Indigestion

Indigestion (or dyspepsia) means pain or discomfort in the upper abdomen or lower chest.

Indigestion symptoms typically happen after you eat or drink. Indigestion is a symptom, not a disease, and it is so common that nearly everyone will experience it at some point. But it’s rare for it to be due to a serious condition.

Causes of indigestion

Indigestion has many causes, but a serious condition is rarely the cause. Almost all of us will likely get indigestion now and then, often after a heavy, spicy or fatty meal. Symptoms can occur if we rush our food. They can also occur if we overeat or overdrink.

Functional dyspepsia

Functional dyspepsia is the most common cause of indigestion. Functional dyspepsia is diagnosed when no structural cause for symptoms is found. It happens when the stomach nerves get too sensitive to acidic foods or natural fluids, like bile. This sensitivity causes pain. Eight out of ten people with indigestion have functional dyspepsia. Test results for Helicobacter Pylori (H. pylori) are usually normal. H Pylori is a bug, or bacterium, that lives in the stomach and can cause symptoms. In some people with functional dyspepsia, symptoms can be quite severe.

Stress, anxiety, and depression can be contributing factors. These are also possible cause of functional dyspepsia. This can work both ways, with long-term severe symptoms having the potential to affect people’s mood. The gut and the brain are connected. This can make the stomach more sensitive to its normal signals from the brain (and vice versa). People with this diagnosis might also have other conditions. An example is irritable bowel syndrome (IBS). The understanding of the relevance of the gut bacteria in these conditions is constantly growing.

Ulcers

Ulcers of the stomach or the first part of the small bowel (duodenum) were once a common cause of indigestion. Now, they happen less often. About 8 in 100 people with indigestion have ulcers. Most of these ulcers are so-called peptic ulcers, which means that they are mainly caused by acid. They are the second most common cause of indigestion. Most ulcers used to be caused by an infection in the stomach from H.Pylori. This stomach bug is also becoming less common in the UK. Today, ulcers occur more often in people who take non-steroidal anti-inflammatory medicines (NSAIDS). Examples include aspirin, ibuprofen or naproxen given for joint and muscle pain. These medicines can damage the stomach lining. Do not stop taking any of your medicines without speaking to your doctor first. Ulcers are also more common in people who smoke tobacco.

Some people are more prone to conditions like peptic ulcers. This may be partly because the infection with H. pylori is mainly transmitted within families, from parents to their children. H. pylori always causes an inflammation of the stomach. Even when there is no ulcer, this inflammation can be the reason for indigestion.

Other causes

Indigestion can, rarely, be due to serious conditions. These include:

• Gallstones
• Diseases of the pancreas
• Very rarely, stomach cancer.

Most often, these conditions present with other symptoms as well. For example, a change in bowel habits, unintentional weight loss or general fatigue. But most people with indigestion don’t have these severe diseases. Routine tests for severe diseases aren’t needed for most people, but might be helpful if more symptoms are present. If this is the case, you should ask your doctor for advice (see further comments on this in the ‘Support’ section below).

What are the usual symptoms of indigestion?

Most people with indigestion have their own individual symptom pattern. They range from mild discomfort in the upper abdomen to severe pain. 

The pain can sometimes radiate towards other areas of the abdomen, or, rarely, even through into the back. Please consult your doctor regarding the need for further tests if this is the case. Others with indigestion feel a general fullness (heaviness or bloating) and discomfort in the upper abdomen after a meal. Sometimes, a localised pain just below the lower end of the breastbone and/or the upper abdomen is felt, or a combination of all symptoms can happen. Symptoms should not be mixed up with symptoms of heartburn: heartburn being a burning sensation or pain behind the breastbone that is linked to reflux symptoms.

Indigestion can happen alone or with other symptoms. These may include feeling sick (nausea), retching, burping, bringing up food or bitter-tasting fluids into your mouth (regurgitation) or, in rare cases, vomiting. It seems to affect 1 or 2 in 5 people at any time. Around 1 in 4 people with symptoms visit their GP for advice.

Does my indigestion need to be investigated?

If your indigestion does not improve with lifestyle changes or over-the-counter remedies, see your doctor. If you notice any of these symptoms, see your doctor first before trying over-the-counter remedies:

• Persistently being sick (vomiting).
• Problems or pain with swallowing.
• Food getting stuck in your gullet.
• Unintentional weight loss.
• If you can feel a lump in your upper belly (abdomen).
• New loss of energy or general fatigue, as well as shortness of breath. This can indicate a low blood count or low iron level in your blood. Your GP can check this with a blood test.
• If your symptoms are new and you are 55 years old or older.

If you have any reason to think there is a serious health problem, see your doctor as soon as possible. Also, seek medical help if symptoms start in middle age or later, or if a family member has had a diagnosis of stomach or gullet (oesophagus) cancers.

You should seek medical advice without delay in case of indigestion with these symptoms:

• Vomiting blood or passing black, tarry poo.
• Pain that suddenly develops and is severe. This pain could travel through to your back. Some people feel less pain hunched forward and more when lying flat.
• A fast heartbeat (tachycardia) or rapid breathing.
• A high temperature of 38 °C or more (fever).

Your GP, after listening to your symptoms and examining you, is likely to reassure you. For most people’s symptoms, there is no serious cause.

