Should we assess H pylori infection in indigestion

Introduction and Symptoms

Indigestion can be defined as pain or discomfort in upper abdomen area or heartburn (pain in the sternal area). Both of them can occur together or on their own. Mostly symptoms appear soon after eating or drinking. Common associated symptoms include feeling full or bloated, nauseated, belching and regurgitation of food

Risk factors or causes

Indigestion can be functional or due to some other underlying condition.  Functional may be due to rapid gastric motility due to some irritation like food, drug, obesity or smoking. Underlying GI conditions like GERD, IBS, hiatal hernia, peptic ulcer, gallbladder pain or stomach cancer can also precipitate dyspepsia. Depression or anxiety can also  cause indigestion symptoms

Treatments

Symptomatic treatment of indigestion is by suppression of acid production with Proton pump inhibitors and H2 receptor antagonist. In the case of functional dyspepsia, symptoms resolve but if symptoms relapse and reoccur, H. Pylori infection should be assessed. Carbon-13 urea breath test, stool antigen or laboratory serology can be done to assess that. If it is positive, eradication therapy should be done followed by retesting at least 1 month after therapy.  Secondly, empirical therapy with PPI should be treated.

Indigestion can be caused secondary to stress, in that case, prokinetic drugs are the first line of therapy. If they fail, then centrally acting drugs should be considered.  Low dose tricyclic antidepressant like amitriptyline can moderately affect post distress dyspepsia. It is found that tricyclics delay gastric emptying while other antidepressants like SSRI have no role on gastric emptying. Hence they have no role in treating indigestion. Apart from pharmacological treatments healthy lifestyle like maintaining weight and avoidance of smoking are also an essential part of treatment therapy.

If indigestion is present along with alarming signs like chronic GI bleeding, unintentional weight loss, dysphagia, persistent vomiting, Iron-deficiency anemia, epigastric mass and suspicious barium meal, endoscopy is recommended.  Patients aged 55 years or older with unexplained dyspepsia should be referred urgently for endoscopy.

Self care

If there is no alarming sign present, chronic indigestion can be prevented by self measures like avoiding food and drugs that irritate stomach, stop smoking  and maintain weight.  Spicy or fatty food, alcohol or caffeine often causes the symptoms.  Chocolate, peppermint, spearmint, and citrus are also found to make symptoms worse in many people.  Small meals several times a day is preferred over a single big meal. NSAIDS, steroids and narcotics are found to irritate the stomach. If these drugs are taken for some condition, they should be replaced with other alternatives.  As   obesity is one of the risk factors for indigestion, regular exercise should be done to overcome the symptoms. Except these measures, care should be taken to relieve stress as indigestion is often precipitated with stress. Deep breathing, meditation and listening to music can be a way to cope with stressful situation

Drugs used in treating

Proton pump inhibitors like Omeprazole etc. decrease the acid secretion.  H2 receptor antagonist like ranitidine, cimetidine, famotidine and nizatidine decrease the acidity level of stomach.  H. Pylori infection is treated with triple therapy i.e. two antibiotics and one PPI. Post distress indigestion are treated with tricyclic antidepressants.