Indigestion

What is indigestion?

Indigestion can be described as pain, or discomfort, in the upper abdomen. It is also known as dyspepsia.

Indigestion is caused by stomach acid coming into contact with the sensitive, protective lining (mucosa) of the digestive system. The stomach acid breaks down the mucosa, causing irritation and inflammation, which brings on the symptoms of indigestion.

In most cases, indigestion is related to eating, and may be accompanied by other symptoms, such as fullness in the stomach, or belching. Sometimes, indigestion can be caused by other factors, such as an infection, or taking certain medications.

Indigestion is a common problem

Indigestion is a common problem and many people have it from time to time, without needing to seek advice from a healthcare professional. However, in some cases, indigestion can be a sign of an underlying condition affecting the digestive system, such as gastroesophageal reflux disease (GORD).

It is therefore important to seek medical advice if you have indigestion regularly, if it is particularly painful, or if you suddenly experience it having never experienced it before.

The main symptom of indigestion is pain, or a feeling of discomfort, in your chest, or stomach. This usually comes on soon after eating, or drinking, but there can sometimes be a delay between eating a meal and having indigestion.

The pain of indigestion may feel like an ache, a feeling of heaviness, or a burning sensation. Indigestion symptoms are often described as heartburn, which you may experience as a burning pain behind your breastbone (in the front of your chest, over your heart).

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

• nausea,
• a feeling of being very full, and
• belching.

In rare cases, indigestion can be a symptom of stomach cancer.

You should seek immediate medical advice if you have recurring indigestion and you:

• are over the age of 55,
• have lost a lot of weight without meaning to,
• have increasing difficulty swallowing,
• have persistent vomiting,
• have anaemia as a result of a lack of iron in your body (which causes tiredness, breathlessness, and an irregular heart beat), or
• have a lump, or mass, in your stomach.

Indigestion can occur when acid from your stomach irritates the lining (mucosa) of your oesophagus (gullet), stomach, or duodenum (top part of your small intestine).

This causes symptoms such as:

• pain and discomfort in your upper abdomen,
• nausea, and
• heartburn.

In most cases, there is no underlying medical reason for indigestion. It is usually caused by a process known as acid reflux, where acid from your stomach escapes and is forced back up into your oesophagus.

However, indigestion can also be caused in other ways, and it can sometimes be a symptom of an underlying medical condition, or problem, particularly if you experience recurrent bouts.

The various other factors and conditions that can cause indigestion are outlined below.

Taking certain medications

You may experience indigestion if you take certain medicines, such as non-steroidal anti-inflammatory drugs (NSAIDs), like aspirin and ibuprofen. You should not take NSAIDs if you have, or have had in the past, stomach problems, such as a peptic ulcer. Check with your GP, or pharmacist, if you are unsure. Children under 16 years of age should not take aspirin.

Obesity

If you are obese, you are more likely to experience indigestion. Being obese increases the pressure inside your abdomen, which can force open the oesophageal sphincter after a large meal, causing stomach acid to escape and travel up your oesophagus.

Hiatus hernia

This type of hernia occurs when part of your stomach pushes up into your diaphragm (the breathing muscle under your lungs) and prevents the oesophageal sphincter from closing.

If you have a hiatus hernia, it can allow stomach acid back up into your oesophagus, causing heartburn.

Helicobacter pylori infection

You may have recurring bouts of indigestion if you have an infection with bacteria known as Helicobacter pylori (H pylori). H pylori infections are common and it is possible to be infected without knowing it because it does not usually cause any symptoms.

However, in some cases, an H pylori infection can damage your stomach lining and increase the amount of acid in your stomach. It is also possible for your duodenum (top of your small intestine) to be irritated by excess stomach acid if you have an H pylori infection.

See the 'treatment' section for information about treatment for an H pylori infection.

Gastroesophageal reflux disease (GORD)

This common condition is one of the main causes of recurring indigestion. It is caused by acid reflux, which occurs when the oesophageal sphincter fails to prevent stomach acid from coming back up into your oesophagus.

Acid reflux becomes GORD when the sensitive lining of your oesophagus is damaged by repeated irritation from stomach acid.

Peptic ulcers

If you have a peptic ulcer, you may have indigestion as a symptom. A peptic ulcer is the name given to an ulcer that appears in your stomach, or duodenum (top of your small intestine).

Peptic ulcers form as a result of stomach acid damaging the lining in your stomach, or duodenum wall. In most cases of peptic ulcers, this damage to the mucosa occurs due to an H pylori infection (see above).

Stomach cancer

In rare cases, recurrent bouts of indigestion can be a symptom of stomach cancer.

