18 Heartburn, Indigestion, and Dyspepsia
Heartburn and indigestion are common presenting complaints. Because these symptoms are often vague, it is difficult for the physician to determine a precise cause, and treatment is frequently ineffective.
Heartburn is a sensation of burning, warmth, or heat in the retrosternal region between the xiphoid and the manubrium that occasionally radiates toward the jaw or (rarely) the arms. Water brash (regurgitation of fluid) may be present.
Dyspepsia is a separate entity. Functional dyspepsia, which is similar to indigestion, is defined, by Rome III criteria, as epigastric pain or burning, postprandial fullness, or early satiety without underlying organic disease. Episodic or persistent abdominal symptoms, often related to feeding, are thought to result from disorders of the proximal portion of the digestive tract. Dyspeptic symptoms include upper abdominal discomfort, postprandial fullness, early satiety, anorexia, belching, nausea, heartburn, vomiting, bloating, borborygmi, dysphagia, and abdominal burning. These symptoms are usually related to eating and occur during the day but rarely at night. Children often present with persistent or recurrent upper abdominal pain.
The most common causes of heartburn and indigestion include reflux esophagitis (with or without hiatal hernia), ingestion of drugs (e.g., aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs], bisphosphonates, metformin, antibiotics, digitalis, potassium or iron supplements, theophylline derivatives), gastritis, nonulcer dyspepsia, excessive consumption of food or alcohol, chronic active gastritis, gallbladder disease, pregnancy, aerophagia, and functional gastrointestinal (GI) disorder. Although patients with tumors of the GI tract may complain of heartburn or indigestion, neoplasms are not common causes of these symptoms.
Dyspeptic symptoms have organic or, most often, functional causes. Younger patients are less likely to have organic causes of indigestion, whereas older patients are more likely to have serious organic causes. The most common functional GI disorders in children are functional dyspepsia, irritable bowel syndrome, and functional abdominal pain. Children rarely complain of indigestion or heartburn, although vague abdominal discomfort may affect children who experience malabsorption or food intolerance. Helicobacter pylori infection is unusual in children. With these conditions, certain foods may cause crampy abdominal pain or diarrhea. Weight loss with significant malabsorption may be noted. When children complain of distention or awareness of peristalsis and gurgling, they often have functional GI disease. If these complaints are intermittent and not disabling, the patient is otherwise healthy, and the results of the physical examination are normal, an emotional cause should be suspected. Questioning the child may reveal depression or other emotional problems. These problems frequently occur with external environmental stress such as divorce, the birth of a sibling, illness in the family, starting school, and problems with a boyfriend or girlfriend.
In adults, heartburn is almost always caused by reflux esophagitis. This is more common in pregnant women, particularly during the later months. Patients with esophagitis may complain of severe heartburn that is relieved by alkali and aggravated by recumbency. Although hiatal hernia is three times more common in multiparous patients than primigravid women, symptoms of heartburn are caused by esophageal reflux and not by the hiatal hernia. Pregnant patients have delayed gastric emptying, increased intra-abdominal pressure, and increased estrogen levels, all of which facilitate esophageal reflux. From 30% to 50% of adults demonstrate hiatal hernias on radiographs; only 5% of this population report symptoms of heartburn.
Travelers and campers who become infested with Giardia may experience only bloating, nausea, and upper abdominal discomfort. These dyspeptic symptoms may persist for months, with only occasional episodes of diarrhea.
About 50% of all diabetic patients, whether or not they are insulin dependent, have delayed gastric emptying (diabetic gastroparesis). Many of these patients complain of pain, nausea, vomiting, or postprandial fullness (diabetic dyspepsia). In addition to these symptoms, the delayed gastric emptying may contribute to erratic absorption of oral hypoglycemic agents and thus poor blood glucose control.
Elderly patients are more likely to complain of atypical symptoms of gastroesophageal reflux disease (GERD) and vague feelings of indigestion, possibly related to bloating. Many of the symptoms of indigestion and abdominal bloating are caused by excessive intestinal gas and disordered motility. Virtually all intestinal gas is the result of bacterial fermentation, although the amount of discomfort is not necessarily proportional to the amount of gas in the intestines. The complaints of indigestion and bloating are more common in elderly patients because of their relative gastric and intestinal stasis, hypomotility of the gut, altered intestinal bacteria, increased incidence of constipation, and lack of exercise, all of which tend to facilitate the production of intestinal gas. Elderly patients with gastritis or duodenal ulcers are usually infected with H. pylori. H. pylori–negative gastritis is usually caused by NSAID ingestion.
Tense and anxious patients are more likely to be aware of normal intestinal movement and are also more likely to complain about these feelings. Many patients with gallbladder disease, irritable bowel syndrome, and ulcers complain of vague abdominal discomfort and occasional distention.
Heartburn is a burning sensation that occurs in the xiphisternal region, with occasional proximal radiation. It may vary in intensity from a mild feeling of warmth to extreme pain. Occasionally, the pain may be indistinguishable from that of severe angina pectoris; therefore, it is important for the physician to note that heartburn has no relation to physical activity. The pain is usually caused by esophageal spasm, is intermittent over several minutes, and recurs over long periods. Pain may radiate into the neck and occasionally into the arms, back, or jaw. In one study, the pain radiated to the back in 40% of patients with proven esophageal reflux but radiated to the arms or neck in only 5%.
Initially, the pain of heartburn is felt only after heavy meals or while the patient is lying down or bending over. In more advanced cases, the pain is more easily provoked, lasts longer, and is accompanied by dysphagia.
Patients with gastritis may have abdominal pain, vague indigestion, or heartburn as a presenting complaint. Epigastric discomfort that is worse after eating, loss of appetite, a sense of fullness, nausea, and occasional vomiting are also common complaints in patients with gastritis. These same symptoms may be seen in patients with nonulcer dyspepsia caused by H. pylori. Studies have shown that symptoms alone cannot differentiate dyspeptic patients without ulcer as having H. pylori or not.
Heartburn is also a common complaint in patients with bile gastritis, which often occurs after gastric resection or pyloroplasty. Bile refluxes into the stomach and subsequently into the distal esophagus, causing heartburn. Some patients who have peptic ulcer disease complain not of the classic symptoms but only of vague indigestion that is sometimes relieved by vomiting.
The symptoms in patients with functional GI disorders are often vague and nonspecific. Patients do not obtain consistent relief with any medication or therapeutic regimen. Other symptoms of anxiety are often present, with no evidence of systemic disease or weight loss despite a long history of vague symptoms. Because various patients with organic pathology (e.g., peptic ulcer, gallbladder disease, colonic tumors) may also have vague symptoms, a specific workup is required in some cases. When these vague symptoms occur in a young adult, it is unlikely that a malignant process is present. Likewise, if the symptoms have been present for many years without any significant progression or evidence of systemic disease, a major disease process is unlikely.
Other distinguishing characteristics often help the physician differentiate functional from organic pain. With functional illness, patients may have severe and continuous pain but no significant weight loss. The patients often give exaggerated descriptions of their pain and have a significant emotional investment; they may come into the office with a list of their symptoms. With organic disease, the pain, though severe, is often periodic and may be associated with weight loss.