Dyspepsia and upper gastrointestinal discomfort is common, affecting about 25% of the population and impacting significantly on quality of life. Symptoms vary from burning or abdominal pain, heartburn, bloating or fullness which often occurs soon after eating food.
Reflux of acid from the stomach into the gullet is one of the commonest causes and gives rise to ‘heartburn’ due to irritation of the lining of the oesophagus. It may however, also cause upper abdominal pain and chest discomfort identical to that of angina. The main reasons for reflux symptoms are increased acidity of gastric contents and reduced function of the sphincter valve in the gullet that prevents regurgitation. The diagnosis is usually made on the basis of clinical history alone, with treatment options and the need for further investigations depending on your age, frequency and severity of symptoms.
For acid reflux, several practical measures focused on changing lifestyle and diet can help. Factors which increase intra-abdominal pressure appear to predispose to reflux of acid into the gullet. For this reason, losing weight if you are overweight or have had recent weight gain is recommended and has been shown to improve symptoms. Indeed, the substantial rise in the prevalence of reflux disease in the last few decades has been attributed to higher levels of abdominal obesity. In a similar way, avoidance of tight fitting clothes around the waistline may help.
Certain foods may cause reflux by increasing stomach acidity or reducing the tone of the oesophageal sphincter that normally prevents backflow of acid into the gullet. These dietary triggers may include fatty and spicy foods, caffeine, chocolate, carbonated drinks and alcohol which if associated with symptoms should be reduced or avoided. If you are prone to reflux, you should avoid lying down or sitting in a semi-recumbent position soon after eating. Indeed, of those who suffer with reflux, about 80% may have symptoms at night.
For quick symptomatic relief, antacids (which are available over the counter) are effective but are only short acting. When symptoms occur twice or more per week, the mainstay of treatment is a once daily tablet (on prescription) that suppresses gastric acid secretion. This is usually given for about three months, but longer term treatment may be required if symptoms relapse or persist.
Peptic ulcers are identified in about 10% of those undergoing investigations for dyspepsia. In the vast majority of cases, this occurs as a result of the bug ‘Helicbacter Pylori’ colonising the stomach and increasing gastric acid secretion. Ulcers typically cause upper abdominal discomfort that can either be aggravated or relieved by taking food.
For non-heartburn dyspepsia or reflux symptoms unresponsive to treatment, identifying this ‘ulcer bug’ with a breath test and /or treating empirically is advised (eradication rate is about 90%). It is also important to review any medications that may be contributory such as aspirin, anti-inflammatories used to control pain and steroids which can all cause gastric inflammation and ulcers.
In those aged over 50 with non-heartburn dyspepsia or where there are persistent symptoms or with other features such as weight loss or swallow difficulties, an endoscopy (camera test) of the gut should be performed to rule out sinister causes such as cancer.
Gallstones can also give rise to dyspepsia that is particularly provoked by eating fatty foods. Discomfort may be episodic and colicky in nature and may occur on the right side of the abdomen and radiate into the back. They are easily identified on ultrasound which your GP can arrange. Whilst most gallstones cause no problems, their presence in the right clinical context warrants consideration for removal of the gallbladder as a treatment.
Coeliac disease can give rise to non-specific upper abdominal symptoms including crampy pain, bloating and loose stools. It is caused by gut insensitivity to gluten which is found in foods made from wheat, barley and rye. As symptoms can be vague and sometimes mild the diagnosis is often missed. However, it is being increasingly identified especially in later life. There is a strong genetic predisposition to coeliac disease and prevalence rates are much higher in those from the West of Ireland. In those with a family history or suggestive symptoms, a blood test to identify coeliac antibodies (which are highly sensitive and specific) should be taken.
The diagnosis is often subsequently confirmed with a small bowel biopsy before adopting a gluten free diet which is a very effective way of treating symptoms.
In many cases, the cause of dyspepsia is unclear despite investigations and may be due to problems like delayed gastric emptying and gut motility problems. Medications like Motilium can sometimes help by promoting gut peristalsis and where there is crampy pain antispasmodics may be of benefit.
Most importantly, if you have ongoing dyspeptic symptoms, make sure to visit your GP so as to optimise treatment and rule out more serious causes.
Dr Kevin McCarroll is a consultant physician in geriatric medicine in St James’ Hospital, Dublin.