Dyspepsia (Indigestion)

Dyspepsia is a functional disease that affects the organs and glands in the abdomen

Dyspepsia, also known as functional dyspepsia, is long-term or recurring indigestion. Dyspepsia can be uncomfortable and often causes pain or distress within your digestive tract. Often, dyspepsia will not cause long-term damage to your body, but it can cause lots of worry, stress, and irritation.

Dyspepsia is best described as a functional disease. The concept of functional disease is particularly useful when discussing diseases of the gastrointestinal tract. The term, functional, in this case, means that either the muscles of the organs or the nerves that control the organs are not working normally, and, as a result, the organs do not function normally, and the dysfunction causes the symptoms. The nerves that control the organs include not only the nerves that lie within the muscles of the organs but also the nerves of the spinal cord and brain.

Indigestion is one of the most common ailments of the bowel (intestines), affecting an estimated 20% of persons in the United States. Perhaps only 10% of those affected seek medical attention for their indigestion.

Indigestion is not a particularly good term for the ailment since it implies that there is abnormal digestion of food, and this most probably is not the case. Doctors frequently refer to the condition as non-ulcer dyspepsia to distinguish it from the more common acid or ulcer-related symptoms.

The 3 types of indigestion (dyspepsia) include:

1. Occasional: Happening occasionally.
2. Chronic: Happening regularly for a few weeks or months.
3. Functional: Having chronic symptoms without a specific cause.

The abdomen and a portion of the small intestine are thought to operate improperly in dyspepsia. Theories propose that the muscles or nerves of these organs work improperly, giving rise to the condition.

There is no single cause of dyspepsia in a person. Rather, a combination of variables, dysfunctions, and other medical issues are thought to cause the muscles of the intestine and the nerves that regulate them to become dysfunctional.

Non-gastrointestinal causes of indigestion

It's not surprising that many gastrointestinal (GI) diseases have been associated with indigestion. However, many non-GI diseases also have been associated with indigestion.

Examples of non-GI causes of indigestion include:

• Diabetes
• Thyroid disease
• Hyperparathyroidism (overactive parathyroid glands)
• Severe kidney disease

It is not clear, however, how these non-GI diseases might cause indigestion.

Another important cause of indigestion is drugs. Many drugs are frequently associated with indigestion, for example, nonsteroidal anti-inflammatory drugs (NSAIDs such as ibuprofen), GLP-1 agonists (for diabetes and weight loss), antibiotics, and estrogens. Most drugs are reported to cause indigestion in at least some people with functional symptoms.

Other diseases and conditions can aggravate indigestion and other functional diseases.

• Infection: In many people, Helicobacter pylori bacterium infection is the most prevalent cause of dyspepsia.
• Wrong eating habits:
  • Eating too much food without thoroughly chewing it can cause indigestion and pain.
  • Certain foods, such as spicy foods, fatty foods, chocolates, citrus fruits, and caffeine, might cause the symptoms.
  • Tobacco and alcohol are suspected of being involved.
• Complications of the intestine can lead to dyspepsia:
  • Gastritis (stomach inflammation)
  • Gallstones
  • Peptic ulcers
  • Hiatus hernia
  • Pancreatitis
  • Gastroesophageal reflux disease (GERD)
• Anxiety and stress: According to research, dyspepsia can be caused by a high level of stress, anxiety, or depression.
• Drug overuse: Specific medications, such as nonsteroidal anti-inflammatory drugs, ibuprofen, and estrogen supplements, can cause dyspepsia symptoms.

A potential cause of indigestion is a bacterial overgrowth of the small intestine (small intestinal bacterial overgrowth or SIBO), although the frequency with which this condition causes indigestion has not been determined, and there is little research in the area. The relationship between overgrowth and indigestion needs to be pursued, however, since many of the symptoms of indigestion are also symptoms of bacterial overgrowth. Overgrowth can be diagnosed by hydrogen breath testing and is treated primarily with antibiotics.

