Indigestion

Indigestion can mean pain or discomfort in your upper abdomen (dyspepsia), or a burning pain behind the breastbone (heartburn). You can have dyspepsia and heartburn together, or just one of them. The symptoms usually start soon after you eat or drink.

Other symptoms often come with indigestion:

• feeling full or bloated
• feeling sick (nausea)
• belching
• bringing up (regurgitating) fluid or food into the gullet (oesophagus)

Indigestion is a common problem and affects many people. In most cases it's mild and only happens now and then.

Indigestion may be caused by stomach acid touching the sensitive, protective lining of the digestive system (the mucosa). The acid breaks down this lining, which leads to irritation and inflammation, and that can be painful.

Most people with indigestion don't actually have inflammation in their digestive system. So their symptoms are thought to come from the mucosa being more sensitive than normal, either to acidity or to stretching.

In most cases, indigestion is linked to eating. Other things can trigger it too, such as smoking, drinking, alcohol, pregnancy, stress or taking certain medicines.

Most people can treat indigestion with simple changes to their diet and lifestyle, or with one of several medicines, such as antacids.

Very rarely, a serious health condition underneath is the cause of indigestion. If a doctor suspects this, you will need further tests, such as an endoscopy.

If you have symptoms of indigestion, you can get treatment directly from a pharmacy.

Most people won't need to see a doctor for their indigestion. But a pharmacist may advise you to see a doctor if the indigestion keeps coming back and any of the following apply to you:

• you are 55 years old or over
• you have lost a lot of weight without meaning to
• you have increasing difficulty swallowing (dysphagia)
• you have persistent vomiting
• you have iron deficiency anaemia
• you have a lump in your stomach
• you have blood in your vomit or blood in your stools

These symptoms may be a sign of an underlying health condition, such as a stomach ulcer or stomach cancer. You may be sent for an endoscopy to rule out any serious cause.

An endoscopy is a procedure where the inside of the body is examined using an endoscope (a thin, flexible tube with a light and camera on one end).

Severe indigestion can cause long-term problems in parts of your digestive tract, such as scarring of the oesophagus or of the passage from your stomach.

The main symptom of indigestion is pain or discomfort in your upper abdomen (this is called dyspepsia). Many people also feel a burning behind the breastbone, which is heartburn, though heartburn can happen on its own too.

These symptoms usually start soon after you eat or drink. Sometimes there's a delay, and the indigestion comes on a while after the meal.

Heartburn is caused by acid that passes from your stomach into your gullet (oesophagus).

If you have indigestion, you may also have symptoms such as:

• feeling uncomfortably full or heavy
• belching or flatulence (passing wind)
• bringing food or fluid back up from your stomach (reflux)
• bloating
• feeling sick (nausea)
• vomiting

Indigestion has several different causes, but it's rarely due to a serious underlying condition.

Your stomach makes acid as a normal part of its work. Sometimes that acid irritates the lining of your stomach, the top part of your bowel (duodenum) or your gullet (oesophagus). The irritation can be painful and often brings a burning feeling. Indigestion may also happen because the lining of your digestive system is overly sensitive to acid, or because of the "stretching" that comes with eating.

Other factors can also trigger indigestion or make it worse.

Some medicines can bring on indigestion. Nitrates, which are taken to widen your blood vessels, relax the oesophageal sphincter. This is the ring of muscle between your oesophagus and your stomach, and when it relaxes, acid can leak back up.

Other medicines, such as non-steroidal anti-inflammatory drugs (NSAIDs), can affect your digestive tract and cause indigestion.

Don't take NSAIDs, such as aspirin and ibuprofen, if you have stomach problems like a stomach ulcer, or if you have had one in the past. Children under 16 years of age should not take aspirin.

Never stop taking a prescribed medicine unless your doctor, or another qualified healthcare professional responsible for your care, tells you to.

If you are very overweight, you're more likely to get indigestion, because of the extra pressure inside your stomach (abdomen). This pressure is highest after a large meal, and it can push acid back up into the oesophagus. That is called acid reflux.

If you often feel stressed or anxious, this can bring on the symptoms of indigestion. Some simple relaxation tips can help you ease that stress.

