Indigestion is one of those words that we all think we understand but which can be rather hard to define. It is best used as a term to describe unpleasant or even painful sensations in the top of the abdomen or perhaps in the lower part of the chest, which usually come on after eating or drinking. Indigestion is a symptom but not a disease as such. It is so common that nearly everyone experiences it from time to time. Doctors sometimes give indigestion the rather grander name of dyspepsia – but the two words actually mean the same thing. Using rather vague terms means that indigestion can mean different symptoms from one person to another. To some extent, these symptoms vary because they depend on the nature of the underlying problem which is causing indigestion. For example, some people may feel a burning sensation rising up into the chest, called heartburn. After a hot or spicy meal, others experience a more general feeling of fullness and discomfort. Sometimes, a more localised painful sensation just below the tip of the breastbone is felt. Indigestion can occur by itself or may be accompanied by other symptoms, such as nausea, and sometimes by vomiting.
Indigestion is so common that many regard it as a normal part of their lives. Almost all of us are likely to experience indigestion from time to time, often after a heavy, spicy or fatty meal, sometimes when we have rushed our food but quite often when we have simply had too much to eat or drink. Most of the time indigestion is irritating, unpleasant or even a nuisance – rather than a danger. Even after medical investigations, most people with indigestion don’t turn out to have an ulcer or anything else serious. Whilst gastric and duodenal ulcers used to be a common cause of indigestion only a few years ago, they occur less frequently nowadays. Part of the reason for this is that most ulcers are caused by an infection with Helicobacter pylori and this bacterium (stomach bug) is becoming less and less common. We know that people who have to take anti-inflammatory drugs for arthritis and similar conditions are at particular risk of getting both indigestion and a peptic ulcer. An increasing number of people get indigestion because the acid in their stomach can reflux back up into their oesophagus (gullet).
Less commonly, indigestion symptoms can be due to gallstones, disease of the pancreas, and rarely are caused by cancer in the stomach or oesophagus. Happily, most people with indigestion don’t have any of these conditions: such patients are said to have ‘non-ulcer dyspepsia’.
Because the cause of indigestion is often difficult to determine, it is not always easy to say why certain individuals get these symptoms. Over-eating, rushed meals and a lot of spicy and fatty food can cause indigestion for anyone but some people are more prone to underlying conditions such as peptic ulcer disease. This may be partly because ulcers tend to run in families, but ulcers are also more common in people who smoke and those who take one of the many anti-inflammatory drugs for joint and muscle pains. Helicobacter infection usually starts in childhood although indigestion can take many years to develop. Reflux is more common in people who are overweight. Others who feel under stress can experience indigestion. But for many people, there is no obvious reason why such symptoms occur – they just do.
Most indigestion sufferers have their own pattern of symptoms which range from mild discomfort in the upper part of the abdomen to quite severe pain, which sometimes might go through into the back. This can be accompanied by a burning discomfort, rising up from the breastbone into the throat, when reflux of stomach contents into the oesophagus takes place. There may also be nausea and retching or vomiting and others feel very full and bloated after meals. Occasionally, people with indigestion go on to develop complications from the condition that is giving rise to their symptoms. For example, ulcers can bleed or they can perforate (make a hole). When ulcers bleed, this results in vomiting blood which either looks quite fresh or it may resemble coffee grounds. Alternatively, the blood may appear at the other end resulting in the passage of black motions that look like tar. A perforated ulcer causes severe abdominal pain.
We know that indigestion is very common, and most people are able to take care of their symptoms by purchasing over-the-counter remedies from the pharmacist. However, it is worth seeking medical attention if you start getting these symptoms in middle age or later. Also, think about making an appointment if your indigestion does not settle with simple over-the-counter remedies (and there are a wide variety of medicines to try). If you are feeling generally unwell, losing weight or have any other reason to think that there is a serious problem with your health, then of course you should arrange to see your doctor. Any signs of possible internal bleeding mean that you should seek medical advice without delay.
There is no simple answer to this question. It was only a few years ago that many doctors thought that almost all patients with indigestion should have investigations at the hospital. This usually meant having an endoscopy examination which would involve you being asked to swallow a flexible tube to examine you internally. Over the past 10 years, guidance to doctors about how best to investigate patients with indigestion has changed several times. It is fair to say that, nowadays, it is not thought necessary to carry out an endoscopy on most people with indigestion. Unless you have symptoms that lead your doctor to have cause for concern, an endosocpy is rarely essential. Many individuals will be advised, in the first instance, to have some treatment either to reduce the amount of acid that the stomach makes, or perhaps to clear Helicobacter pylori.
