What are the treatment options for indigestion?

Treatment Options for Indigestion

The first-line approach to managing indigestion should include lifestyle modifications, dietary changes, and over-the-counter medications such as antacids, with escalation to prescription medications like proton pump inhibitors or H2-receptor antagonists for persistent symptoms. 1

Understanding Indigestion

Indigestion (dyspepsia) presents with symptoms such as:

• Pain or burning in the upper abdomen
• Feeling abnormally full early during meals
• Heaviness in the abdomen that may worsen after eating
• Nausea, bloating, and flatulence

These symptoms typically arise from issues with the stomach or duodenum. While sometimes caused by underlying conditions like ulcers, most cases reveal no abnormalities on testing and are classified as functional dyspepsia (FD).

Initial Management Approach

Lifestyle and Dietary Modifications

• Regular exercise and healthy lifestyle habits 1
• Avoid eating 2-3 hours before lying down 2
• Elevate the head of bed 6-8 inches if nighttime symptoms occur 2
• Smaller, more frequent meals 2
• Weight loss if overweight/obese 2
• Smoking cessation 2

Dietary Considerations

• Identify and avoid personal trigger foods 1
• Consider reducing intake of:
  • Caffeine and alcohol (especially with diarrhea symptoms) 1
  • Gas-producing foods 3
  • Spicy foods that may trigger heartburn

While specialized diets like low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) may help some patients, they should be implemented with professional guidance to avoid nutritional deficiencies 1, 4.

Pharmacological Treatment Options

First-Line Medications

1. Antacids

   • Provide rapid but short-term relief
   • Useful for occasional symptoms
   • Example: Bismuth subsalicylate has demonstrated efficacy for nausea, fullness, heartburn, and bloating 5

2. H2-Receptor Antagonists

   • Example: Ranitidine (when available)
   • Reduces acid production
   • Caution with drug interactions (affects bioavailability of other medications) 6

3. Proton Pump Inhibitors (PPIs)

   • Example: Omeprazole 20mg daily taken 30-60 minutes before meals 2, 7
   • More potent acid suppression than H2-blockers
   • Consider for persistent symptoms
   • Should be used at lowest effective dose 2

Second-Line Medications

1. Antispasmodics

   • Example: Anticholinergic agents like dicyclomine 1
   • Target abdominal pain and cramping

2. Neuromodulators

   • Tricyclic antidepressants (TCAs) like amitriptyline at low doses 1
   • Particularly helpful when pain and sleep disturbances are prominent
   • Can worsen constipation

Special Considerations

Testing for H. pylori

• All patients with persistent dyspepsia should be offered testing for Helicobacter pylori infection 1
• If positive, provide appropriate antibiotic treatment
• Reassess symptoms after eradication therapy

When to Consider Referral

Refer for further investigation if:

• Older age at symptom onset
• Family history of upper GI cancers
• Alarm symptoms (weight loss, bleeding, persistent vomiting)
• Symptoms refractory to initial management 1

Psychological Aspects

• Stress can significantly exacerbate indigestion symptoms 8
• Consider brain-gut psychotherapies like cognitive behavioral therapy for refractory cases 1
• Explain the brain-gut connection to patients to improve understanding and compliance 1

Treatment Algorithm

1. Initial approach:

   • Lifestyle and dietary modifications
   • Trial of antacids for immediate symptom relief

2. If symptoms persist after 2 weeks:

   • Test for H. pylori and treat if positive
   • Trial of H2-blocker or PPI for 4-8 weeks

3. If inadequate response:

   • Consider increasing PPI to twice daily dosing 2
   • Add antispasmodic for pain-predominant symptoms
   • Consider low-dose TCA for persistent pain 1

4. For refractory symptoms:

   • Refer to gastroenterologist
   • Consider psychological therapies 1
   • Evaluate for other conditions that may mimic indigestion

Pitfalls to Avoid

1. Overreliance on medications: Long-term PPI use should be periodically reassessed due to potential adverse effects 2

2. Overly restrictive diets: Can lead to malnutrition or disordered eating; dietitian involvement is recommended for patients with severe symptoms 1

3. Dismissing psychological factors: Stress and anxiety significantly impact gut function and symptom perception 8

4. Missing alarm symptoms: Always evaluate for concerning features that may indicate serious underlying conditions

5. Failing to follow up: Symptoms that don't improve with initial management require reassessment and possibly additional testing