppressing effect.
Once symptoms are controlled, doctors are advised to maintain people on the lowest dose of PPI or other treatment which will keep their symptoms at bay.
For people with more severe symptoms of dyspepsia or GORD, the guidance recommended a 'step down' approach:
- start with a high dose of PPI and reduce the dose or switch to another medication once symptoms are controlled.
Although this approach makes good economic sense, many people do not go to their doctor until they have tried antacids and H2 antagonists themselves. So they want something more powerful. And, as Professor Pounder explains, once they have tried a PPI they don't want to go back to less powerful treatment.
'It's a bit like asking someone to drive a Mondeo after they've had a Rolls Royce. The problem with PPIs is that they stop acid 24 hours a day and most people don't need that level of control. All vertebrates have acid in their stomach so there must be some reason why we have it. But once people have experienced the effects of PPIs, they don't want to stop,' he says.
Dr Delaney also supports starting with a PPI for fast relief of symptoms, especially for people with more heartburn than stomach pain. But he believes that most people prefer to reduce the amount of medicine they take, when they have the chance.
'If people can get control of their symptoms quickly they don't want to continue on more medication than they need and I suggest they halve the dose of PPI and then try stopping it for a few days and see how they get on. It's not about Rolls Royces and Mondeos, but about whether you'd get the car out at all if you're only going 100 yards!' he says.
self help treatments
Whether or not you take medicines to relieve your indigestion, there are a number of things you can do to help prevent symptoms:
- avoid large fatty meals, especially within three hours of bed time
- eat smaller, healthier meals spread through the day
- if you are overweight, find a realistic diet that can help retrain your eating habits and take more exercise
- avoid or reduce smoking since this can make leaky gastric valves worse, leading to more reflux
- avoid non-steroidal anti-inflammatory drugs (eg, aspirin, ibuprofen) which may irritate the stomach lining
- reduce alcohol intake
- avoid or reduce any food or drink that triggers attacks (eg, spicy food, fruit juices, tea and coffee)
- eat meals in an upright chair rather than slumped in front of the TV
- avoid tight clothes that put pressure on the stomach
- avoid bending from the waist or stooping just after meals. Bend from the knees, keeping the back straight
- raise the head of the bed by about 15cm (6in) to reduce the risk of night-time symptoms.
testing for Helicobacter
Nearly 20 years ago, Australian researchers discovered a link between stomach infection with a bacterium called Helicobacter pylori and gastric and duodenal ulcers. It took several years of research to confirm that the microbe is indeed the main cause of ulcer disease but, fortunately, it can be eradicated with a combination of antibiotics and a PPI.
Doctors are continuing to debate who should be tested for H. pylori, but mass screening is not considered worthwhile. Instead, testing and treatment are usually reserved for people with clear evidence of an ulcer or who have dyspepsia that does not respond to antacids and H2 antagonists.
'Testing and treating these patients is as effective as sending them for an endoscopy, and cheaper. The question is where to draw the line. Should we test and treat at an earlier stage?' questions Dr Delaney.
As no one is sure, a new study is going to compare the benefits of testing and treating H. pylori when people first go to their doctor with dyspepsia, compared with putting them on a PPI.
Whether to test for H. pylori in people with GORD is even more controversial. Getting rid of the bacterium is unlikely to relieve symptoms, and further research is planned to decide the best approach.
help and info
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organisations
Digestive Disorders Foundation
PO Box 251
Edgware HA8 6HG
Tel: 020 7486 0341
E-mail: ddf@digestivedisorders.org.uk
Website: www.digestivedisorders.org.uk
Funds research into digestive disorders and provides information for sufferers, their families and friends (although does not deal with individual medical enquiries). Leaflets are available on the informative website.
websites
GastroHep.com
www.gastrohep.com
Online resource for all aspects of gastroenterology, hepatology and endoscopy.
Indigestion (dyspepsia)
http://hcd2.bupa.co.uk/fact_sheets/html/Dyspepsia.html
BUPA factsheet on the symptoms and causes of indigestion.
Rennie
www.rennie.co.uk
Website by the makers of Rennie, featuring information on indigestion, heartburn, bloating and trapped wind, and details of products.
reading
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Stop Belly-aching: Banish indigestion and irritable bowel syndrome by Peter Mansfield (Souvenir Press Ltd, 2001) |
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BMA Family Doctor Series: Indigestion and ulcers by Tony Smith (Dorling Kindersley, 2000) |
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Healthy Digestion the Natural Way by Lindsey Berkson (John Wiley & Sons, 2000) |
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(June 2003, resources updated January 2005)