Researchers do not fully understand what causes dyspepsia, but risk factors may include:

• Anxiety
• Depression
• Smoking
• Alcohol consumption
• Obesity

Dyspepsia can also be caused by your diet. A low-level, undiagnosed food allergy, could be triggering inflammation accounting for the symptoms felt.

Women and older people are more likely to experience dyspepsia than other populations.

We usually think of symptoms of indigestion as originating from the upper gastrointestinal tract, primarily the stomach and the first part of the small intestine. These symptoms include:

• Upper abdominal pain or discomfort (above or around the navel)
• Belching
• Nausea (with or without vomiting)
• Abdominal bloating (the sensation of abdominal fullness without visible distention)
• Early satiety (the sensation of fullness after a very small amount of food)
• Abdominal distention (visible swelling as opposed to bloating)
• Lower chest pain

Symptoms most often are provoked by eating, which is a time when many different gastrointestinal functions are called upon to work in concert. This tendency to occur after meals is what gave rise to the erroneous notion that indigestion might be caused by an abnormality in the digestion of food.

It is appropriate to discuss belching in detail since it is a commonly misunderstood symptom associated with indigestion.

• Belching, also known as burping or eructating, is the act of expelling gas from the stomach out through the mouth.
• The usual cause of belching is a distended (inflated) stomach that is caused by swallowed air or gas.
• The distention of the stomach causes abdominal discomfort, and the belching expels the air and relieves the discomfort.
• The common reasons for swallowing large amounts of air (aerophagia) or gas are:
  • gulping food or drink too rapidly,
  • anxiety, and
  • carbonated beverages.
• People often are unaware that they are swallowing air.
• "Burping" infants during bottle or breastfeeding is important to expel air in the stomach that has been swallowed with the formula or milk.

Excessive air in the stomach is not the only cause of belching.

• For some people, belching becomes a habit and does not reflect the amount of air in their stomachs.
• For others, belching is a response to any type of abdominal discomfort and not just to discomfort due to increased gas.

Everyone knows that when they have mild abdominal discomfort, belching often relieves the problem. This is because excessive air in the stomach often is the cause of mild abdominal discomfort; as a result, people force belches whenever mild abdominal discomfort is felt, whatever the cause.

Unfortunately, if there is no excessive gas to be expelled, forced belches do nothing more than draw air into the esophagus. Usually, this air is expelled during the same belch (referred to as a supradiaphragmatic belch), but the air also may enter the stomach, and itself result in excess gas that must be expelled with additional belching.

If the problem causing the discomfort is not excessive air in the stomach, then belching does not provide relief. As mentioned previously, it even may make the situation worse by increasing the air in the stomach. When belching does not ease the discomfort, the belching should be taken as a sign that something may be wrong within the abdomen, and the cause of the discomfort should be sought. Belching by itself, however, does not help the physician determine what may be wrong because belching can occur in virtually any abdominal disease or condition that causes discomfort.

Since indigestion is very common, almost all doctors see and treat patients with indigestion, especially family practitioners, internists, and even pediatricians. If these generalists are unable to provide adequate treatment, the patient usually is referred to a gastroenterologist, an internist, or a pediatrician with specialty training in gastrointestinal diseases.

Indigestion is diagnosed primarily based on typical symptoms and the exclusion of non-functional gastrointestinal diseases (including acid-related diseases), non-gastrointestinal diseases, and psychiatric illnesses. There are tests for identifying abnormal gastrointestinal function directly, but they are limited in their ability to do so.

Exclusion of non-functional gastrointestinal disease

A detailed history of the patient and a physical examination frequently will suggest the cause of dyspepsia.

• Routine screening blood tests are often performed looking for clues to unsuspected diseases.
• Examinations of the stool are a part of the evaluation since they may reveal infection, signs of inflammation, or blood and direct further diagnostic testing.
• Sensitive stool testing (antigen/antibody) for Giardia lamblia would be reasonable because this parasitic infection is common and can be acute or chronic.
• Some physicians do blood testing for celiac disease (sprue), but the value of doing this is unclear. (Moreover, if an EGD is planned, biopsies of the duodenum usually will make the diagnosis of celiac disease.)
• If bacterial overgrowth of the small intestine is being considered, breath hydrogen testing can be considered.