There is good evidence that Helicobacter infection not only increases your chance of having a peptic ulcer, but possibly also causes you to have indigestion without necessarily having an ulcer. If you have indigestion, your doctor can check if you have Helicobacter infection either by doing a test on blood taken in the surgery or by a simple breath test. If the results are positive and suggest you have the infection, you are likely to be advised to take a one-week course of treatment with three separate drugs (triple therapy) which are often given without the need for any further investigation. However, if you are an older patient, or someone whose symptoms are persistent and respond badly to treatment, your doctor may recommend that you undergo further investigations.
The most common investigation for those suffering with indigestion is an upper gastrointestinal endoscopy (known as gastroscopy for short) which is a day-case procedure in hospital. As technology improves, this procedure is becoming less and less uncomfortable. Although it is not especially pleasant, most people can tolerate just a few minutes of discomfort (the procedure is not painful) by having an anaesthetic spray to the throat. If you are apprehensive or feel you have a sensitive throat, there are alternatives to make the procedure less daunting. Endoscopy provides a great deal of information about your gullet, stomach and duodenum, and gives the specialist the opportunity to take samples of tissue to look for inflammation and infection.
No one is going to insist that you have an endoscopy, although the procedure is much less unpleasant than it used to be. However, if you are unwilling to have an endoscopy for any reason, it may be reasonable to check whether you have Helicobacter infection and give you treatment if the result is positive. This is called ‘test-and-treat’. This way of helping patients with indigestion is proving increasingly attractive to GPs. Unless there is strong evidence that you have something quite seriously wrong, many of the causes of indigestion can also be controlled by taking tablets that reduce the amount of acid that is made in your stomach. A wide variety of medicines is available to your GP to cut down stomach acid. Your doctor will advise which is most appropriate for you.
Treating indigestion starts by looking for causes which can easily be remedied: over-eating, excess alcohol, heavy smoking, rushed meals, eating too much fatty or spicy foods and taking medications which cause indigestion. Most patients with indigestion are able to control their symptoms simply by taking over-the-counter antacid tablets or liquids from the pharmacist. Some of these treatments work by neutralising stomach acid while others reduce the amount of acid your stomach produces. The Helicobacter test-and-treat approach, which can be organised by your general practitioner, is also often very effective.
As indicated above, an inappropriate diet and eating habits, and taking drugs likely to cause stomach irritation, are common causes of indigestion, and present obvious opportunities for you to help yourself. There isn’t much evidence that stress and worry are linked with indigestion but any measures which promote good health – exercise, weight loss, healthy eating and cutting down on smoking and alcohol, are also likely to improve your general sense of well being.
Some individuals find that particular foods bring on indigestion every time they are eaten – bananas, cucumbers, nuts, tomatoes, citrus fruit, curry – the list is almost endless. Large quantities of spicy and fatty foods, large meals and large amounts of alcohol are likely to bring on indigestion in anyone. Changing your diet is one way of reducing the amount of trouble your indigestion gives you.
Your general practitioner can help in a number of ways. Having listened to your symptoms and examined you, the GP is likely to be able to reassure you that there is no serious underlying cause for your symptoms. Your GP can request a Helicobacter test on a blood sample taken in the surgery, and triple antibiotic therapy can be prescribed in general practice. Your GP can also arrange a follow up breath test to make sure the Helicobacter infection has cleared up. Your doctor will also be able to advice you about whether any other medication that you are taking is likely to be causing indigestion and, should simple medicines obtained from the pharmacist be ineffective, will be able to prescribe longer-term antacid or acid suppressing medication for you.
Many patients with indigestion find that their symptoms improve after they have been investigated and treated by their GP. A small number, however, do go on to have longer-term problems, and they may find that they need to take treatment over a prolonged period. Sometimes, treatment need not be continuous. Finding the lowest dose of the medicine that keeps you well is a wise strategy. You may be able to have breaks between courses of tablets, and just take your treatment when you feel worse.
The short answer is rarely. Most people with indigestion don’t have anything seriously wrong. A small proportion will have an ulcer in their stomach or duodenum, and this can usually be easily dealt with. Only a tiny number of, usually considerably older, patients turn out to have a growth of some kind in their stomach or oesophagus. A small number of patients with reflux symptoms, such as heartburn, may be advised to have regular but infrequent endoscopy tests.
Medical research has enabled many of the important questions about ulcer disease to be answered. However, we have much to learn about Helicobacter pylori and why it causes important problems for some but not all. It would be a major breakthrough to find out why there are people with Helicobacter infection who never have symptoms. Indigestion is one of the commonest reasons for people to visit a GP. We must find out why it is so common – prevention is much better than cure.