Cancer cells in your stomach break down the protective sticky lining (mucosa) allowing acid to come into contact with your stomach wall.

For most people, indigestion is mild and infrequent, and does not require treatment from a healthcare professional. However, you should see your GP if you are experiencing indigestion regularly, or if it is causing you severe pain, or discomfort.

Your GP will ask you about your symptoms and examine your abdomen (your chest and stomach). They may also press gently on different areas of your abdomen in order to see whether or not it is painful.

Your GP may also carry out a blood test if you have any symptoms of anaemia (a condition that is caused by a lack of red blood cells). The symptoms of anaemia can include:

• tiredness,
• breathlessness, and
• an irregular heart beat.

The test will indicate your full blood count, highlighting whether or not there is a shortage of red blood cells in your bloodstream. Blood loss may be caused by a gastrointestinal bleed (internal bleeding) which will cause your blood count to go down.

Depending on the type of indigestion symptoms that you have, your GP may also want to investigate your condition further. This is because indigestion can sometimes be a symptom of an underlying condition, or health problem, such as a Helicobacter pylori infection. Details of some of the further investigations you may have are outlined below.

Endoscopy

Although it is not often needed to diagnose indigestion, your GP may suggest that you have an endoscopy if they need to examine your abdomen in more detail. You may also need to have an endoscopy if you have had treatment for your indigestion which has not been effective.

An endoscopy takes place in hospital, and allows your surgeon to examine the inside of your abdomen.

If you need to have an endoscopy, you will be awake, but you may be given a sedative to help relax you. A long thin tube with a light and camera on the end (endoscope) will be gently fed down your throat and into your stomach. This will allow your surgeon to see images of the inside of your abdomen on an external monitor.

Taking certain medicines for indigestion can hide some of the problems that could otherwise be spotted during an endoscopy. If you are due to have an endoscopy, you will need to stop taking proton pump inhibitors (PPIs), or H2-receptor antagonists, at least 14 days before your procedure.

See the 'treatment' section for more information about proton pump inhibitors and H2-receptor antagonists.

Tests to diagnose Helicobacter pylori infection

If your GP thinks that your symptoms may be due to an infection with Helicobacter pylori (H pylori) bacteria, you may need to have several tests. See the 'causes' and 'treatment' sections for more information about H pylori infections.

The tests used to diagnose an H pylori infection are:

• a urea breath test - where your breath is tested for H pylori, after you have had a special drink containing a chemical which can be digested by the bacteria,
• a stool antigen test - where a pea-sized stool sample (faeces) is tested for H pylori bacteria, or
• a blood test - where a sample of your blood is tested for antibodies to H pylori bacteria. Antibodies are proteins that help fight infection and are produced naturally in your blood.

Tests to diagnose other conditions

If your GP thinks that your indigestion symptoms may be caused by an underlying condition, you may need to have some other tests.

For example, abdominal pain and discomfort can also be caused by biliary conditions, which affect the bile ducts in your liver. If your GP thinks that you may have a biliary condition, they may suggest that you have a liver function test, which is a kind of blood test that can be used to assess how well your liver is working.

You may also need to have an abdominal ultrasound, where a long, thin probe is inserted into either your mouth, or your rectum (anus), and fed gently through to your abdomen while you are sedated. The probe emits high frequency sound waves which transmit images of the inside of your body to an external monitor.

Testing for GORD

In most cases, gastro-oesophageal reflux disease (GORD) can be diagnosed by your GP asking you about your symptoms. Further testing is not usually required.

Further testing for GORD - for example, by endoscopy - is usually only recommended in the following circumstances.

• If you are 55 years of age, or over, and you have unexplained and persistent symptoms of heartburn. This is because those over the age of 55 have a slightly higher chance of developing cancers of the digestive system, such as stomach, or bowel, cancer.
• If there is evidence of internal bleeding.
• If you are experiencing persistent weight loss.
• If you are experiencing persistent difficulties with swallowing.
• If you are experiencing persistent vomiting.
• If you are showing symptoms of anaemia (a lack of red, oxygen-carrying blood cells).

Treatment for indigestion varies depending on what is causing your condition, and how severe your symptoms are.

Diet and lifestyle changes

If you only have indigestion occasionally, with mild pain and discomfort, you may not need to visit your GP for treatment. You may be able to ease your symptoms by making a few simple changes to your diet and lifestyle. See the 'self help' section for more information about what you can do to relieve your indigestion.

Medication

If your indigestion is more severe, or is due to an infection with Helicobacter pylori (H pylori) bacteria, your GP may suggest or prescribe one of the treatments described below.

