Dyspepsia is gastric upset due to the inability to digest one’s food.
Dyspepsia is a word that has been used in English since the early eighteenth century not only for a variety of stomach ailments but also for bad moods or temper outbursts that were thought to be caused by indigestion. The English word comes from two Greek words meaning “hard or difficult’ and “digestion.’ For many years dyspepsia was a catchall term for any kind of stomach upset characterized by burning, nauseous, or gassy sensations in the upper abdomen. Several phrases that are still used almost interchangeably for the condition are gastric indigestion, nervous dyspepsia, and impaired gastric function.
Dyspepsia was not defined more closely until the mid-1980s, when an international group of gastroen-terologists (doctors who specialize in treating disorders of the digestive system) met in Rome to create a set of criteria for distinguishing dyspepsia from other disorders of the upper digestive tract (known as the Rome criteria); and to distinguish between organic dyspepsia—stomach upset that can be shown to have a physical cause (for example, stomach irritation caused by alcohol consumption ), and functional dyspepsia (FD)—dyspepsia that cannot be traced to any specific physical cause. FD accounts for a majority of cases of dyspepsia, as many as 60% in some studies, and for 30–50% of all referrals from primary care doctors to gastroenterologists.
Dyspepsia is considered a difficult condition to treat, even though it is widespread in the general population. An estimated 25–40% of adolescents and.
adults in North America experience dyspepsia each year. Most people with the disorder do not seek medical treatment because it may be intermittent as well as persistent. FD is responsible for high health care costs in terms of prescription as well as over-the-counter medications, diagnostic tests, and time lost from work.
In the nineteenth and early twentieth centuries, FD was commonly treated with various forms of dietary therapies. Treatments commonly recommended by doctors in the 1920s included vegetarian diets as well as the use of laxatives and enemas to cure the patient of autointoxication—an imaginary disorder that originated in ancient Egypt and is based on the belief that the contents of the colon are toxic and capable of poisoning other body organs. Folk dietary remedies for dyspepsia included drinking peppermint tea or milk, eating spearmint leaves, or chewing mint-flavored chewing gum, which first became popular in the 1860s.
Although FD is not fully understood, there are several theories regarding its underlying mechanisms or possible causes:
- FD reflects greater than average sensitivity to uncomfortable sensations in the digestive tract. This theory holds that patients with FD perceive sensations in the stomach or intestines as painful that most people experience as ordinary or do not feel at all
Autointoxication —A belief, now discredited, that the contents of the intestine are toxic and produce poisons that can damage other body organs.
Endoscope —A special tube-shaped instrument that allows a doctor to examine the interior of or perform surgery inside the stomach or intestines. An examination of the digestive system with this instrument is called an endoscopy.
Gastroenterologist —A doctor who specializes in diagnosing and treating disorders of the digestive system.
Gastroesophageal reflux disease (GERD) —A disorder caused by the backward flow of stomach acid into the esophagus. It is usually caused by a temporary or permanent change in the sphincter that separates the lower end of the esophagus from the stomach.
Helicobacter pylori —A spiral-shaped Gram-negative bacterium that lives in the lining of the stomach and is known to cause gastric ulcers.
Placebo effect —A term that describes the improvement in symptoms that some patients experience when they are given a placebo (sugar pill or other inert substance that does not contain any medication) as part of a clinical trial. Patients with functional dyspepsia show a high rate of placebo effect in trials of new medications for the disorder.
Prokinetic drugs —A class of medications given to strengthen the motility of the digestive tract.
Rome criteria— A set of guidelines for defining and diagnosing functional dyspepsia and other stomach disorders, first drawn up in the mid-1980s by a group of specialists in digestive disorders meeting in Rome, Italy. The Rome criteria continue to be revised and updated every few years.
- FD is a motility disorder. FD may result from a decreased ability of the digestive system to contract and push food through the system. This, in turn, causes lower than normal stomach emptying
- FD is caused by Helicobacter pylori infection. H. pyloriis a spiral-shaped bacterium that is the only known microorganism that can live in the acidic environment of the stomach. It is now known to be a cause of peptic ulcers, but doctors do not yet agree on its role in functional dyspepsia
The Rome criteria for FD specify that the patient must have had 12 weeks (not necessarily consecutively) of the following symptoms in the previous 12 months:
- Persistent or recurrent pain or discomfort centered in the upper abdomen
- No evidence of an organic disease (including the findings from an endoscopy of the upper digestive tract) that is likely to explain the symptoms; and
- No evidence that the dyspepsia is relieved exclusively by defecation or associated with the onset of a change in bowel habits
The Rome criteria specify three subtypes of FD based on the most bothersome symptom: ulcer-like dyspepsia (pain in the upper abdomen); dysmotility-like dyspepsia (an unpleasant but nonpainful feeling of bloating, fullness, or nausea); and unspecified dyspepsia (patient’s digestive discomfort does not fit either of the first two categories).