A hernia happens when an internal part of the body, such as an organ, pushes through a weak spot in the surrounding muscle or tissue wall.

With a hiatus hernia, part of your stomach pushes up into your diaphragm (the sheet of muscle under your lungs). This can partly block stomach acid that has flowed back up from clearing out of your oesophagus, and that leads to heartburn.

Helicobacter infection is very common. It can lead to stomach ulcers or, rarely, stomach cancer. Most of the time, though, it causes no symptoms at all.

Some people do get bouts of indigestion from helicobacter infection. If that's the case for you, clearing the bug with antibiotics (this is called eradication) will help. But many cases of indigestion aren't caused by helicobacter, and in those cases eradication won't get rid of the symptoms.

Gastro-oesophageal reflux disease (GORD) is a common condition, and it's one of the main reasons people get indigestion again and again. The cause is acid reflux. This happens when the oesophageal sphincter fails to stop stomach acid from moving back up into your oesophagus.

A little acid reflux is normal and rarely causes any symptoms. It becomes GORD when large amounts of reflux happen. The sensitive lining of your oesophagus may then get inflamed from being irritated by stomach acid again and again. This can lead to heartburn, the sensation of regurgitation or painful swallowing.

A stomach ulcer is an open sore on the inside lining of your stomach (a gastric ulcer) or of your small intestine (a duodenal ulcer). Indigestion can be one of the symptoms if you have one.

Ulcers form when stomach acid damages the lining of the stomach or the wall of the duodenum. Most of the time, the damage comes from an H pylori infection.

Indigestion that keeps coming back can, in rare cases, be a sign of stomach cancer. The cancer cells break down the protective lining of your stomach, so acid comes into contact with the stomach wall.

For most people, indigestion (dyspepsia) is mild and doesn't happen often, so it doesn't need treatment from a healthcare professional. But if you have indigestion regularly, or if it causes you severe pain or discomfort, see your pharmacist.

The pharmacist will ask about your indigestion symptoms, and also about:

• any other symptoms you have, which may point to an underlying health condition
• any medicine you are taking, as some medicines can cause indigestion
• your lifestyle, as some lifestyle factors, such as smoking, drinking alcohol or being overweight, can cause indigestion

Depending on the type of symptoms you have, your pharmacist may suggest you see your doctor so that your condition can be looked into further. This is because indigestion can sometimes be a symptom of an underlying condition or health problem, such as a Helicobacter pylori (H pylori) bacterial infection.

You may be referred to hospital to have an endoscopy.

An endoscopy is a procedure that lets doctors look at the inside of your body. They use an endoscope, which is a thin, flexible tube about the width of your little finger. It has a light and a camera on one end, and the camera sends images of the inside of your body to a TV monitor.

An endoscopy is not often needed to diagnose indigestion, but your doctor may suggest one if:

• they need to examine the inside of your abdomen in more detail
• you have had treatment for indigestion that has not worked
• you have any serious symptoms of indigestion

Some medicines for indigestion can hide problems that an endoscopy would otherwise pick up. So for at least two weeks before your endoscopy, you will need to stop taking proton pump inhibitors (PPIs) and H2-receptor antagonists.

Your doctor may also recommend changing other medicines that could be causing your indigestion. But only stop a medicine if your doctor, or another healthcare professional responsible for your care, advises you to.

If your doctor thinks your symptoms may be caused by an infection with H pylori bacteria, you may need a test for it. These are the tests you might be offered:

• a stool antigen test, where a pea-sized stool (faeces) sample is tested for H pylori bacteria
• a breath test
• a blood test, where a blood sample is tested for antibodies to H pylori bacteria (antibodies are proteins the body produces to fight infection)

Antibiotics and PPIs can affect the results of a urea breath test or a stool antigen test. So these tests may need to wait until two weeks after you last used a PPI, and 4 weeks after you last used an antibiotic.

If your doctor thinks your indigestion may be caused by another underlying medical condition, you may need some further tests to rule this out.

