Patient information: Abdominal pain (functional dyspepsia) in adults

ABDOMINAL PAIN OVERVIEW

Dyspepsia is a recurrent or persistent pain or discomfort that is primarily located in the upper abdomen. Approximately 25 percent of people in the United States and other western countries experience dyspepsia.

Dyspepsia can develop because of an underlying medical problem. However, the most common type of dyspepsia is "functional" (or "non-ulcer") dyspepsia. This refers to dyspepsia that occurs without an identifiable cause.

This topic provides an overview of functional dyspepsia and strategies for diagnosis and treatment. For information about chronic abdominal pain in children and adolescents, (see "Patient information: Chronic abdominal pain in children and adolescents".

ABDOMINAL PAIN SYMPTOMS

The most common symptoms of dyspepsia include:

• Indigestion
• Discomfort or pain in the abdominal area
• Bloating
• An early sense of fullness with meals

You may also experience nausea, vomiting, a lack of appetite, weight loss, or other symptoms and findings.

Definitions — The definition of dyspepsia is as follows [1]:

• Recurrent or persistent abdominal pain or abdominal discomfort centered in the upper abdomen.
• The "discomfort" is an uncomfortable feeling but does not reach the level of pain.
• The discomfort is mainly concentrated in the upper abdomen, although you may also have pain in other areas.

Types of dyspepsia — There are two major categories of dyspepsia:

• "Functional" dyspepsia refers to the dyspepsia that occurs with no identifiable abnormality in the digestive tract (such as an ulcer).
• "Organic" or "non-functional" dyspepsia refers to conditions that have a visible abnormality in the digestive tract.

ABDOMINAL PAIN CAUSES

It is not clear what causes the signs and symptoms of functional dyspepsia. However, researchers have focused on several factors that may be involved.

Motor or nerve coordination — Normally, the process of digesting food involves a complex series of events that requires coordination of the nerves and muscles of the digestive tract. Abnormalities in this system may cause the stomach to empty more slowly than normal, causing nausea and vomiting, an early sense of fullness with eating, and bloating. Delayed emptying is found in approximately 30 percent of people with dyspepsia. However, many people with delayed emptying have no symptoms of dyspepsia.

About 40 percent of people with dyspepsia have impaired relaxation of the upper region of the stomach after meals. This can cause an early sensation of fullness.

Visceral sensitivity — Enhanced visceral sensitivity is an increased sensitivity to pain, or a lower threshold for pain, that occurs when normal stretching or enlargement of the stomach occurs. Studies have consistently shown that people with functional dyspepsia often have visceral hypersensitivity.

Helicobacter pylori infection — Helicobacter pylori (H. pylori) is a bacterial infection of the stomach that can lead to inflammation (gastritis) or ulcers. There may be a relationship between infection with H. pylori and functional dyspepsia, although a clear association has not been established. (See "Patient information: Helicobacter pylori infection and treatment".)

Psychological and social (psychosocial) factors — People with functional dyspepsia may be more likely to have certain mood problems, such as anxiety or depression. This is not to say that your pain is "in your head" or "made up", although treating the underlying depression or anxiety may improve your symptoms of abdominal discomfort.

ABDOMINAL PAIN DIAGNOSIS

There are a number of reasons why you can develop symptoms of dyspepsia. Organic (non-functional) dyspepsia can cause symptoms that are similar to those of functional dyspepsia, or the symptoms may be slightly different. A healthcare provider will perform a medical history and physical examination to narrow the possible list of causes, with special attention to the following:

• Is the pain "gnawing" or worsened by hunger?
• Is the pain worsened by certain movements or pressure on certain areas of the abdomen?
• Do you take medications for pain, such as aspirin, ibuprofen (Advil, Motrin) or naproxen (Aleve)? Do you have a history of ulcers?
• Do you have heartburn in addition to upper abdominal discomfort?
• Do you have intense pain in the upper right or middle of the abdomen? Does the pain extend to the back or between the shoulder blades? Does this happen periodically, along with vomiting, sweating, or feeling restless?
• Have there been changes in your bowel habits (eg, constipation or diarrhea)?
• Have you recently unintentionally lost weight, vomited repeatedly, or had difficulty swallowing?

