Indigestion Or Dyspepsia

“Indigestion” is a layman term which doctors call “Dyspepsia”. The definition is not simple as it is a very subjective set of symptoms which may be called different things depending on language and culture.

The symptoms in question are:

• Upper abdominal (epigastric) pain or burning
• Fullness or bloatedness especially after food
• Early satiation after eating small amounts of food

The symptom of heartburn is excluded from the definition as this is thought to be specific to gastro-oesophageal reflux disease, which is quite different from dyspepsia. Chest pain per se is also not included in the definition as the approach to this is somewhat different.

Un-investigated dyspepsia must be distinguished from dyspepsia from organic diseases and “functional dyspepsia” (that for which no disease is obvious after investigation, more of which later). Of the organic diseases, the common ones are:

• Peptic ulcer disease (gastric and duodenal ulcers)
• Gastritis or duodenitis, including that related to Helicobacter pylori infection
• Reflux disease (where heartburn is not the predominant symptom)
• Gastric cancer
• Oesophageal cancer

It is important to note that whether organic disease is found or it is thought to be “functional dyspepsia”, it has been shown by studies that the quality of life of patients may be equally impacted. Therefore “functional dyspepsia” is not something to be dismissed and must be actively managed.

The initial management of dyspepsia is intended to determine whether there is demonstrable disease in the upper digestive tract as well as to exclude non digestive causes of upper abdominal pain, such as liver, bile duct or pancreatic disease. Some metabolic disorders also lead to abdominal pain, such as diabetes mellitus, thyroid or parathyroid disorders or electrolyte imbalance, including that due to kidney disease. Drug use must be elucidated as some drugs cause similar symptoms, e.g. non-steroidal anti-inflammatory analgesics (NSAIDs), antibiotics, asthma medicines, iron supplements or alcohol. A good clinical history and thorough physical examination are therefore important.

If investigations are thought to be necessary, first line tests would include some or all of the following depending on the clinical circumstances:

• Blood count
• Biochemistry (urea, electrolytes)
• Liver function test
• Faecal occult blood test
• Gastroscopy
• Ultrasound of the abdomen

Other tests that are less commonly done, but which may be indicated in specific clinical scenarios include:

• Gastric emptying studies
• Oesophageal manometry, pH monitoring or impedance manometry
• Food intolerance tests

Some patients may have a higher suspicion of serious illness and they should be investigated early. They are:

• Previously well patients who present with newly-developed dyspepsia
• Patients older than 50 years of age, when the risk of cancer sharply rises
• Patients smoking or drinking or using NSAIDs
• Patients whose true agenda is exclusion of cancer
• Patients with strong family history of cancer, especially gastrointestinal cancer
• Patients with severe, long-standing symptoms which were not investigated previously
• Patients with psychological problems
• Patients whose symptoms are very typical of either peptic-ulcer disease

Certainly patients with “alarm” symptoms or signs should be given special attention as they usually suggest serious illness. Alarm symptoms and signs include:

• Weight loss
• Dysphagia (food not going down upon swallowing)
• Persistent vomiting
• Severe pain
• Bleeding (including occult bleeding found on faecal occult blood test & unexplained anaemia)
• Jaundice
• Palpable mass

There is a school of thought that recommends that patients who do not have suspicious or alarming features may be managed by first being given empirical treatment to see if they get well, so as to avoid expensive investigations in patients in whom serious diseases seems unlikely. The problem is that it is unclear what to treat or what medicines to treat with (e.g. whether to use acid lowering medicines alone, or to treat possible H. pylori infection). On top of that, response or non-response provides no information at all on what the diagnosis might be and there remains the chance that serious disease such as cancer might be missed with consequent delay in treating it. One possible strategy for places where the prevalence of H. pylori is high is to test for this by blood or breath tests and treat if positive, assuming that even if present, H. pylori is the cause of symptoms rather than an incidental finding.

On balance it seems more reasonable to have some certainty as to what the cause of dyspepsia is, given that blood tests and other tests such as ultrasound or upper gastrointestional endoscopy are all easily available, affordable and mostly harmless. Certainty of diagnosis is also also very helpful in reassuring patients that they have no dangerous disease.

“Functional dyspepsia” is a well-recognised entity of dyspeptic symptoms where no specific disease has been found. Recent consensus is that this may be divided into 2 sub-groups: Postprandial distress syndrome (more meal related) and epigastric pain syndrome (persistent pain unrelated to meals). The cause of functional dyspepsia is unclear, but it is thought to be due to a combination of motility disturbances, sensory hypersensitivity, aberrant processing of stimuli or unknown inflammation. Treatment is empirical and usually includes acid suppressing drugs such as proton pump inhibitors and prokinetic drugs that alter motility of the upper digestive tract. Sometimes there is a psychological overlay as well, which may require drugs or psychotherapy.

In conclusion, dyspepsia is a common complaint for which there are a number of specific diseases that may cause symptoms. If un-investigated, it may remain unclear if there is organic disease, or whether it is functional dyspepsia. Some investigations may be necessary to rule out serious disease such as cancer, to diagnose other specific illnesses that can be specifically treated, or simply to provide reassurance to a patient that there is no serious diagnosis. Where functional dyspepsia is diagnosed, patients must be reassured that it is not dangerous, that it can be managed, but that they must have realistic expectations of empirical treatments. A good patient doctor relationship is crucial in such cases.