Abdominal pain and discomfort can also come from conditions that affect the bile ducts in your liver. These ducts are a series of tubes that carry bile from the liver to the gallbladder and the bowel. Bile is a fluid the digestive system uses to break down fats, and the gallbladder is a pouch that holds it. If your doctor suspects a condition of this kind, they may suggest a liver function test. This is a type of blood test that shows how well your liver is working.

You may also need an abdominal ultrasound. An ultrasound scan uses high-frequency sound waves to create an image of the inside of your body.

How indigestion (dyspepsia) is treated depends on what's causing it and how severe your symptoms are.

If a doctor has diagnosed an underlying health condition, you may want to read about:

• treating gastro-oesophageal reflux disease (GORD)
• treating a stomach ulcer

If you only get indigestion now and then, you may not need to see a pharmacist or doctor for treatment. A few simple changes to your diet and lifestyle can often ease the symptoms, and they're summarised below.

Extra weight puts more pressure on your stomach, and that makes it easier for stomach acid to be pushed back up into your gullet (oesophagus). This is called acid reflux, and it is one of the most common causes of indigestion.

If you are overweight or obese, you should lose weight safely and steadily. Do this through regular exercise and a healthy, balanced diet.

Write down any food or drink that seems to make your indigestion worse, and stay away from it if you can. In practice, this may mean:

• eating less rich, spicy and fatty food
• cutting down on drinks that contain caffeine, such as tea, coffee and cola
• avoiding alcohol, or cutting down on it

If indigestion tends to bother you at night, don't eat for three to four hours before you go to bed. When you lie down with a full stomach, there's a greater chance that acid will be forced up from your stomach into your oesophagus.

At bedtime, use a couple of pillows to prop up your head and shoulders. Better still, raise the head of your bed by a few inches by putting something underneath the mattress. The slight slope should help stop stomach acid moving up into your oesophagus while you sleep.

If you often feel stressed or anxious, this can bring on the symptoms of indigestion. Some simple relaxation tips can help you ease that stress.

Your pharmacist may suggest changing a medicine you already take if they think it could be causing your indigestion.

If it's safe to do so, you may need to stop certain medicines, such as aspirin or ibuprofen. Where needed, your pharmacist may advise you to see your doctor, who can prescribe an alternative that won't cause indigestion. But never stop taking any medicine without asking your pharmacist or doctor first.

If your indigestion needs quick relief, a pharmacist can advise you on the best way to treat it. Along with changes to your lifestyle and a review of the medicines you already take, your doctor may prescribe or recommend:

• antacid medicines
• alginates

Antacids are a type of medicine that can give quick relief from mild to moderate symptoms of indigestion. They neutralise the acid in your stomach (so it becomes less acidic), which means it no longer irritates the lining of your digestive system.

You can get antacids as tablets or as a liquid. Most pharmacies sell them over the counter, so you don't need a prescription.

The effect of an antacid lasts only a few hours at a time, so you may need to take more than one dose. Always follow the instructions on the packet so you don't take too much.

It is best to take antacids when you expect symptoms of indigestion, or just as they begin, such as:

• after meals
• at bedtime

At these times antacids stay in your stomach longer, so they have more time to work. For example, if you take an antacid while eating a meal, it can work for up to three hours. Taken on an empty stomach, it may work for only 20 to 60 minutes.

Read more about antacids, including possible interactions with other medicines and side effects.

Some antacids also contain a medicine called an alginate. It helps relieve indigestion that is caused by acid reflux.

Acid reflux happens when stomach acid leaks back up into your oesophagus and irritates its lining. Alginates form a foam barrier that floats on top of what's in your stomach. This keeps the acid in your stomach and away from your oesophagus.

If you have symptoms of acid reflux, or if you have GORD, your pharmacist may suggest an antacid that contains an alginate.

Take these antacids after you eat, because that helps the medicine stay in your stomach longer. On an empty stomach, alginates leave too quickly to work well.

If your indigestion is persistent or keeps coming back, antacids and alginates may not control your symptoms well enough. Your pharmacist may then suggest a different type of medicine, prescribed at the lowest possible dose that keeps your symptoms under control. The possible medicines include:

• proton pump inhibitors (PPIs)
• H2-receptor antagonists

Your pharmacist may also advise you to see your doctor. The doctor may test you for the Helicobacter pylori (H pylori) bacteria (see Indigestion: diagnosis) and prescribe treatment for it if necessary.