There are many tests to exclude non-functional gastrointestinal diseases. The primary issue, however, is deciding which tests are reasonable to perform. Since each case is individual, different tests may be reasonable for different patients. Nevertheless, certain basic tests are often performed to exclude non-functional gastrointestinal diseases. These tests identify anatomic (structural) and histological (microscopic) diseases of the esophagus, stomach, and intestines.

Diagnostic tests

Both X-rays and endoscopies can identify anatomic diseases. Only endoscopies, however, can diagnose histological diseases because biopsies (samples of tissue) can be taken during the procedure. The X-ray tests include:

• Esophagram and video-fluoroscopic swallowing study for examining the esophagus
• Upper gastrointestinal series for examining the stomach and duodenum
• Small bowel series for examining the small intestine
• Barium enema for examining the colon and terminal ileum
• Computerized tomography (CT) scan for examining the small intestine

The endoscopic tests include:

• Upper gastrointestinal endoscopy (esophago-gastro-duodenoscopy or EGD) to examine the esophagus, stomach, and duodenum
• Colonoscopy to examine the colon and terminal ileum
• Endoscopy also is available to examine the small intestine, but this type of endoscopy is complex, not widely available, and of unproven value in indigestion.
• To examine the small intestine, a capsule containing a tiny camera and transmitter that can be swallowed (capsule endoscopy). As the capsule travels through the intestines, it transmits pictures of the inside of the intestines to an external recorder for later review. The capsule is not widely available and its value, particularly in indigestion, has not yet been proven.
• Newer endoscopes, similar to those used for EGD and colonoscopy are available that allow the entire small intestine to be examined. Unlike the capsule, however, the endoscope has channels in it that allow instruments to be passed into the intestine to collect samples of tissue (biopsies) and to treat abnormal findings such as polyps.
• X-rays are easier to perform and less costly than endoscopies. The skills necessary to perform gastrointestinal X-rays, however, are becoming rare among radiologists because they are doing them less often. Therefore, the quality of the X-rays often is not as high as it used to be, and, as a result, CT scans of the small intestine are replacing small intestinal X-rays. As noted previously, endoscopies have an advantage over X-rays since at the time of endoscopies, biopsies can be taken to diagnose or exclude histological diseases, something that X-rays cannot do.

The treatment of indigestion is a difficult and unsatisfying topic because so few drugs have been studied and are effective. Moreover, effective drugs are not very effective. This difficult situation exists for many reasons including:

• Life-threatening illnesses (for example, cancer, heart disease, and high blood pressure) are the illnesses that capture the public's interest and, more importantly, research funding. Indigestion is not a life-threatening illness and has received little research funding. Because of the lack of research, an understanding of the physiologic processes (mechanisms) that are responsible for indigestion has been slow to develop. Effective drugs cannot be developed until there is an understanding of these mechanisms.
• Research into indigestion is difficult. Indigestion is defined by subjective symptoms (such as pain) rather than objective signs (for example, the presence of an ulcer). Subjective symptoms are more unreliable than objective signs in identifying homogenous groups of patients. As a result, groups of patients with indigestion who are undergoing treatment are likely to contain some patients who do not have indigestion, which may dilute (negatively affect) the results of the treatment. Moreover, the results of treatment must be evaluated based on subjective responses (such as improvement of pain). In addition to being more unreliable, subjective responses are more difficult to measure than objective responses (for example, healing of an ulcer).
• Different subtypes of indigestion (for example, abdominal pain and abdominal bloating) are likely to be caused by different physiologic processes (mechanisms). It also is possible, however, that the same subtype of indigestion may be caused by different mechanisms in different people. What's more, any drug is likely to affect only one mechanism. Therefore, it is unlikely that any one medication can be effective in all-even most patients with indigestion, even patients with similar symptoms. This inconsistent effectiveness makes the testing of drugs particularly difficult. Indeed, it can easily result in drug trials that demonstrate no efficacy (usefulness) when, in fact, the drug is helping a subgroup of patients.
• Subjective symptoms are particularly prone to responding to placebos (inactive drugs). In fact, in most studies, 20% to 40% of patients with indigestion will improve if they receive placebo drugs. Now, all clinical trials of drugs for indigestion require a placebo-treated group for comparison with the drug-treated group. The large placebo response means that these clinical trials must utilize large numbers of patients to detect meaningful (significant) differences in improvement between the placebo and drug groups. Therefore, these trials are expensive to conduct.

