|Symptoms||Upper abdominal pain|
Indigestion, also known as dyspepsia or upset stomach, is a condition of impaired digestion. Symptoms may include upper abdominal fullness, heartburn, nausea, belching, or upper abdominal pain. People may also experience feeling full earlier than expected when eating.
Indigestion is a common ailment and is frequently caused by gastroesophageal reflux disease (GERD) or gastritis. In a small minority of cases it may be the first symptom of peptic ulcer disease (an ulcer of the stomach or duodenum) and, occasionally, cancer. Hence, unexplained newly onset indigestion in people over 55 or the presence of other alarming symptoms may require further investigations.
In those who are older or with worrisome symptoms such as trouble swallowing, weight loss, or blood loss, endoscopy is recommended. Otherwise, testing for H. pylori followed by treatment of the infection if present is reasonable.
Indigestion is common. Functional indigestion (previously called nonulcer dyspepsia) is indigestion without evidence of underlying disease. Functional indigestion is estimated to affect about 15% of the general population in western countries.
Signs and symptoms
In a study, people with peptic ulcer disease were compared with people with functional dyspepsia in an age- and sex-matched study. Although the functional dyspepsia group reported more upper abdominal fullness, nausea, and overall greater distress and anxiety, almost all the same symptoms were seen in both groups. Therefore, it is the clinician’s challenging task to separate people who may have an organic disorder and thus warrant further diagnostic testing, from people who have functional dyspepsia and who are given empiric symptomatic treatment. The workup should be targeted to identify or rule out specific causes. Traditionally, people at high risk have been identified by "alarm" features. However, the utility of these features in identifying the presence of upper cancer of the esophagus or stomach has been debated. A meta analysis looking at the sensitivity and specificity of alarm features found a range of 0–83% and 40–98%, respectively. However, there was high heterogeneity between studies.
The physical examination may elicit abdominal tenderness, but this finding is nonspecific. A positive Carnett sign, or focal tenderness that increases with abdominal wall contraction and palpation, suggests an etiology involving the abdominal wall musculature. Cutaneous dermatomal distribution of pain may suggest a thoracic polyradiculopathy. Thump tenderness over the right upper quadrant may suggest chronic cholecystitis.
Also known as Alarm features, alert features, red flags, or warning signs in GI literature.
Alarm features are thought to be associated with serious gastroenterologic disease and include:
- chronic gastrointestinal bleeding
- progressive unintentional weight loss
- progressive difficulty swallowing (dysphagia)
- persistent vomiting
- iron deficiency anemia
- epigastric mass
When dyspepsia can be attributed to a specific cause, the majority of cases concern gastroesophageal reflux disease (GERD) and gastritis disease. Less common causes include peptic ulcer, gastric cancer, esophageal cancer, coeliac disease, food allergy, inflammatory bowel disease, chronic intestinal ischemia, and gastroparesis.
In about 50-70% of people with dyspepsia, no definite organic cause can be determined. In this case, dyspepsia is referred to as non-ulcer dyspepsia and its diagnosis is established by the presence of epigastralgia for at least 6 months, in the absence of any other cause explaining the symptoms.
Gastroenteritis increases the risk of developing chronic dyspepsia. Post infectious dyspepsia is the term given when dyspepsia occurs after an acute gastroenteritis infection. It is believed that the underlying causes of post-infectious IBS and post-infectious dyspepsia may be similar and represent different aspects of the same pathophysiology.
Functional dyspepsia is the most common cause of chronic heartburn. More than 70% of people have no obvious organic cause for their symptoms after evaluation. Symptoms may arise from a complex interaction of increased visceral afferent sensitivity, gastric delayed emptying (gastroparesis) or impaired accommodation to food. Anxiety is also associated with functional dyspepsia. In some people, it appears before the onset of gut symptoms; in other cases, anxiety develops after onset of the disorder, which suggests that a gut-driven brain disorder may be a possible cause. Although benign, these symptoms may be chronic and difficult to treat.
Wheat and dietary fats can lead to dyspepsia and their reduction or withdrawal may improve symptoms.