Proton pump inhibitors (PPIs) restrict the acid your stomach produces.

You take them as tablets. If you are over 18, you can buy some types of PPIs over the counter in pharmacies, but these should only be used for short-term treatment. PPIs may strengthen the effect of certain medicines. So if you're prescribed a PPI and you also take other medicines, your progress will be monitored. Examples include:

• warfarin, a medicine that stops the blood clotting
• phenytoin, a medicine to treat epilepsy

If your indigestion is persistent, your pharmacist might advise you to see your doctor.

If your doctor refers you for an endoscopy (a procedure that allows a surgeon to see inside your abdomen), you will need to stop taking a PPI at least 14 days before it. PPIs can hide some of the problems that would otherwise be spotted during the endoscopy.

PPIs can sometimes cause side effects, but these are usually mild and reversible. They may include:

• headaches
• diarrhoea
• constipation
• feeling sick (nausea)
• vomiting
• flatulence
• stomach pain
• dizziness
• skin rashes

H2-receptor antagonists are another type of medicine your pharmacist or doctor may suggest if antacids, alginates and PPIs haven't kept your indigestion under control. There are four of them:

• cimetidine
• famotidine
• nizatidine
• ranitidine

These medicines work by lowering the acidity level in your stomach.

Your doctor may prescribe any one of the four, although ranitidine is also available from pharmacies under the Pharmacy First service. H2-receptor antagonists are usually taken as tablets.

As with PPIs, you will need to stop taking H2-receptor antagonists at least 14 days before an endoscopy, if your doctor has arranged one for you. They can hide some of the problems that the endoscopy might otherwise pick up.

If your indigestion is caused by an infection with H pylori bacteria, you will need treatment to clear the infection from your stomach. This should ease your indigestion, because the bacteria will no longer be pushing up the amount of acid in your stomach.

H pylori infection is usually treated with triple therapy, which means treatment with three different medicines. Your doctor will prescribe a course containing:

• two different antibiotics (medicines to treat infections that are caused by bacteria)
• a PPI

You will need to take these medicines twice a day for seven days. Follow the dosage instructions closely, because that is what makes the triple therapy work.

In up to 85% of cases, one course of triple therapy clears an H pylori infection. But if the infection doesn't clear the first time, you may need more than one course of treatment.

Most of the time, indigestion (dyspepsia) is mild and only turns up now and then. But when it's severe, it can lead to complications, and some of these are described below.

Indigestion is often caused by acid reflux. This happens when stomach acid leaks back up into your gullet (oesophagus) and irritates its lining. If the irritation builds up over time, your oesophagus can become scarred, and the scarring can eventually leave it narrow and constricted. This is known as oesophageal stricture.

If you have an oesophageal stricture, you may notice symptoms such as:

• difficulty swallowing (dysphagia)
• food that becomes lodged in your throat
• chest pain

Oesophageal stricture is often treated with surgery to widen your oesophagus.

Pyloric stenosis, like oesophageal stricture, comes from long-term irritation of the lining of your digestive system by stomach acid.

The condition develops when the passage between your stomach and your small intestine, known as the pylorus, becomes scarred and narrowed. You then start vomiting, and the food you eat can't be digested properly.

In most cases, doctors treat pyloric stenosis with surgery that brings the pylorus back to its proper width.

If you have repeated episodes of gastro-oesophageal reflux disease (GORD), the cells lining your lower oesophagus can change. This condition is known as Barrett's oesophagus.

It's estimated that 1 in 10 people with GORD will develop Barrett's oesophagus. Most cases first develop in people aged 50 to 70 years old, and the average age at diagnosis is 62.

Barrett's oesophagus doesn't usually cause noticeable symptoms other than those linked to GORD.

The worry is that it's a pre-cancerous condition. The changes in the cells are not cancerous, but there is a small risk they could develop into cancer in the future. That would then bring on oesophageal cancer.