The lack of understanding of the physiologic processes (mechanisms) that cause indigestion has meant that treatment usually cannot be directed at the mechanisms. Instead, treatment usually is directed at the symptoms. For example, nausea is treated with medications that suppress nausea but do not affect the cause of the nausea. On the other hand, psychotropic drugs (antidepressants) and psychological treatments (such as cognitive behavioral therapy) treat hypothetical causes of indigestion (for example, abnormal function of sensory nerves and the psyche) rather than causes or even symptoms. Treatment for indigestion often is similar to that for irritable bowel syndrome (IBS) even though the causes of IBS and indigestion are likely to be different.

Education

It is important to educate patients with indigestion about their illness, particularly by reassuring them that the illness is not a serious threat to their physical health (though it may be to their emotional health). Patients need to understand the potential causes of the symptoms. Most importantly, they need to understand the medical approach to the problem and the reasons for each test or treatment. Education prepares patients for a potentially prolonged course of diagnosis and trials of treatment. Education also may prevent patients from falling prey to charlatans who offer unproven and possibly dangerous treatments for indigestion. Many symptoms are tolerable if patients' anxieties about the seriousness of their symptoms can be relieved. It also helps patients deal with symptoms when they feel that everything that should be done to diagnose and treat is being done. The truth is that psychologically healthy people can tolerate a good deal of discomfort and continue to lead happy and productive lives.

Dietary factors have not been well-studied in the treatment of indigestion. Nevertheless, people often associate their symptoms with specific foods (such as salads and fats). Although specific foods might worsen the symptoms of indigestion, they usually are not the cause of indigestion. (Intolerance to specific foods, for example, lactose intolerance [milk] and allergies to wheat, eggs, soy, and milk protein are not considered functional diseases like indigestion). The common placebo response in functional disorders such as indigestion also may explain the improvement of symptoms in some people with the elimination of specific foods.

Dietary fiber often is recommended for patients with IBS, but fiber has not been studied in the treatment of indigestion. Nevertheless, it probably is reasonable to treat patients with indigestion with fiber if they also have constipation.

Lactose intolerance (the sugar in milk) often is blamed for indigestion. Since indigestion and lactose intolerance both are common, the two conditions may coexist. In this situation, restricting lactose will improve the symptoms of lactose intolerance, but will not affect the symptoms of indigestion. Lactose intolerance is easily determined by a milk challenge testing the effects of lactose (hydrogen breath testing) or trying a strict lactose elimination diet. If lactose is determined to be responsible for some or all of the symptoms, elimination of lactose-containing foods is appropriate. Unfortunately, many patients stop drinking milk or eating milk-containing foods without good evidence that it improves their symptoms. This often is detrimental to their intake of calcium which may contribute to osteoporosis.

One of the food substances most commonly associated with the symptoms of indigestion is fat. The scientific evidence that fat causes indigestion is weak. Most of the support is anecdotal (not based on carefully done, scientific studies). Nevertheless, fat is one of the most potent influences on gastrointestinal function. (It tends to slow down the gastrointestinal muscles while it causes the muscles of the gallbladder to contract.) Therefore, fat may worsen indigestion even though it doesn't cause it. Moreover, reducing the ingestion of fat might relieve symptoms. A strict low-fat diet can be accomplished fairly easily and is worth trying. Additionally, there are other health-related reasons for reducing dietary fat.

