Dyspepsia (Indigestion)

INTRODUCTION

Dyspepsia is a pain, burning or discomfort centred in the upper abdomen which is chronic or recurrent in nature. Functional dyspepsia is a diagnosis of exclusion after normal investigation.

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

DYSPEPSIA IN CHILDREN

Dyspepsia is an uncommon problem in children but can be caused by drugs, cow’s milk protein allergy, oesophageal disorders and gastro-oesophageal reflux in particular. It tends to be overdiagnosed and overtreated.

Gastro-oesophageal reflux

Prognosis Reflux gradually improves with time and usually ceases soon after solids are introduced into the diet. Most cases clear up completely by the age of 9 or 10 months, when the baby is sitting. Severe cases tend to persist until 18 months.

Investigations These are not necessary in most cases, but in those with persistent problems or complications referral to a paediatrician is recommended.

Management

• Provide appropriate reassurance with parental education.

• Changes in feeding practice and positioning will control most reflux.

• Place infant on left side for sleeping (prop up head of cot with bricks or boards to elevate it ~20–30 degrees).

• Give smaller, more frequent feeds.

• Thicken feeds (e.g. expressed milk) with Carobel, infant Gaviscon powder, cornflour or Karicare.

• Medication not usually indicated but if persistent and complications such as painful oesophagitis use antacids or a gastric acid reducing agent, e.g. ranitidine.

DYSPEPSIA IN ADULTS

Gastro-oesophageal reflux disease (GORD)

Features

• Heartburn

• Acid regurgitation, esp. lying down at night

• Water brash

• Diagnosis usually made on history

• Investigation usually not needed (reserve for danger signs and non-responsive treatment)—gastroscopy is the investigation of choice

• Consider barium swallow/meal and 24 hr ambulatory oesophageal pH monitoring

• Complications include oesophagitis, stricture, iron-deficiency anaemia, respiratory (chronic cough, asthma), Barrett oesophagus

Management

Stage 1

• Patient education/appropriate reassurance

• Consider acid suppression or neutralisation

• Attend to lifestyle, incl. stress management:

  • – weight reduction if overweight (this alone may abolish symptoms)

  • – reduction or cessation of smoking

  • – reduction or cessation of alcohol (esp. with dinner)

  • – avoid trigger/fatty foods (e.g. pastries, fatty or spicy foods, caffeine, chocolate, tomato products)

  • – reduction or cessation of coffee, tea and chocolate

  • – avoid coffee ...