Liver and pancreas diseases
Food or drug intolerance
Acute, self-limited dyspepsia may be caused by overeating, eating too quickly, eating high-fat foods, eating during stressful situations, or drinking too much alcohol or coffee. Many medications cause dyspepsia, including aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics (metronidazole, macrolides), diabetes drugs (metformin, Alpha-glucosidase inhibitor, amylin analogs, GLP-1 receptor antagonists), antihypertensive medications (angiotensin converting enzyme [ACE] inhibitors, Angiotensin II receptor antagonist), cholesterol-lowering agents (niacin, fibrates), neuropsychiatric medications (cholinesterase inhibitors [donepezil, rivastigmine]), SSRIs (fluoxetine, sertraline), serotonin-norepinephrine-reuptake inhibitors (venlafaxine, duloxetine), Parkinson drugs (Dopamine agonist, monoamine oxidase [MAO]-B inhibitors), corticosteroids, estrogens, digoxin, iron, and opioids.
Helicobacter pylori infection
The role of Helicobacter pylori in functional dyspepsia is controversial, and no clear causal relationship has been established. This is true for both the symptom profile and pathophysiology of functional dyspepsia. Although some epidemiologic studies have suggested an association between H. pylori infection and functional dyspepsia, others have not. The discrepancy may stem in part from differences in methodology and lack of adequate consideration of confounding factors such as past history of peptic ulcer disease and socioeconomic status. Controlled trials disagree about whether or not H. pylori eradication is beneficial in functional dyspepsia, with roughly half of the trials showing improvement and the other half no improvement. In a multicenter U.S. trial that randomized 240 people to treatment or placebo, and followed them for 12 months, 28% of treated people versus 23% of those receiving placebo reported relief of symptoms at the 12-month follow-up. Similarly, recent European trials have not shown significant differences in symptoms after H. pylori eradication as compared with controls. Systematic reviews of eradication have been conducted, with varying results. A systematic review in the Annals of Internal Medicine suggested no statistically significant effect, with an odds ratio (OR) for treatment success versus control of 1.29 (95% CI, 0.89–1.89; P = 0.18). Still, no effect was seen after adjusting for heterogeneity and for cure of H. pylori. In contrast, a Cochrane review found a small but statistically significant effect in curing symptoms (H. pylori cure vs placebo, 36% vs 30%, respectively).
There are a number of systemic diseases that may involve dyspepsia, including coronary disease, congestive heart failure, diabetes mellitus, hyperparathyroidism, thyroid disease, and chronic kidney disease.
Psychosomatic and cognitive factors are important in the evaluation of people with chronic dyspepsia. The psychiatric hypothesis holds that the symptoms of dyspepsia may be due to depression, increased anxiety, or a somatization disorder. Epidemiological studies suggest there is an association between functional dyspepsia and psychological disorders. Symptoms of neurosis, anxiety, hypochondriasis, and depression are more common in people being evaluated for unexplained gastrointestinal complaints than in healthy controls. Comparisons of functional and organic dyspepsia have demonstrated that people with functional dyspepsia are less likely to have decreased stress or anxiety at 1-year follow-up after being reassured of having no serious disease. This suggests that functional dyspepsia symptoms are long-lasting, compared with those of organic dyspepsia, and that the emotional ties are strong.
In people without red flags, it is recommended to test for H. pylori noninvasively and to perform upper GI endoscopy in those who test positive. In most cases, the clinical history is of limited use in distinguishing between organic causes and functional dyspepsia. A large systematic review of the literature was recently performed to evaluate the effectiveness of diagnosing organic dyspepsia by clinical opinion versus computer models in people referred for upper endoscopy. The computer models were based on patient demographics, risk factors, historical items, and symptoms. The study showed that neither clinical impression nor computer models were able to adequately distinguish organic from functional disease.
Medication-related dyspepsia is usually related to NSAIDs and can be complicated by bleeding or ulceration with perforation of the stomach wall.
Functional and undifferentiated dyspepsia have similar treatments. Drug therapy decisions are difficult because trials included heartburn in the definition of indigestion. This led to the results favoring proton pump inhibitors (PPIs), which are effective for the treatment of heartburn.
Traditional therapies used for this diagnosis include lifestyle modification, antacids, H2-receptor antagonists (H2-RAs), prokinetic agents, and antiflatulents. It has been noted that one of the most frustrating aspects of treating functional dyspepsia is that these traditional agents have been shown to have little or no efficacy.