Other dietary factors, fructose, and other sugar-related foods (fermentable, oligo- di- and mono-saccharides and polyols or FODMAPs), have been suggested as a cause of indigestion since many people do not fully digest and absorb them before they reach the distal intestine. Fructose intolerance and perhaps also FODMAP intolerance can be diagnosed with a hydrogen breath test using fructose and treated by elimination of fructose and/or FODMAP-containing foods from the diet. Unfortunately, fructose and FODMAPs are widespread among fruits and vegetables, and fructose is found in high concentrations in many food products sweetened with corn syrup. Thus, an elimination diet can be difficult to maintain.

Patients with functional disorders, including indigestion, are frequently found to be suffering from depression and/or anxiety. It is unclear, however, if depression and anxiety are the cause or the result of the functional disorders or are unrelated to these disorders. (Depression and anxiety are common and, therefore, their occurrence together with functional disorders may be coincidental.)

Several clinical trials have shown that antidepressants are effective in IBS in relieving abdominal pain. Antidepressants also are effective in unexplained (non-cardiac) chest pain, a condition thought to represent a dysfunction of the esophagus. Antidepressants have not been studied adequately in other types of functional disorders, including indigestion. It probably is reasonable to treat patients with indigestion with psychotropic drugs if they have moderate or severe depression or anxiety.

The antidepressants work in functional disorders at relatively low doses that have little or no effect on depression. It is believed, therefore, that these drugs work not by combating depression, but in different ways (through different mechanisms). For example, these drugs have been shown to adjust (modulate) the activity of the nerves and to have analgesic (pain-relieving) effects as well.

Commonly used psychotropic drugs include tricyclic antidepressants, desipramine (Norpramine), and trimipramine (Surmontil). Although studies are encouraging, it is not yet clear whether the newer class of antidepressants, the serotonin-reuptake inhibitors such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil), are effective in functional disorders, including indigestion.

The most widely studied drugs for the treatment of abdominal pain in functional disorders are a group of drugs called smooth-muscle relaxants.

The gastrointestinal tract is primarily composed of a type of muscle called smooth muscle. (By contrast, skeletal muscles such as the biceps are composed of a type of muscle called striated muscle.) Smooth muscle relaxant drugs reduce the strength of contraction of the smooth muscles but do not affect the contraction of other types of muscles. They are used in functional disorders, particularly IBS, with the assumption (not proven) that strong or prolonged contractions of smooth muscles in the intestine spasms are the cause of pain in functional disorders. There are even smooth muscle relaxants that are placed under the tongue, as is nitroglycerin for angina, so that they may be absorbed rapidly.

There are not enough studies of smooth muscle relaxants in indigestion to conclude that they are effective at reducing pain. Since their side effects are few, these drugs probably are worth trying. As with all drugs that are given to control symptoms, patients should carefully evaluate whether or not the smooth muscle relaxant they are using is effective at controlling the symptoms. If it is not effective, the option of discontinuing the relaxant should be discussed with a physician.

Commonly used smooth muscle relaxants are hyoscyamine (Levsin, Anaspaz, Cystospaz, Donnamar) and methscopolamine (Pamine, Pamine Forte). Other drugs combine smooth muscle relaxants with a sedative chlordiazepoxide hydrochloride and clidinium bromide (Donnatal, Librax), but there is no evidence that the addition of sedatives adds to the effectiveness of the treatment.

One of the leading theories for the cause of indigestion is abnormalities in the way gastrointestinal muscles function. The function of muscles may be abnormally increased, abnormally decreased, or it may be uncoordinated. There are medications, called smooth muscle relaxants that can reduce the activity of the muscles and other drugs that can increase the activity of the muscles, called promotility drugs.