FD is widespread in the general population, however, the subtypes identified by the Rome working group appear to show slight gender differences. Ulcer-like dyspepsia appears to be more common in men and dysmotility-like dyspepsia more common in women. FD is equally widespread in all racial and ethnic groups.
Some medications other than aspirin and other over-the-counter pain relievers may cause dyspepsia: alendronate (Fosamax); codeine and aspirin fortified with codeine; iron supplements; metformin (Gluco-phage); oral antibiotics, particularly erythromycin; orlistat (Xenical); corticosteroids, especially predni-sone; and theophylline. Patients should consult their doctors before discontinuing these drugs or changing the dosage.
Dietary treatment for dyspepsia generally consists of cutting down on alcohol intake; avoiding fatty or highly spiced foods; and avoiding any other food that appears to trigger episodes of dyspepsia. Therapeutic fasting, which is thought to give the digestive system a period of rest before making other changes in the patient’s diet or beginning medication therapy, may be recommended.
Patients with FD may also benefit from discontinuing certain herbal remedies that produce symptoms of dyspepsia. These include garlic, gingko, saw palmetto, feverfew, chaste tree berry, and willow bark.
Other treatments for functional dyspepsia include complementary and alternative (CAM) therapies and psychotherapy. CAM treatments include such herbal remedies as peppermint, turmeric, and aloe vera gel taken by mouth, and such non-dietary treatments as yoga, meditation, relaxation techniques, acupuncture, and music therapy. Psychotherapy is most likely to be helpful for patients with a history of abuse or post-traumatic stress as well as functional dyspepsia.
Prokinetic drugs may be prescribed for patients with dysmotility-like FD. These medications speed up or strengthen the contractions of the small intestine. Available medications include metoclopramide (Reglan), cisapride (Propulsid), and domperidone (Motilium). Domperidone is not approved for use in the United States because its adverse effects include abnormalities of heart rhythm. In addition to prokinetic drugs, some doctors prescribe antidepressant medications in order to lower the patient’s stress level and awareness of sensations coming from the stomach and intestines, but only a minority of patients with FD benefit from either proki-netics or antidepressants.
Medical management of FD in patients typically begins with either testing and treating the patient for infection with H. pylori or by prescribing medications to lower the level of stomach acid secretions for a trial period of 4–8 weeks. The two classes of medications most commonly prescribed to reduce acid secretion are H2-receptor blockers and proton pump inhibitors (PPIs). The first group, which is the older of the two, was developed in the late 1970s and early 1980s and includes such drugs as cimetidine (Tagamet) and rani-tidine (Zantac). The proton pump inhibitors are more powerful than the H2-receptor blockers and have fewer adverse effects. The PPIs include omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), pantoprazole (Protonix), and rabeprazole (Rabecid). In general, trial therapy with acid-reducing medications is considered more effective for FD than testing for and treating H. pylori infection, because only a small minority of patients with FD report.
QUESTIONS TO ASK YOUR DOCTOR
- What are the chances that dyspepsia in a person of my age and sex represents a serious disorder?
- What is your opinion of dietary changes in treating dyspepsia?
- Would you recommend therapeutic fasting before beginning medication treatment for dyspepsia?
improvement in their symptoms after treatment for the infection.
The function of medical and dietary treatment of FD is to manage or relieve the patient’s symptoms in order to improve his or her quality of life. Therapeutic fasting is intended to give the digestive system a brief period of rest prior to medication therapy or antibiotics to eradicate H. pylori Since the cause(s) of FD are not yet known for certain, these treatments cannot be considered cures.
The benefits of medical and dietary treatment of FD are improved symptom management and better quality of life, with less time lost from school or work.
Patients who experience dyspepsia for several weeks or longer should consult their physician for an evaluation to rule out more serious disorders; even if the indigestion is intermittent rather than continuous. Patients over age 45 who develop dyspepsia suddenly should see their doctor immediately, particularly if the indigestion is accompanied by black tarry stools, loss of appetite, painful swallowing, bloody vomit, or unintentional weight loss.
Patients who experience indigestion unrelated to eating, or indigestion accompanied by sweating, shortness of breath, or pain radiating to the neck, jaw, or arm should also see a doctor at once, as these symptoms may indicate a heart attack.
There are no known risks associated with modifying one’s diet to relieve functional dyspepsia, although patients considering a therapeutic fast should consult their doctor first. Medications given to treat FD may have any of the following adverse effects: skin rashes; constipation or diarrhea; confusion; higher risk of osteoporosis and bone fractures; headache; fatigue; dizziness; and low blood pressure. Cimetidine has been reported to cause impotence and loss of interest in sex in males; these symptoms disappear when the drug is discontinued.
A population-based case-control study of adults in Minnesota found that there was no detectable difference in the consumption of frequently suspected culprit foods by patients with FD and the control subjects. There is also no evidence that a strictly vegetarian diet is useful in treating FD. Recent studies carried out in Germany indicate that a brief period of fasting under a doctor’s supervision is beneficial to patients with FD.
