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Tuesday, August 12, 2025

Indigestion


Definition

Indigestion, medically termed dyspepsia, refers to a group of upper abdominal symptoms that occur during or after eating. It is not a disease but a symptom complex, which may be functional (non-ulcer) or secondary to underlying conditions.

Classification

1. Functional (non-ulcer) dyspepsia

  • No identifiable structural cause after investigation

  • Often related to gastric motility disorders, visceral hypersensitivity, or psychosocial factors

2. Organic dyspepsia

  • Due to identifiable pathology such as:

    • Peptic ulcer disease

    • Gastroesophageal reflux disease (GERD)

    • Gastritis

    • Gastric cancer

    • Gallstones or pancreatic disease

Etiology and Risk Factors

Causes

  • Overeating or eating too quickly

  • High-fat, spicy, or greasy foods

  • Caffeine, alcohol, carbonated drinks

  • Smoking

  • Stress and anxiety

  • Medications: NSAIDs, corticosteroids, antibiotics (e.g., doxycycline), bisphosphonates, potassium supplements

Underlying conditions

  • Peptic ulcer disease

  • GERD

  • Gastritis

  • Helicobacter pylori infection

  • Gastroparesis

  • Biliary disease

Pathophysiology

Indigestion symptoms can arise from:

  • Increased gastric acid exposure

  • Delayed gastric emptying

  • Visceral hypersensitivity of the upper gastrointestinal tract

  • Gastric accommodation disorders (impaired relaxation after a meal)

  • Mucosal inflammation due to infection (e.g., H. pylori) or chemical irritation

Clinical Features

Typical symptoms

  • Upper abdominal discomfort or pain

  • Bloating, fullness, or early satiety

  • Belching

  • Nausea, sometimes with vomiting

  • Burning sensation in the upper abdomen

Alarm (red flag) symptoms – suggest possible serious pathology:

  • Unintentional weight loss

  • Persistent vomiting

  • Dysphagia or odynophagia

  • Gastrointestinal bleeding (hematemesis, melena)

  • Iron deficiency anemia

  • Family history of upper GI malignancy

Diagnosis

Initial evaluation

  • Detailed history and physical examination

  • Identification of alarm symptoms

  • Review of diet, lifestyle, and medications

Investigations

  • H. pylori testing: urea breath test, stool antigen test, or biopsy via endoscopy

  • Upper gastrointestinal endoscopy (especially in patients >55 years or with alarm features)

  • Abdominal ultrasound if gallbladder or biliary pathology is suspected

  • Blood tests: CBC, liver function tests, amylase/lipase, metabolic panel

Management

1. Lifestyle Modifications

  • Eat smaller, more frequent meals

  • Avoid foods and drinks that trigger symptoms (fatty, spicy, acidic foods, alcohol, caffeine, carbonated beverages)

  • Avoid lying down immediately after eating; wait at least 2–3 hours

  • Elevate head of bed if nighttime symptoms occur

  • Quit smoking

  • Manage stress through relaxation techniques

2. Pharmacological Treatment

A. Antacids – For rapid short-term relief of mild symptoms

  • Aluminium hydroxide + magnesium hydroxide: 10–20 mL orally as needed

  • Calcium carbonate: 500–1000 mg orally as needed

B. Alginates – Form a protective barrier on top of stomach contents

  • Sodium alginate: 10–20 mL orally after meals and at bedtime

C. H₂ Receptor Antagonists – Reduce gastric acid secretion

  • Ranitidine: 150 mg orally twice daily or 300 mg at bedtime (note: use restricted in many countries due to safety concerns)

  • Famotidine: 20 mg orally twice daily or 40 mg once daily at bedtime

D. Proton Pump Inhibitors (PPIs) – More potent acid suppression

  • Omeprazole: 20 mg orally once daily before breakfast

  • Lansoprazole: 30 mg orally once daily before breakfast

  • Pantoprazole: 40 mg orally once daily before breakfast

  • Esomeprazole: 20–40 mg orally once daily before breakfast

  • Typical course: 4–8 weeks for suspected acid-related dyspepsia

E. Prokinetic Agents – Improve gastric emptying and motility (use in selected cases)

  • Domperidone: 10 mg orally 3 times daily before meals

  • Metoclopramide: 10 mg orally 3 times daily before meals (short-term only due to risk of extrapyramidal side effects)

F. Helicobacter pylori eradication therapy (if positive) – Standard triple therapy for 14 days:

  • PPI (e.g., omeprazole 20 mg twice daily) + clarithromycin 500 mg twice daily + amoxicillin 1 g twice daily

  • In penicillin-allergic patients: replace amoxicillin with metronidazole 400 mg twice daily

3. Management of Functional Dyspepsia

If organic disease is excluded and H. pylori is negative or eradicated, functional dyspepsia may be managed with:

  • Low-dose PPIs or H₂ blockers

  • Prokinetics

  • Low-dose tricyclic antidepressants (e.g., amitriptyline 10–25 mg at bedtime) in refractory cases

  • Dietary modification and psychological support

Complications

  • Delay in diagnosis of underlying serious pathology (e.g., gastric cancer) if red flag symptoms are missed

  • Chronic symptoms affecting quality of life

  • Complications of underlying causes (e.g., bleeding ulcer, esophageal stricture)

Prognosis

  • Many patients improve with lifestyle changes and short-term acid suppression

  • Relapses may occur, especially if dietary triggers persist or underlying conditions are untreated

  • Good prognosis if underlying serious causes are excluded and managed early




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