Many of the symptoms of indigestion can be explained based on the reduced activity of the gastrointestinal muscles that results in slowed transport (transit) of food through the stomach and intestine. (It is clear, as discussed previously, that there are other causes of these symptoms in addition to slowed transit.) Such symptoms include nausea, vomiting, and abdominal bloating. When transit is severely affected, abdominal distention (swelling) also may occur and can result in abdominal pain. (Early satiety is unlikely to be a function of slowed transit because it occurs too early for slowed transit to have consequences.) Theoretically, drugs that speed up the transit of food should, in at least some patients, relieve symptoms of indigestion that are due to slow transit.

The number of promotility drugs that are available for use clinically is limited. Studies of their effectiveness in indigestion are even more limited. The most studied drug is cisapride (Propulsid), a promotility drug that was withdrawn from the market because of serious cardiac side effects. (Newer drugs that have similar effects but lack toxicity are being developed.) The few studies with cisapride for indigestion were inconsistent in their results. Some studies demonstrated benefits whereas others showed no benefit. Cisapride was effective in patients with severe emptying problems of the stomach (gastroparesis) or severely slowed transit of food through the small intestine (chronic intestinal pseudo-obstruction). These two diseases may or may not be related to indigestion.

Another promotility drug that is available is erythromycin, an antibiotic that stimulates gastrointestinal smooth muscle as one of its side effects. Erythromycin is used to stimulate smooth muscles of the gastrointestinal tract at doses that are lower than those used for treating infections. There are no studies of erythromycin in indigestion, but erythromycin is effective in gastroparesis and probably also in chronic intestinal pseudo-obstruction.

Metoclopramide (Reglan) is another promotility drug that is available. It has not been studied, however, in indigestion. Moreover, it is associated with some troubling side effects. Therefore, it may not be a good drug to undergo further testing for indigestion.

Domperidone (Motilium) is a promotility drug that is available in the U.S. but requires a special permit from the US Food and Drug Administration. As a result, it is not very commonly prescribed. It is an effective drug with minimal side effects.

Studies of natural and home remedies for indigestion are few. Most recommendations for natural and home remedies have little evidence to support their use. Several potential remedies, however, deserve mention including:

• Acid-suppressing remedies: The most common cause of dyspepsia is probably gastrointestinal reflux disease (acid reflux or GERD). That may be why remedies such as baking soda, which neutralizes stomach acid, have been recommended. Even if baking soda works, it is more effective (and probably safer) to use antacids in liquid or pill form for this purpose.
• Ginger: Ginger has been demonstrated to relieve nausea. One small study showed it to be ineffective in relieving dyspepsia, but ginger is harmless and worth a try if nausea is a component of dyspepsia.
• Peppermint: Peppermint has been demonstrated to have effects on the function of the gastrointestinal tract; it is among the most potent inhibitors of intestinal muscles. It is effective in another functional disease, irritable bowel syndrome, but there is minimal evidence that it is effective in dyspepsia. Nevertheless, like ginger, it is harmless and worth a try.
• Meals: Eating smaller, more frequent meals.
• Lifestyle changes: Stay away from specific foods and drinks, smoking, and alcohol if they provoke symptoms.

Psychological treatments include cognitive-behavioral therapy, hypnosis, psychodynamic or interpersonal psychotherapy, and relaxation/stress management. Few studies of psychological treatments have been conducted on indigestion, although more studies have been done on IBS. Thus, there is little scientific evidence that they are effective in indigestion, although there is some evidence that they are effective in IBS.

Hypnosis has been proposed as an effective treatment for IBS. It is unclear exactly how effective hypnosis is, or how it works.

Indigestion is a chronic disease that usually lasts years, if not a lifetime. It does, however, display periodicity, which means that the symptoms may be more frequent or severe for days, weeks, or months and then less frequent or severe for days, weeks, or months. The reasons for these fluctuations are unknown.

Because of the fluctuations, it is important to judge the effects of treatment over many weeks or months to be certain that any improvement is due to treatment and not simply to a natural fluctuation in the frequency or severity of the disease.

