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Half the patients who get you up in the middle of the night and think they are dying are suffering from wind!


Dyspepsia or indigestion is a difficult, sometimes vague, symptom to define or evaluate and requires very careful questioning to clarify the exact nature of the complaint.

Dyspepsia embraces the following:

  • nausea

  • heartburn/regurgitation

  • upper abdominal discomfort

  • lower chest discomfort

  • acidity

  • epigastric fullness, bloating or unease

  • abdominal distension

The discomfort can sometimes amount to pain. Diagnoses to consider in dyspeptic patients are summarised in TABLE 47.1.

Table 47.1Diagnoses to consider in dyspeptic patients1

Glossary of terms

Dyspepsia Pain or discomfort centred at the upper abdomen that is chronic or recurrent in nature.

Flatulence Excessive wind. It includes belching, abdominal bloating or passing excessive flatus.

Heartburn A central retrosternal or epigastric burning sensation that spreads upwards to the throat.


Excessive belching

  • Usually functional

  • Organic disease uncommon

  • Due to air swallowing (aerophagy)

  • Common in anxious people who gulp food and drink

  • Associated hypersalivation

Management tips

  • Make patient aware of excessive swallowing

  • Avoid fizzy (carbonated) soft drinks

  • Avoid chewing gum

  • Don’t drink with meals

  • Don’t mix proteins and starches

  • Eat slowly and chew food thoroughly before swallowing

  • Eat and chew with the mouth closed

If persistent: simethicone preparation (e.g. Mylanta II, Phazyme).

If desperate: place one small cork between the back teeth after meals for 30 minutes.

Excessive flatus

Flatus arises from two main sources:

  • swallowed air

  • bacterial fermentation of undigested carbohydrate


  • malabsorption

  • irritable bowel syndrome

  • anxiety → aerophagy

  • drugs, especially lipid-lowering agents

  • lactose intolerance


  • Assess diet (e.g. high fibre, beans and legumes, cabbage, onions, grapes and raisins)

  • Avoid drinking with eating, especially with leafy vegetables

  • Cook vegetables thoroughly

  • Trial a lactose-free diet

  • Consider simethicone preparations (e.g. No Gas)

Key facts and checkpoints

  • Dyspepsia or indigestion is a common complaint; 80% of the population will have experienced it at some time.

  • Consider heartburn as ischaemic heart disease until proved otherwise.

  • The presence of oesophagitis is suggested by pain on swallowing hot or cold liquids (odynophagia).

  • All reflux is not due to ...

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