Testing recommendations — The best way to diagnose functional dyspepsia is not clear. The American Gastroenterological Association suggests the following:

• People who are older than 55 or with serious symptoms, such as repeated vomiting, weight loss, difficulty swallowing, or a low blood count, should have an upper endoscopy procedure. (See "Patient information: Upper endoscopy".)

• People who are younger than 55 and who do not have serious symptoms are generally offered noninvasive testing to detect infection with H. pylori (eg, stool or breath testing). (See "Patient information: Helicobacter pylori infection and treatment".)

If symptoms fail to improve within four to eight weeks or if more serious symptoms develop, further testing, including upper endoscopy, is usually recommended. Other diagnostic tests may be recommended in selected cases.

ABDOMINAL PAIN TREATMENT

Understanding the condition — Being diagnosed with functional dyspepsia may be a relief to some people and a frustration to others. It is important to understand that symptoms are not imaginary. One or more treatments may be recommended, often in combination; having realistic expectations of the benefits of treatment may help to reduce frustration. If there are mood problems, such as anxiety or depression, an evaluation with a mental health specialist (eg, social worker, psychologist, counselor) may be recommended.

Lifestyle changes — Some people benefit from avoiding fatty foods (which can slow the emptying of the stomach), and eating small frequent meals. Foods that aggravate symptoms should be avoided, if possible, although eliminating entire food groups is not recommended. If you have questions about which foods should be avoided, discuss this with a healthcare provider and/or dietitian.

Medications — Certain medications may help to reduce the symptoms of functional dyspepsia.

Acid reducing medications — Some people benefit from treatment with medications that inhibit or reduce the production of stomach acid (eg, H2 blockers such as Zantac®, Axid®, or Pepcid® or proton pump inhibitors such as Prilosec®, Nexium®, Prevacid® AcipHex®, or Protonix®).

H. pylori therapy — Treatment of H. pylori is recommended if an ulcer is diagnosed. (See "Patient information: Helicobacter pylori infection and treatment".)

This treatment may be considered for people who have H. pylori, but who are not known to have an ulcer. However, the benefit of treating H. pylori in this situation is unclear. At best, a small proportion of people with functional dyspepsia improve following treatment of H. pylori.

Visceral analgesics — As mentioned previously, some people with dyspepsia are sensitive to enlargement (distension) of the stomach. Medications that relieve visceral pain are being studied, but are not yet available.

Pain medications — Low doses of an antidepressant medication may be recommended to reduce pain, even if the patient is not depressed. The dose of TCAs is typically much lower than that used for treating depression. It is believed that these drugs reduce pain perception when used in low doses, but the exact mechanism of their benefit is unknown.

TCAs commonly used for pain management include amitriptyline, desipramine, and nortriptyline. In the beginning, many people who take TCAs experience fatigue; this is not always an undesirable side effect since it can help improve sleep when TCAs are taken in the evening. TCAs are generally started in low doses and increased gradually. Their full effect may not be seen for weeks to months.

Narcotic pain medications, such as codeine, hydrocodone, or oxycodone, are not usually recommended for long-term relief of functional dyspepsia because of the risk of side effects (eg, constipation) and the potential risk of becoming addicted.

Complementary and alternative medicine — Several complementary and alternative medicine approaches to functional dyspepsia have been described. Studies involving herbal and natural products, acupuncture, and homeopathy suggested a benefit from peppermint oil and STW5 (a European multi-herbal preparation that includes peppermint and caraway, also known as Iberogast). However, the quality of the evidence supporting these treatments is generally poor.

More research is needed before these approaches can be routinely recommended.

ABDOMINAL PAIN PROGNOSIS

Dyspepsia is typically a relapsing condition. In studies, 60 to 90 percent of people continue to have symptoms of varying degree two to three years after being diagnosed. However, most people feel better once their condition has been diagnosed, and many will respond to the treatments discussed above.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Chronic abdominal pain in children and adolescents
Patient information: Helicobacter pylori infection and treatment
Patient information: Upper endoscopy

Professional Level Information:
Approach to the patient with dyspepsia
Chronic abdominal wall pain
Diagnostic approach to abdominal pain in adults
Differential diagnosis of abdominal pain in adults
Functional dyspepsia
History and physical examination in adults with abdominal pain

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Institute of Diabetes and Digestive and Kidney Diseases

      (www.niddk.nih.gov/)

• International Foundation for Functional Gastrointestinal Disorders (IFFGD)

      Phone: (888) 964-2001
      (www.iffgd.org)

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