Your GP may also recommend making changes to your current medication if they think it could be contributing to your indigestion. As long as it is safe to do so, you may need to stop taking certain medications such as aspirin or ibuprofen. Where possible, your GP will prescribe an alternative medication which will not cause indigestion. However, you should never stop taking any medication without consulting your GP first.

If you have indigestion that often recurs, you may be able to use some of the treatments listed below as and when your symptoms appear. Your GP will be able to advise you about the best way to treat your indigestion, and will always prescribe the lowest possible dose to control your symptoms.

Antacids

Antacids are a type of medicine that can provide immediate relief for mild to moderate symptoms of indigestion. They work by neutralising the acid in your stomach (making it less acidic), so that it no longer irritates the lining (mucosa) of your digestive system.

Antacids are available in tablet and liquid form. You can buy them over-the-counter (OTC) from pharmacies. Check with your pharmacist if you are unsure about which type of antacid is appropriate for you.

The effect of an antacid only lasts for a few hours at a time, so you may need to take more than one dose. However, you should always follow the instructions on the pack to ensure that you do not take too much.

It is best to take antacids when you are expecting symptoms of indigestion, or when they start to occur, such as after meals, or at bedtime. This is because antacids stay in your stomach for longer at these times and have more time to work. For example, if you take an antacid at the same time as eating a meal, it can work for up to three hours. In comparison, if you take an antacid on an empty stomach, it may only work for between 20-60 minutes.

You should not take antacids at the same time as other medicines because they can prevent other medicines from being properly absorbed by your body. However, you should not stop taking any other medicines before first speaking to your GP.

You may find that antacids cause mild side effects, such as diarrhoea, or constipation. These side effects may be relieved by switching to an antacid that contains both magnesium salts and aluminium salts, such as Mucogel, Maalox or Altacite.

Alginates

Some antacids also contain a medicine called an alginate, which helps to relieve indigestion caused by acid reflux. Acid reflux occurs when stomach acid leaks back up into your oesophagus (gullet) and irritates its lining (mucosa). Alginates work by forming a foam barrier that floats on the surface of your stomach contents, keeping stomach acid in your stomach and away from your oesophagus.

Your GP may suggest that you take an antacid containing an alginate if you experience symptoms of acid reflux, or if you have gastroesophageal reflux disease (GORD). Examples of antacids containing alginates that are available over-the-counter (OTC) from pharmacies are Gaviscon and Rennie Duo.

You should take antacids containing alginates after eating because this helps the medicine to stay in your stomach for longer. If you take alginates on an empty stomach they will leave your stomach too quickly to be effective.

Proton pump inhibitors (PPIs)

If your indigestion is severe, or recurring, treatment with antacids and alginates may not be effective enough to control your symptoms. If this is the case, your GP may prescribe proton pump inhibitors (PPI).

Like antacids, PPIs affect the acid in your stomach. However, rather than neutralising the acid, PPIs inhibit the acid production in your stomach.

PPIs are taken as tablets and are generally only available on prescription. However, if you are over 18 years of age, you can buy a type of PPI, called omeprazole, over-the-counter (OTC) in pharmacies.

If you are prescribed a PPI, and you are also taking warfarin, or phenytoin, your progress will be monitored because PPIs may enhance the effects of these medicines.

If your GP thinks that you should have 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 the procedure. This is because PPIs can hide some of the problems that would otherwise be spotted during the endoscopy.

See the 'diagnosis' and 'related links' sections for more information about endoscopies.

In some cases, PPIs can cause side effects, but they are usually mild and reversible. These side effects may include:

• headaches,
• diarrhoea, or constipation,
• nausea,
• stomach pain,
• dizziness, and
• skin rashes.

H2-receptor antagonists

H2-receptor antagonists are another medicine that your GP may suggest if antacids and alginates, and proton pump inhibitors (PPIs) have been ineffective in controlling your indigestion. There are four H2-receptor antagonists available:

• cimetidine,
• famotidine,
• nizatidine, and
• ranitidine.

They reduce the amount of acid in your stomach, thus making the stomach less acidic.

Your GP may prescribe any one of these four H2-receptor antagonist, although both famotidine and ranitidine are available to buy over-the-counter (OTC) in pharmacies. H2-receptor antagonists are taken either in tablet, or liquid, form.

Cimetidine is not suitable if you are taking certain medicines, such as erythromycin, or warfarin, because it can interact with these medications.

As with proton pump inhibitors (PPIs) you will need to stop taking H2-receptor antagonists at least 14 days before having an endoscopy because they can hide some of the problems that could otherwise be spotted during the endoscopy. See the 'diagnosis' and 'related links' sections for more information about endoscopies.

Side effects of H2-receptor antagonists are uncommon but can include:

• diarrhoea,
• headaches,
• dizziness,
• skin rashes, and
• tiredness.