Antacids and sucralfate were found to be no better than placebo in a literature review. H2-RAs have been shown to have marked benefit in poor quality trials (30% relative risk reduction), but only a marginal benefit in good quality trials. Prokinetic agents would empirically seem to work well since delayed gastric emptying is considered a major pathophysiological mechanism in functional dyspepsia. They have been shown in a meta-analysis to produce a relative risk reduction of up to 50%, but the studies evaluated to come to this conclusion used the drug cisapride which has since been removed from the market (now only available as an investigational agent) due to serious adverse events such as torsades, and publication bias has been cited as a potential partial explanation for such a high benefit. Modern prokinetic agents such as metoclopramide, erythromycin and tegaserod have little or no established efficacy and often result in substantial side effects. Simethicone is of some value, as one trial suggests potential benefit over placebo and another shows equivalence with cisapride. So, with the somewhat recent advent of the proton pump inhibitor (PPI) class of medications, the question of whether these new agents are superior to traditional therapy has arisen.
Currently, PPIs are, depending on the specific drug, FDA indicated for erosive esophagitis, gastroesophageal reflux disease (GERD), Zollinger-Ellison syndrome, eradication of H. pylori, duodenal and gastric ulcers, and NSAID-induced ulcer healing and prevention, but not functional dyspepsia. However, evidence-based guidelines and literature evaluate the use of PPIs for this indication. A helpful chart summarizing the major trials is available from the functional dyspepsia guidelines published in the World Journal of Gastroenterology in 2006.
A 2002 systemic review of herbal products found that several herbs, including peppermint and caraway, have anti-dyspeptic effects for non-ulcer dyspepsia with "encouraging safety profiles". A 2004 meta-analysis of the multiple herbal extract Iberogast found it to be more effective than placebo in people with functional dyspepsia.
- Eusebi, Leonardo H; Black, Christopher J; Howden, Colin W; Ford, Alexander C (11 December 2019). "Effectiveness of management strategies for uninvestigated dyspepsia: systematic review and network meta-analysis". BMJ. 367: l6483. doi:10.1136/bmj.l6483. PMC 7190054. PMID 31826881.
- "dyspepsia" at Dorland's Medical Dictionary
- Duvnjak, edited by Marko (2011). Dyspepsia in clinical practice (1. Aufl. ed.). New York: Springer. p. 2. ISBN 9781441917300.CS1 maint: extra text: authors list (link)
- Talley NJ, Vakil N (October 2005). "Guidelines for the management of dyspepsia". Am. J. Gastroenterol. 100 (10): 2324–37. PMID 16181387.
- Zajac, P; Holbrook, A; Super, ME; Vogt, M (March–April 2013). "An overview: Current clinical guidelines for the evaluation, diagnosis, treatment, and management of dyspepsia". Osteopathic Family Physician. 5 (2): 79–85. doi:10.1016/j.osfp.2012.10.005.
- National Institute for Health and Clinical Excellence. Clinical guideline 17: Dyspepsia. London, 2004.
- Saad RJ, Chey WD (August 2006). "Review article: current and emerging therapies for functional dyspepsia" (PDF). Aliment. Pharmacol. Ther. 24 (3): 475–92. doi:10.1111/j.1365-2036.2006.03005.x. hdl:2027.42/74835. PMID 16886913.
- van Kerkhoven LA, van Rossum LG, van Oijen MG, Tan AC, Laheij RJ, Jansen JB (September 2006). "Upper gastrointestinal endoscopy does not reassure people with functional dyspepsia" (PDF). Endoscopy. 38 (9): 879–85. doi:10.1055/s-2006-944661. PMID 16981103. Archived from the original (PDF) on 2011-07-27.
- Vakil N, Moayyedi P, Fennerty MB, Talley NJ (Aug 2006). "Limited value of alarm features in the diagnosis of upper gastrointestinal malignancy: systematic review and meta-analysis". Gastroenterology (Review). 131 (2): 390–401. doi:10.1053/j.gastro.2006.04.029. PMID 16890592.
- Flier, SN; S, Rose (2006). "Is functional dyspepsia of particular concern in women? A review of gender differences in epidemiology, pathophysiologic mechanism, clinical presentation and management". Am J Gastroenterol. 101 (12 Suppl): S644–53. PMID 17177870.
- Vakil, Nimish (2006). "Limited Value of Alarm Features in the Diagnosis of Upper Gastrointestinal Malignancy: Systematic Review and Meta-analysis". Gastroenterology. 131 (2): 390–401. doi:10.1053/j.gastro.2006.04.029. PMID 16890592.
