Stomach Pain and Bloating? – Causes and Treatments for Indigestion (Dyspepsia)

In 2017, the American College of Gastroenterology published guidelines for dealing with dyspepsia. Here’s the upshot and the stepwise plan you and your doctor should take to relieve your symptoms.

Symptoms of dyspepsia

Dyspepsia arises from the gastroduodenal region and is defined by the following symptoms:

• Pain or burning around where your stomach sits (the epigastric area)
• Early satiety (when you can’t finish a normal sized meal)
• Feeling too full after you eat (also known as bloating)

Don’t confuse dyspepsia (indigestion) with GERD (gastroesophageal reflux disease), which is caused by stomach acid reflux or regurgitation.

Causes of dyspepsia

The most common cause of dyspepsia is “unexplained”, and no, I’m not kidding. That means it just happens with no explanation.

The following are examples of other known causes of dyspepsia:

• Peptic ulcer disease
• Reflux esophagitis
• Medication side effects
• Cancer of the stomach or esophagus (rare)

Diagnosing dyspepsia

Endoscopy

If you are 60 years old or older, your doctor may refer you straight to a gastroenterologist (GI doctor) for an endoscopy to rule out the most serious cause of dyspepsia: cancer of the stomach or esophagus.

Alarms should go off in your head if you notice unintentional weight loss, difficulty swallowing (dysphagia), new and sudden bouts of vomiting, or evidence of iron deficiency (anemia) from your blood tests. If you have any of those features, go straight to your GI doctor for an endoscopy. Full stop.

H. pylori testing

If you are younger than 60, the first step for you should be a Helicobacter pylori testing to rule out an H. pylori infection. This would be the next step for patients 60 years of age or older if your endoscopy turns out to be normal. Research suggests that this is the most cost-saving and effective approach.

To test for H. pylori, your primary care doctor will order an H. Pylori stool (poop) antigen test or a urea breath test. (There’s also an H. Pylori blood test, but it’s not recommended because it isn’t accurate for detecting a current infection.) The presence of H. pylori would mean that you likely have peptic ulcer disease, or ulcers on the lining of your stomach or esophagus.

Dyspepsia treatments

Antibiotics

If your H. pylori test is positive, you’ll typically take Prevpac twice a day for 14 days. Prevpac is a combination of lansoprazole, a proton-pump inhibitor that reduces stomach acid, and two antibiotics, clarithromycin and amoxicillin. There are other options if you have an intolerance to any of these medicines. Symptoms of dyspepsia usually resolve once the H. pylori is gone.  

Proton-pump inhibitors (PPIs)

If your H. Pylori test is negative, you may have “functional dyspepsia”. Early satiety, or feeling full early, is a very specific symptom of functional dyspepsia. At this point, your doctor may also order a blood test for you to rule out iron deficiency anemia due to blood loss from the gut.

With functional dyspepsia, your doctor will typically start you on a proton-pump inhibitor— like lansoprazole, pantoprazole, omeprazole or esomeprazole—if they haven’t already. According to clinical trials, when it comes to symptoms of functional dyspepsia, PPIs may help with early satiety and feeling too full and/or bloated after eating, but NOT stomach pain.

Other medications

If taking a PPI doesn’t help, your doctor may recommend a prokinetic medication like metoclopramide (Reglan), which stimulates gut movement, or a low-dose tricyclic antidepressant like amitriptyline (Elavil). In addition to treating depression, amitriptyline works better than placebo at treating epigastric pain, and can help with early satiety as well.

If you continue having symptoms despite the treatments listed above, you need further investigation and possibly an endoscopy. That’s when your primary care doctor should refer you to a gastroenterologist (GI doctor).

Hope this helps.

Dr O.

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