Prokinetics (domperidone or metoclopramide)

If you are still experiencing symptoms of indigestion after taking both antacids and alginates, and proton pump inhibitors (PPIs), your GP may suggest a medicine known as a prokinetic.

There are two types of prokinetics available - domperidone and metoclopramide. They work by helping to make food pass through your stomach and the first part of your small intestine (duodenum) more quickly, so that indigestion is less likely to occur.

You may be prescribed domperidone by your GP, although it is also available over-the-counter (OTC) in pharmacies for those who are over 16 years of age. Metoclopramide is only available on prescription from your GP. Both medicines can be taken in tablet, or liquid, form.

If you are prescribed domperidone, you will need to take it 15-30 minutes before a meal so that it has time to work before your symptoms of indigestion start.

Treatment for an Helicobacter pylori (H pylori) infection

If your indigestion symptoms are caused by an infection with Helicobacter pylori (H pylori) bacteria, you will need to have treatment to clear the infection from your stomach. This should help to relieve your indigestion because the H pylori bacteria will no longer be increasing the amount of acid in your stomach.

H pylori infection is usually treated using triple therapy. Your GP will prescribe a course of treatment containing two different antibiotics and a proton pump inhibitor. You will need to take these medicines twice a day, for seven days. You must follow the dosage instructions closely to ensure that the triple therapy is effective.

In most cases, one course of triple therapy is effective in clearing an H pylori infection. However, you may need to have more than one course of treatment if it does not clear the infection the first time.

For most mild cases of indigestion, treatment from your GP is not needed and making certain changes to your diet and lifestyle can control your symptoms. Even if you are taking treatment for indigestion, making these changes may help to ease your symptoms and keep them from recurring.

Lose weight if you are overweight or obese

Being overweight, or obese, means that more pressure is put on your stomach, which makes it easier for stomach acid to be pushed up into your oesophagus (gullet). This is known as acid reflux, and is one of the most common causes of indigestion.

You can find out whether or not you are overweight, or obese, by using our body mass index (BMI) calculator. If you are either overweight, or obese, it is important to lose weight safely and steadily through regular exercise and by eating a healthy, balanced diet.

Stop smoking

If you smoke, the chemicals that you inhale in cigarette smoke may be contributing to your indigestion. These chemicals can cause the ring of muscle that separates your oesophagus (gullet) from your stomach to relax, allowing stomach acid to leak back up into your gullet more easily (acid reflux).

As well as helping to cause indigestion, smoking increases your risk of developing lung cancer, chronic obstructive pulmonary disease (COPD), chronic bronchitis (infection of the main airways of the lungs), emphysema (damage of the small airways of the lungs), as well as heart disease and stroke.

Diet and alcohol

You should avoid any food and drink that makes your indigestion symptoms worse. For example, this may mean eating less rich, spicy, and fatty foods, and cutting down on drinks that contain caffeine, such as tea, coffee, and cola. You should also avoid drinking alcohol if it is aggravating your indigestion symptoms and making them worse.

Avoid eating before bed

If you tend to experience indigestion symptoms at night, try to avoid eating or drinking anything for between 3-4 hours before you go to bed.

Going to bed with a full stomach means that the acid in your stomach will be more likely to be forced up into your oesophagus (gullet) while you are lying down.

In most cases, indigestion is mild and only occurs occasionally. However, severe indigestion can sometimes cause complications, some of which are outlined below.

Oesophageal stricture

Indigestion is often caused by acid reflux, which occurs when stomach acid leaks back up into your oesophagus (gullet) and irritates its lining (mucosa). If this irritation builds up over time, it can cause your oesophagus to become scarred. This scarring can eventually lead to your oesophagus becoming narrow and constricted (known as oesophageal stricture).

If you have oesophageal stricture, you may have symptoms such as difficulty swallowing, food becoming lodged in your throat, and chest pain. It is often treated using surgery to widen your oesophagus.

Pyloric stenosis

Like oesophageal stricture, pyloric stenosis is caused by long-term irritation of the lining of your digestive system from stomach acid. Pyloric stenosis occurs when the passage between your stomach and your small intestine (known as the pylorus) becomes scarred and narrowed. This causes vomiting and prevents any food you eat from being properly digested.

In most cases, pyloric stenosis is treated using surgery to return the pylorus to its proper width.

Peritonitis

Chronic (long-term) indigestion can break down and infect the lining of your intestinal tract (peritoneum), which is known as peritonitis. This usually occurs if there is a tear, or other damage to your peritoneum, which can be caused by repeated exposure to stomach acid.

Peritonitis can be treated using surgery to repair the damage to your peritoneum, and antibiotics may sometimes be used to clear the infection.