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Digestive Disorders


Dyspepsia: Soothing the Sour Stomach

Last year, Americans spent millions on medications for dyspepsia, a catch-all term for an assortment of upper abdominal symptoms—including pain, bloating, and burping—commonly 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 spared—the 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 disorder—in 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 treated—sometimes to prevent complications, sometimes simply to relieve discomfort and improve the quality of life. Fortunately, the proper medications—often combined with lifestyle measures—are 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.

Therapeutic options

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 measures—such 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 with surgery.

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 available—but 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 peristaltic malfunction.

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.


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