Everything you ever wanted to know about indigestion (but were too bloated to ask)

Stomach pain can be hard o avoid at Christmas. Is it a sign of underlying health problems? And will changing your lifestyle help?

Most of us, particularly at this time of year, recognize the symptoms of indigestion: feeling sick, pain at the top of the abdomen (dyspepsia) or behind the breastbone (heartburn) and lots of burping. You may also feel bloated and particularly full up, even after eating small meals. About a fifth of adults in the developed world get recurring bouts of indigestion that can be distressing and debilitating. There may be an obvious trigger - such as vindaloo washed down by five pints - but, equally, there may not be anything obvious.

A specific cause is rarely found, even if you have a tube threaded down your throat and into your stomach (an endoscopy) to have a good look around. People often worry about having underlying cancers, but if there are no other worrying symptoms, such as weight loss, difficulty swallowing or repeated vomiting, the risk is extremely low. Drugs that switch off acid production in the stomach, block pain messages to the brain or eliminate the gastrointestinal bacteria Helicobacter pylori(HP) can work wonders. Exercise, relaxation therapies and acupuncture may also help, though the evidence is scarce. Cutting out obvious triggers (such as alcohol, spicy foods and painkillers) makes sense - but, then again, this may not be the easiest month to try.

If feels as if I'm having heart attack

That's because the brain finds it hard to distinguish whether pain is coming from the heart or from the stomach and oesophagus. It can be hard to know the difference and, if you are really worried, it's best to seek urgent medical help. A heart attack may start when you're exerting yourself - using a treadmill or having sex, for instance. It will usually be a pressure, ache or tight band of pain on the left side of your chest. It can then spread up to your neck and jaw and make you breathless, faint and sweaty. Indigestion (confusingly called "heartburn") typically starts in the upper abdomen and moves up behind your breastbone. It gets worse when you lie down or bend over because that causes stomach acid to reflux up into the oesophagus. You get a sour taste in your mouth if the acid reaches that far. Antacids (such as Gaviscon or Rennie) that neutralize acid help the pain. If you've had it for years, it's clearly more likely to be indigestion than a heart attack.

My GP says I need tests. Why?

Your GP might want to make sure you haven't got a specific underlying problem causing inflammation of the lining of oesophagus, stomach or the duodenum, the first part of the intestine. This section of the gut is called the upper gastrointestinal tract or UGI. Inflammation there might be due to acid reflux (gastroesophageal reflux disease, or Gord), ulcers, the effects of drugs (such as ibuprofen), bacterial infection (by HP, for example) or, rarely, a cancer. The tests will include a blood test for anaemia, stool test for HP and referral for endoscopy for a direct view. You're more likely to have them if you're over 50, or have developed persistent indigestion recently that is getting worse.

The tests are clear but I'm still in pain

Sixty percent of people with recurrent dyspepsia don't have sign of inflammation of the oesophagus (oesophagitis) or stomach (gastritis). There are no ulcers or cancers to be seen. Experts call this functional dyspepsia (FD) and think it's due to unusual sensitivity of the nerves of the oesophagus and stomach. Tests for the bacteria HP, which is associated with inflammation, are usually negative. Even if HP is found, getting rid of it may not cure the symptoms, though family physican Professor Nigel Flook, of the University of Alberta in Canada, says it's worth a try. "Treatment of HP can bring lasting relief for a small portion of dyspepsia suffers."

So my gut is highly strung. What can I do?

It may help to know that although functional dyspepsia's a pain, it's not dangerous. A one-month trial of acid-suppressing treatment (proton pump inhibitors or PPIs) is often prescribed. Dr Alex Ford, a gastroenterologist at the University of Leeds, says that low-dose amitriptyline (used in the past, in much higher doses, to treat depression) can work well as it reduces pain signals to the brain.

Should I change my lifestyle?

The National Institute for Health and Care Evidence (Nice) recommends lifestyle changes such as losing weight if you're overweight, cutting down alcohol, eating regular meals and giving up smoking. But according to Flook, it's hard to predict what, if anything, will help. "The measures that make a difference to dyspepsia are a very individual matter. Possible triggers include eating large and late meals, caffeine, alcohol, fatty meals, NSAIDs [non-steroidal anti-inflammatory drugs such as ibuprofen] and other medications." Exercise, relaxation techniques, psychological therapies and acupuncture may help, but evidence is hard to come by because it hasn't been a reseach priority, says Ford. Special diets, such as ones low in short-chain carbohydrate Fodmaps (fermentable, oligo-, di-, mono- saccharides and polyols) that can help people with irritable bowel syndrome, need further research to see whether they will help those with dyspepsia.

Is acupuncture worth a try?

Acupuncturist Rhiannon Griffiths naturally think so: "Using a combination of acupuncture points on the legs, feet, hands, arms or tummy to re-regulate the correct flow of energy in the body can settle down the stomach, help digestion and calm irritable bowel syndrome. In Chinese medicine we also see the stomach like a cauldron - warm and bubbling away, so it's important, especially in winter, to avoid putting cold or raw foods into the stomach as this brings the temperature down too much. THe stomach then has to work really hard and expend all its energy in bringing it back up to optimum temperature for best digestion. This can leave you feeling lethargic, with indigestion, or even loose bowels." No robust evidence has been found for the use of acupuncture in treating functional dyspepsia, though it is unlikely to cause harm.

Why is my indigestion worse after fried foods?

It's possible you may have gallstones. The symptoms are very similar to dyspepsia: bloating, burping and pain in the upper abdomen. Gallstone pain may be worse after a fatty meal, starts 30 minutes to two hours after eating and is worse on the right-hand side where the gallbladder and liver lie. Your GP can organize an ultrasound scan that will inform diagnosis. If you've got lots of stones, you can have your gallbladder removed.

I'm terrified of cancer. What should I look out for?

Most people with indigestion don't have cancer. These are the warning signs that should make you get urgent medical help: unexplained vomiting, bleeding, anaemia, weight loss and difficulty swallowing. But, remember: if you take 100 people with these alarm symptoms, fewer than four will turn out to have cancer, and only 13 will have some serious problem such as a bleeding ulcer.