Research is ongoing to improve the number and effectiveness of treatment options for dyspepsia. In 2006, a new drug called itopride was tested for eight weeks on a group of 523 patients with functional dyspepsia. The drug requires further study, but the results of the initial trial are encouraging. Clinical trials sponsored by the National Institutes of Health are recruiting subjects to study medications or other forms of therapy for dyspepsia. They include studies of the effectiveness of acid-reducing therapy or eradication of H. pylori, and evaluation of food hyper-sensitivity in patients with dyspepsia.
In the field of CAM therapies, studies are being conducted of peppermint oil and turmeric as plant- or food-based treatments for dyspepsia. With regard to aloe vera, research indicates that it should not be taken by mouth as a remedy for dyspepsia because it has laxative qualities and can lower the body’s absorption of prescription medications. Other CAM approaches for dyspepsia being studied are mind/body approaches like relaxation training, yoga, and hypnosis, and energy therapies like acupuncture and therapeutic touch. European studies indicate that hydrotherapy and massage therapy are beneficial to patients with functional FD.
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American College of Gastroenterology (ACG). 6400 Goldsboro Road, Suite 450, Bethesda, MD 20817. Telephone: (301) 263-9000. Website: <http://www.acg.gi.org>
International Foundation for Functional Gastrointestinal Disorders (IFFGD). P.O. Box 170864, Milwaukee, WI 53217. Telephone: (888) 964-2001 or (414) 964-1799. Website: <http://www.iffdg.org>
National Center for Complementary and Alternative Medicine (NCCAM). 9000 Rockville Pike, Bethesda, MD 20892. Telephone: (888) 644-6226. Website: <http://nccam.nih.gov>
National Digestive Diseases Information Clearinghouse (NDDIC). 2 Information Way, Bethesda, MD 20892-3570. Telephone: (800) 891-5389. Website: <http://digestive.niddk.nih.gov/>
North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN). P.O. Box 6, Flourtown, PA 19031. Telephone: (215) 233-0808. Website: <http://www.naspghan.org>
Rebecca J. Frey, PhD
Dyspepsia can be defined as painful, difficult, or disturbed digestion, which may be accompanied by symptoms such as nausea and vomiting, heartburn, bloating, and stomach discomfort.
Causes and symptoms
The digestive problems may have an identifiable cause, such as bacterial or viral infection, peptic ulcer, gallbladder, or liver disease. The bacteria Helicobacter pylori is often found in those individuals suffering from duodenal or gastric ulcers. Investigation of recurrent indigestion should rule out these possible causes.
Often, there is no organic cause for the problem, in which case dyspepsia is classified as functional or nonulcer dyspepsia. There is evidence that functional dyspepsia may be related to abnormal motility of the upper gastrointestinal tract (a state known as dysmotility in which the esophagus, stomach, and upper intestine behave abnormally). These patients may respond to a group of drugs called prokinate agents. A review of eating habits (e.g., chewing with the mouth open, gulping food, or talking while chewing) may reveal a tendency to swallow air. This may contribute to feeling bloated, or to excessive belching. Smoking, caffeine, alcohol, or carbonated beverages may contribute to the discomfort. When there is sensitivity or allergy to certain food substances, eating those foods may cause gastrointestinal distress. Some medications are associated with indigestion. Stomach problems may also be a response to stress or emotional unrest.
A physical examination by a health care professional may reveal mid-abdominal pain. A rectal examination may be done to rule out bleeding. If blood is found on rectal exam, laboratory studies, including a blood count may be ordered. Endoscopy and barium studies may be used to rule out underlying gastrointestinal disease. Upper gastrointestinal x-ray studies using barium may allow for visualization of abnormalities. Endoscopy permits collection of tissue and culture specimens which may be used to further confirm a diagnosis.
The treatment of dyspepsia is based on assessment of symptoms and suspected causative factors. Clinical evaluation is aimed at distinguishing those patients who require immediate diagnostic work-ups from those who can safely benefit from more conservative initial treatment. Some of the latter may require only reassurance, dietary modifications, or antacid use. Medications to block production of stomach acids, prokinate agents, or antibiotic treatment may be considered. Further diagnostic investigation is indicated if there is severe abdominal pain, pain radiating to the back, unexplained weight loss, difficulty swallowing, a palpable mass, or anemia. Additional work-up is also indicated if a patient does not respond to prescribed medications.
Statistics show an average of 20% of patients with dyspepsia have duodenalor gastric ulcer disease, 20% have irritable bowel syndrome, fewer than 1% of patients had cancer, and the range for functional, or non-ulcer dyspepsia (gastritis or superficial erosions), was from 5-40%.
Talley, N. J. "Non-ulcer Dyspepsia: Current Approaches to Diagnosis and Management." American Family Physician May 1993: 1407-1416.
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Anemia— Diagnosed through laboratory study of the blood, a deficiency in hemoglobin or red blood cells, often associated with paleness or loss of energy.
Endoscopy— A diagnostic procedure using a lighted instrument to examine a body cavity or internal organ. Endoscopy permits collection of tissue and culture specimens.
See alimentary system; indigestion.