Dyspepsia: Soothing the Sour Stomach
Last year, Americans spent millions on medications
for dyspepsia, a catch-all term for an assortment of upper abdominal
symptomsincluding pain, bloating, and burpingcommonly
referred to as indigestion. At any given time, about one fourth
of American adults suffer from some degree of dyspepsia. Indeed,
the problem accounts for 5% of all office visits to primary care
doctors and up to 70% of all gastrointestinal complaints. Women
are more vulnerable to dyspepsia than men, but older adults are
often sparedthe prevalence of dyspepsia appears to remain
stable or even decline with age.
Although effective treatment is available, only
about one fourth of those with persistent symptoms see a doctor
for help. About 40% of those who do seek assistance are worried
that they may have a life-threatening disorderin particular,
stomach or esophageal cancer. In reality, such malignancies are
the culprit in fewer than 3% of cases. Dyspepsia is far more
likely to be caused by one of a host of other, less serious problems.
Nevertheless, these conditions should still be treatedsometimes
to prevent complications, sometimes simply to relieve discomfort
and improve the quality of life. Fortunately, the proper medicationsoften
combined with lifestyle measuresare usually helpful.
In search of the cause
The hallmark of dyspepsia is persistent or recurrent
pain or discomfort in the mid- to upper abdomen. Other symptoms
include bloating, a premature feeling of fullness after meals
(early satiety), and excessive burping. Nausea and heartburn
(a burning sensation just under the breastbone that sometimes
radiates to the neck) may be present, but recurrent vomiting
and nutritional problems are not typical.
Many underlying causes can prompt these symptoms.
Among the most common are gastroesophageal reflux disease (GERD)
and stomach ulcers. GERD is characterized by upper abdominal
pain and heartburn. Stomach ulcers cause periodic episodes of
upper abdominal pain that get worse with hunger and improve after
eating or taking antacids. Nighttime pain is often so severe
that sufferers waken frequently.
Dismotility disorders, such as esophageal spasms
or weak esophageal contractions (achalasia), are another possibility.
These neurologic problems are characterized by peristaltic impairment,
malfunction of the involuntary muscle contractions that push
food down the esophagus into the stomach. Symptoms include generalized
upper abdominal pain that is usually aggravated by food and accompanied
by other symptoms such as bloating, early satiety, loss of appetite,
nausea, retching, and occasionally vomiting.
Finally, dyspepsia is a potential side effect of
many medications. Among the more likely culprits are aspirin
and other nonsteroidal anti-inflammatory drugs (NSAIDs), certain
antibiotics, theophylline, digitalis, corticosteroids, iron,
niacin, chemotherapy drugs, and certain narcotics. No matter
what the cause, stress and other psychological factors can clearly
trigger or worsen symptoms.
When to see a doctor
Antacids and histamine (H2) blockers are the two
most effective over-the-counter dyspepsia medications. But they
are appropriate only for occasional episodes of heartburn. Antacids
such as calcium carbonate (Tums and others) and magnesium salts
(Mylanta and others) neutralize stomach acid, which can cause
inflammation in the stomach and the esophagus, resulting in abdominal
discomfort or heartburn. Antacids are intended for quick symptom
relief. H2 blockers such as cimetidine (Tagamet), famotidine
(Pepcid), nizatidine (Axid), and ranitidine (Zantac) suppress
the production of stomach acids so that irritated tissues have
a chance to heal.
When these medications are effective, there is
no reason to see a doctor. But recurrent or persistent symptoms
require medical attention. Be specific about your symptoms. Describe
the location and quality of the pain. Explain whether it is sharp
or dull, concentrated or diffuse, burning or stabbing. Note whether
you feel better after eating or when you are hungry; if over-the-counter
medications help; if you feel very full after eating a small
meal; and if you are plagued by bloating, nausea, or burping.
Diagnostic studies include endoscopy (direct examination
of the esophagus using a flexible, illuminated tube), certain
imaging studies, blood work, and testing for Helicobacter pylori
(the bacterium responsible for most stomach ulcers). The American
Gastroenterological Association recommends endoscopy to rule
out cancer for adults over age 45 with new, unexplained dyspepsia.
Proper treatment usually brings significant relief
and prevents complications, such as Barrett's esophagus (cellular
changes due to persistent irritation that may lead to cancer)
from GERD, and perforation of the stomach wall from stomach ulcers.
If either of these disorders is suspected, a trial of therapy
may be recommended based on symptoms alone. Prescription-strength
H2 blockers or proton pump inhibitors (a potent type of acid
suppressor) such as omeprazole (Prilosec) are useful for GERD.
Also essential are lifestyle measuressuch as not eating
near bedtime (because lying down encourages partially digested
food and stomach acid to flow backward from the stomach into
the esophagus) and avoiding caffeinated and alcoholic beverages
(which may irritate the stomach and esophageal lining). In some
instances, the cause of GERD is a malfunctioning lower esophageal
sphincter (LES). This muscle, located at the bottom of the esophagus,
keeps partially digested food and digestive acids from flowing
backward out of the stomach. LES malfunctions can often be repaired
If symptoms persist despite GERD treatment, a stomach
ulcer is often suspected. H. pylori causes about 90% of all stomach
ulcers; NSAID use is responsible for most of the remainder. If
H. pylori is thought to be the cause, antibiotic therapy can
cure it. However, many people harbor H. pylori, and yet this
is not the cause of their dyspeptic symptoms. In such cases,
antibiotic therapy is not helpful. If NSAIDs or other medications
are implicated, it is necessary to stop using the offending drug.
Other alternatives, such as acetaminophen (Tylenol) for short-term,
over-the-counter pain relief, are usually availablebut
consult your doctor before adjusting any prescription medications.
Dismotility disorders can be treated with antispasmodics such
as dicyclomine (A-Spas and others) and propantheline or stimulants
such as cisapride (Propulsid), depending on the nature of the
When the cause is elusive
In at least 25% of cases, no underlying cause of
dyspepsia can be found. Yet, certain abnormalities are prevalent
in these patients. In about one third, solids leave the stomach
more slowly than normal, a condition called impaired gastric
emptying. In some, the amount of food the stomach can comfortably
hold may be limited, a condition called postprandial accommodation
impairment. Finally, the stomach may be unusually sensitive to
stimulation, a condition called gastric hypersensitivity. Exactly
what causes these abnormalities, how they contribute to dyspepsia,
and whether or how they should be treated is unknown.
When symptoms persist and the known causes of dyspepsia
have been ruled out, the lifestyle measures used for GERD are
sometimes effective. Some people find that keeping a diary of
symptoms, foods, and emotions helps them identify and control
factors that trigger symptoms. If symptoms continue, antianxiety
medications, dismotility drugs, or antidepressants (especially
selective serotonin reuptake inhibitors) may be helpful.
From The Johns
Hopkins Medical Letter: Health After 50, March 2000.