Introduction Indigestion or "gastric" is the commonly used term to describe the discomfort or pain felt in the upper abdomen or chest, usually after meals. An alternative term is "dyspepsia". This symptom can be caused by peptic ulcers, gastritis or "nonulcer dyspepsia". An ulcer is a break in the lining of the stomach or duodenum (the first part of the small intestine), and it resembles ulcers people get from time to time in the mouth. They are called "peptic ulcer" because these ulcers are caused by acid and, a component of digestive juice called pepsin. Indigestion may also be caused by an inflammation of the stomach lining termed "gastritis". Gastritis can occur as a result of over-indulgence in alcohol, the use of aspirin and painkillers (particularly for arthritis and rheumatism) called non-steroidal anti-inflammatory drugs or NSAIDs, or due to Helicobacter pylori (H. pylori) infection. When tests are performed and no cause is found, the term "nonulcer dyspepsia" or "sensitive stomach" may be used, meaning that no ulcer has been found to account for the symptoms.

Picture of gastric ulcer during gastroscopy

An important cause of ulcer is a bacterium (germ) called Helicobacter pylori. This bacteria can be found in the lining of the stomach of about half of the adults in Singapore. Patients with duodenal ulcer almost always have this infection present and at least 80% of gastric ulcer patients also have it. Another important cause is the consumption drugs like aspirin or NSAIDs, which are quite commonly prescribed for pain, rheumatism or arthritis. Stress does not cause ulcers, but may cause dyspepsia (indigestion). This association is not fully understood, but stressful situations possibly result in more acid being produced. Very rarely there is no obvious explanation or cause for the presence of an ulcer. What are the symptoms? Most people experience intermittent pain or discomfort in the upper abdomen. The pain of duodenal ulcers tends to be eased by food and to recur once the stomach is empty. Patients are often woken up at night with pain. For those with nonulcer dyspepsia, they tend to experience the sensation of fullness or bloatedness after eating, so that it is difficult to finish a meal. In addition, some individuals may also have the symptoms of nausea, retching or even vomiting after food. Pain from the heart is sometimes felt in the upper abdomen. Heart pain should be suspected if the pain is brought on by exercise and relieved by rest. You must consult your physician immediately if you have such pain. What are the treatments? Most dyspeptic sufferers can obtain relief from simple antacids, which are available over the counter from pharmacists. However, you should see your doctor if your symptoms persist for more than two weeks, especially if this is a new symptom and has not responded to antacids. This advice is particularly important if you: Are over 45-years old. Have a family history of gastric problem. Take aspirin/painkillers regularly. Have red or altered blood (like coffee grounds) in vomit. Have black (tarry) stools. Rapid and unintentional weight loss. Recurrent vomiting or difficulty in swallowing. People who have peptic ulcers caused by H. pylori should also receive treatment to clear this infection. Combinations of drugs including antibiotics are used for one or two weeks to kill the germ. For individuals with gastritis or ulcers caused by NSAIDs, they require medications to reduce stomach acid production. NSAIDs will need to be discontinued or substituted with alternative painkillers at their doctor's advice. The commonly used drugs to reduce acid secretion are either the proton pump inhibitors (PPI) e.g. omeprazole, lansoprazole, or H2 antagonists e.g. famotidine, ranitidine, cimetidine. PPIs are much more powerful in acid inhibition than H2 antagonists. These drugs are also quite successful in giving symptomatic relief for patients with "sensitive stomach" or nonulcer dyspepsia. What investigations can be performed to diagnose ulcers? The majority of individuals with indigestion do not have an underlying harmful disease, and many do not require investigations. Persistent indigestion may suggest the presence of a more serious underlying condition and the doctor may decide to arrange for either gastroscopy or barium meal. Blood tests may also be ordered. What is the prognosis? do ulcers come back after treatment? Most ulcers heal in four to eight weeks with PPI or H2 antagonists. They are unlikely to recur if H. pylori infection is successfully eradicated. Ulcers caused by NSAIDs will not recur unless patients go back on NSAIDs. Avoid taking aspirin or NSAIDs - take paracetamol instead. If you are on low dose aspirin for heart disease or strokes, you should discuss with your doctor alternative medication. Surgery for peptic ulcers is rarely performed these days. Should complications such as severe bleeding, perforation or narrowing occur, endoscopic therapy or surgery may then be needed. For patients with nonulcer dyspepsia, certain contributory lifestyles may have to be changed. Although more research is necessary to determine all the risk factors, the following steps should help. Do not smoke Eat meals at regular times and do not rush through your meals. Avoid heavy meals and excessive alcohol. Avoid those foods you associate with symptoms for e.g. spicy or sour foods. Try not to let stressful situations upset you.