- Futagami S, Itoh T, Sakamoto C (2015). "Systematic review with meta-analysis: post-infectious functional dyspepsia". Aliment. Pharmacol. Ther. 41 (2): 177–88. doi:10.1111/apt.13006. PMID 25348873.
- Talley NJ, Ford AC (Nov 5, 2015). "Functional Dyspepsia" (PDF). N Engl J Med (Review). 373 (19): 1853–63. doi:10.1056/NEJMra1501505. PMID 26535514.
- Duncanson KR, Talley NJ, Walker MM, Burrows TL (2017). "Food and functional dyspepsia: a systematic review". J Hum Nutr Diet (Systematic Review). 31 (3): 390–407. doi:10.1111/jhn.12506. PMID 28913843. S2CID 22800900.
- Ford AC, Moayyedi P (2013). "Dysepsia". BMJ. 347: f5059. doi:10.1136/bmj.f5059. PMID 23990632. S2CID 220190440.
- Laine L, Schoenfeld P, Fennerty MB (2001). "Therapy for Helicobacter pylori in patients with nonulcer dyspepsia. A meta-analysis of randomized, controlled trials". Ann Intern Med. 134 (5): 361–369. doi:10.7326/0003-4819-134-5-200103060-00008. PMID 11242496. S2CID 12951466.
- Moayyedi, P; Deeks, J; Talley, NJ (2003). "An update of the Cochrane systematic review of Helicobacter pylori eradication therapy in nonulcer dyspepsia". Am J Gastroenterol. 98 (12): 2621–6. CiteSeerX 10.1.1.663.6840. PMID 14687807.
- Talley, NJ (2002). "Review article: Helicobacter pylori and nonulcer dyspepsia". Aliment Pharmacol Ther. 16 (1): 58–65. doi:10.1046/j.1365-2036.2002.0160s1058.x. PMID 11849130. S2CID 71535649.
- Jung HK, Talley NJ (2018). "Role of the Duodenum in the Pathogenesis of Functional Dyspepsia: A Paradigm Shift". J Neurogastroenterol Motil (Review). 24 (3): 345–354. doi:10.5056/jnm18060. PMC 6034675. PMID 29791992.
- Pajala, M; Heikkinen, M (2006). "A prospective 1-year follow-up study in patients with functional or organic dyspepsia: changes in gastrointestinal symptoms, mental distress and fear of serious illness". Aliment Pharmacol Ther. 24 (8): 1241–1246. doi:10.1111/j.1365-2036.2006.03108.x. PMID 17014583.
- Milivojevic, Vladimir; Rankovic, Ivan; Krstic, Miodrag N.; Milosavljevic, Tomica (2021-06-14). "Dyspepsia-challenge in primary care gastroenterology". Digestive Diseases. S. Karger AG. doi:10.1159/000517668. ISSN 0257-2753. PMID 34126614.
- Moayyedi P, Talley NJ, Fennerty MB, Vakil N (Apr 5, 2006). "Can the clinical history distinguish between organic and functional dyspepsia?". JAMA (Review). 295 (13): 1566–76. doi:10.1001/jama.295.13.1566. PMID 16595759.
- Mönkemüller K, Malfertheiner P (2006). "Drug treatment of functional dyspepsia". World J. Gastroenterol. 12 (17): 2694–700. doi:10.3748/wjg.v12.i17.2694. PMC 4130977. PMID 16718755.
- Talley NJ, Vakil N (2005). "Guidelines for the management of dyspepsia". Am. J. Gastroenterol. 100 (10): 2324–37. PMID 16181387.
- Information regarding withdrawal of Propulsid (cisapride) by Janssen Pharmaceutica. From FDA
- Thompson Coon J, Ernst E (October 2002). "Systematic review: herbal medicinal products for non-ulcer dyspepsia". Aliment. Pharmacol. Ther. 16 (10): 1689–99. doi:10.1046/j.1365-2036.2002.01339.x. PMID 12269960.
- Melzer J, Rösch W, Reichling J, Brignoli R, Saller R (2004). "Meta-analysis: phytotherapy of functional dyspepsia with the herbal drug preparation STW 5 (Iberogast)". Aliment. Pharmacol. Ther. 20 (11–12): 1279–87. doi:10.1111/j.1365-2036.2004.02275.x. PMID 15606389.
|Look up indigestion in Wiktionary, the free dictionary.|