In the first instance, your GP can request an H. pylori poo test. They will also tell you which medicines you need to stop taking for this test, for example acid blockers (PPIs). If a doctor diagnoses you with H. pylori infection, they will prescribe treatment. They should also arrange a follow-up test to make sure the H. pylori infection has cleared up after completion of your treatment.

Most people will not need an endoscopy, but if you are 55 or older, or if your symptoms keep coming back or don’t improve, your doctor might suggest this or other tests. These can include additional blood or poo tests or scans such as an ultrasound scan on your tummy or a CT.

How likely is it that H. pylori is the cause of my indigestion?

H.pylori bacteria usually infect the lower stomach (the antrum). For some people it can infect the whole stomach. It always causes inflammation of the stomach lining (gastritis). But, about half of people who have this infection don’t have any symptoms at all. Out of 100 upper gut endoscopies done for indigestion symptoms, one person may have cancer. It is very rare.

There is good evidence that an H. pylori infection in your stomach increases your chance of a peptic ulcer. Out of 100 upper endoscopies done, four people may have a diagnosis of a peptic ulcer. H. pylori and the inflammation it causes in the stomach is also linked to dyspepsia. H. pylori should always be treated when it is present. This is true even if the doctor can’t be sure it’s causing your symptoms. Treating the infection successfully will lower your risk of stomach ulcers and cancer. Your GP should also check that treatment has worked.

It is important to know that clearing the infection does not always mean you will stop having indigestion. Some people have both H. pylori infection and functional dyspepsia, and they won’t feel better just by treating the infection. Some might only experience symptom relief for some time.

What further tests might I be offered?

The most common test for indigestion, if you present with any of the more severe symptoms listed above, is an upper gastrointestinal endoscopy, or gastroscopy for short. It is a day case procedure in hospital. This involves swallowing a thin, flexible tube with a camera on the end. The endoscopist can then view your oesophagus, stomach and duodenum to check for inflammation or infection. The procedure isn’t painful, thanks to a local anaesthetic spray used on the throat, but it can still feel somewhat awkward and uncomfortable. If you are worried or have a sensitive throat, there are other options. Light sedation can make the procedure less uncomfortable.

If you are offered a gastroscopy, check that your doctor has ruled out H. pylori or other causes of your indigestion first. This can be done with non-invasive tests, such as poo or blood tests. For most people, H. pylori is easily treated at their GP surgery.

The doctor may prefer to check for a serious condition that only an endoscopy could detect, depending on your symptoms. See the symptom list on page 3 of this leaflet. The final decision whether to have an endoscopy is always yours. It’s important to think carefully about this. If you have a serious issue causing your indigestion, then a few minutes of potential discomfort during the endoscopy is worth it to find out for sure.

What treatment is available for indigestion?

Treatment usually starts by looking for fixable causes, in the first instance, by having the test for H. pylori infection. If the test is negative or if treatment of the infection did not resolve your symptoms, then simple lifestyle changes are advised. Consider these lifestyle changes:

• Avoid overeating or drinking too many caffeine-containing drinks.
• Avoid excess alcohol and drink within recommended guidelines.
• Don’t smoke tobacco.
• Don’t rush meals or eat too much fatty or spicy food.
• Eat a healthy diet, maintain an adequate daily fluid intake and be active

Lifestyle changes can be hard to achieve. If you are struggling, ask your GP about local services to help with making changes. Our health and lifestyle information may also be useful.

Some people with indigestion can control their symptoms this way, whereas others might need medicines for further support. These can be over-the-counter antacid tablets or liquids from the pharmacist. Some of these treatments neutralise stomach acid. Others reduce acid production in your stomach. With many products on the market, discuss all options with your pharmacist. If simple medicines from the pharmacist don’t work, your GP can prescribe stronger anti-acid or acid-suppressing medicines.

Your doctor can also advise you if any of your other medications may be causing indigestion. Don’t stop taking your medicines before talking to your doctor.

How can indigestion affect me over time?

Many people with indigestion find that their symptoms improve. This happens either through self-help or after their GP has treated them. A small number, however, do have longer-term symptoms. They may need prolonged treatment. It’s wise to find the lowest dose of the medicine that controls your symptoms. You may be able to take breaks between courses of tablets. Just use your treatment when your symptoms are worse. Talk to your doctor or a pharmacist about your treatment.

If someone has long-term indigestion due to stress or anxiety, it’s best to focus on treating the stress. Your GP can refer you to a psychologist for cognitive behavioural therapy (CBT) or hypnotherapy. If symptoms are associated with functional dyspepsia, there are also other medicines, called neuromodulators, which could be tried. They can reduce the sensitivity of the stomach’s nerves. They are often used to treat people with mental ill health, but not in this case. For functional dyspepsia, they are prescribed at a much lower dose to treat symptoms. They work at the level of the gut, not on the brain. Ask your doctor about this if you feel this is relevant to you.

If your symptoms change over time and you develop symptoms mentioned in this information, contact your doctor.

What to ask your doctor?

• How can I best self-manage my indigestion?
• Should I be tested for H.pylori infection?
• Do I need an endoscopy, and if so, why?
• What follow-up or monitoring do I need?

If you would like a paper copy of any of the information contained in this leaflet, please contact info@gutscharity.org.uk or 020 7486 0341.

Where can I get more information?

Guts UK has further information on:

• Functional dyspepsia
• Heartburn
• Stomach cancer
• H. Pylori