The initial approach to dyspepsia, whether it be treatment or testing, depends on the patient's age, symptoms, and the duration of the symptoms. If the patient is younger than 50 years of age and serious disease, particularly cancer, is not likely, testing is less important. If the symptoms are typical for dyspepsia and have been present for many years without change, then there is less need for testing, or at least extensive testing, to exclude other gastrointestinal and non-gastrointestinal diseases.

On the other hand, if the symptoms are of recent onset (weeks or months), progressively worsening, severe, or associated with "warning" signs, then early, more extensive testing is appropriate. Warning signs include loss of weight, nighttime awakening, blood in the stool or the material that is vomited (vomitus), and signs of inflammation, such as fever or abdominal tenderness. Testing also is appropriate if, in addition to symptoms of dyspepsia, other prominent symptoms are not commonly associated with dyspepsia.

If there are symptoms that suggest conditions other than dyspepsia, tests that are specific for these diseases should be done first. The reason is that if these other tests disclose other diseases, it may not be necessary to do additional testing. Examples of such symptoms and possible testing include:

• Vomiting: upper gastrointestinal endoscopy to diagnose inflammatory or obstructing diseases; gastric emptying studies and/or electrogastrography to diagnose impaired emptying of the stomach.
• Abdominal distention with or without increased flatulence: upper gastrointestinal and small intestinal x-rays to diagnose obstructing diseases; hydrogen breath testing to diagnose bacterial overgrowth of the small intestine.

For a patient with typical symptoms of dyspepsia who requires testing to exclude other diseases, a standard screening panel of blood tests would reasonably be included. These tests might reveal clues to non-gastrointestinal diseases. Sensitive stool testing (antigen/antibody) for Giardia lamblia would be reasonable because this parasitic infection is common and can be acute or chronic. Some physicians do blood testing for celiac disease (sprue), but the value of doing this is unclear. Moreover, if an EGD is planned, biopsies of the duodenum usually will make the diagnosis of celiac disease. A plain X-ray of the abdomen might be done during an episode of abdominal pain (to look for an intestinal blockage or obstruction). Testing for lactose intolerance or a trial of a strict lactose-free diet should be considered. The physician's clinical judgment should determine the extent to which initial testing is appropriate.

Once testing has been done to an extent that is appropriate for the clinical situation, it is reasonable to first try a therapeutic trial of stomach acid suppression to see if symptoms improve. Such a trial may involve a PPI (proton pump inhibitor) for 8 to 12 weeks. If there is no clear response to symptoms, the options then are to discontinue the PPI or confirm its effectiveness in suppressing acid with 24-hour acid testing. If there is a clear and substantial decrease in symptoms with the PPI, then decisions need to be made about continuing acid suppression and which drugs to use.

Another therapeutic approach is to test for Helicobacter pylori infection of the stomach (with blood, breath, or stool tests) and to treat patients with infection to eradicate the infection. It may be necessary to retest patients after treatment to prove that treatment has effectively eradicated the infection, particularly if dyspeptic symptoms persist after treatment.

If treatment with a PPI has satisfactorily suppressed acid according to acid testing (or acid suppression has not been measured) and yet the symptoms have not improved, it is reasonable to conduct further testing as described above. Esophago-gastro-duodenoscopy, or EGD, (and, possibly, colonoscopy) would be the next consideration, probably with multiple biopsies of the stomach and duodenum (and colon if colonoscopy is done). Finally, small intestinal X-rays and an ultrasound examination of the gallbladder might be done. An abdominal ultrasound examination, CT scan, or MRI scan can exclude non-gastrointestinal diseases. Once appropriate testing has been completed, empiric trials of other drugs (for example, smooth muscle relaxants, psychotropic drugs, and promotility drugs) can be done. (An empiric trial of a drug is a trial that is not based on an understanding of the exact cause of the symptoms)

If all of the appropriate tests reveal no disease that could be causing the symptoms and the dyspeptic symptoms have not responded to empiric treatments, other, more specialized tests should be considered. These tests include hydrogen breath testing to diagnose bacterial overgrowth of the small intestine, gastric emptying studies, EGG, small intestinal transit studies, antro-duodenal motility, and barostatic studies, and possibly capsule endoscopy. These specialized studies will most likely be performed by specialists and be done at centers that have experience and expertise in diagnosing and treating functional diseases.

The complications of functional diseases of the gastrointestinal tract are relatively limited. Since symptoms are most often provoked by eating, patients who alter their diets and reduce their intake of calories may lose weight. However, loss of weight is unusual in functional diseases. Loss of weight should suggest the presence of non-functional diseases. Symptoms that awaken patients from sleep also are more likely to be due to non-functional rather than functional disease.

Most commonly, functional diseases interfere with patients' comfort and daily activities. Individuals who develop nausea or pain after eating may skip breakfast or lunch because of the symptoms they experience. Patients also commonly associate symptoms with specific foods (for example, milk, fat, and vegetables). Whether or not the associations are real, these patients will restrict their diets accordingly. Milk is the most common food that is eliminated, often unnecessarily, and this can lead to inadequate intake of calcium and osteoporosis. The interference with daily activities also can lead to problems with interpersonal relationships, especially with spouses. Most patients with functional disease live with their symptoms and infrequently visit physicians for diagnosis and treatment.

Managing or preventing dyspepsia is typically possible through modest lifestyle modifications.

More serious conditions may cause indigestion in some circumstances, but even if more active therapy is required, minor modifications in your eating habits can help manage your symptoms.

The following are a few of the many things you can take to help minimize the severity of dyspepsia. If you require additional assistance, speaking with your nutritionist can be an excellent resource to help you take control of your symptoms.

Common preventing methods of dyspepsia include:

• Eat more slowly
• Eat smaller meals
• Quit smoking
• Maintain ideal weight
• Avoid acidic foods, such as citrus fruits and tomatoes
• Do not lie down right after eating
• Cut out caffeine by removing coffee, tea, and other beverages
• Reduce your consumption of alcohol because alcoholic drinks can irritate your stomach lining
• If your indigestion is related to stress, work on meditation, biofeedback, and other techniques to relieve or lower your stress
• Use pillows to prop your head and torso up while you sleep
• Avoid exercising on a full stomach

Although many people have identified certain foods that cause dyspepsia, it has been shown that this varies with people. As a result, no universal advice on diet is recommended.

The future of dyspepsia will depend on our increasing knowledge of the processes (mechanisms) that cause dyspepsia. Acquiring this knowledge, in turn, depends on research funding. Because of the difficulties in researching dyspepsia, this knowledge will not come quickly. Until we have an understanding of the mechanisms of dyspepsia, newer treatments will be based on our developing a better understanding of the normal control of gastrointestinal function, which is proceeding more rapidly. Specifically, there is intense interest in intestinal neurotransmitters, which are chemicals that the nerves of the intestine use to communicate with each other. The interactions of these neurotransmitters are responsible for adjusting (modulating) the functions of the intestines, such as the contraction of muscles and secretion of fluid and mucus.

5-hydroxytriptamine (5-HT or serotonin) is a neurotransmitter that stimulates several different receptors on nerves in the intestine. Examples of experimental drugs for intestinal neurotransmission are sumatriptan (Imitrex) and buspirone (Buspar). These drugs are believed to reduce the responsiveness (sensitivity) of the sensory nerves to what's happening in the intestine by attaching to a particular 5-HT receptor, the 5-HT1 receptor. The 5-HT1 receptor drugs, however, have received only minimal study so far and their role in the treatment of dyspepsia, if any, is unclear.

Promotility drugs similar to cisapride, as previously discussed, are being pursued actively.

Another area of active research is the relaxation of the muscles of the stomach for the treatment of dyspepsia. Normally when food enters the stomach, the stomach relaxes to accommodate the food and the secretions it stimulates. Many patients with dyspepsia have been found to have reduced relaxation of the stomach when food enters, and it is possible that this results in discomfort. Drugs that specifically relax the muscles of the stomach are being developed, but more clinical trials showing their benefit are needed.