Indigestion can appear as heartburn or it could be a sign of a more serious condition. Dr Chris Brown explores causes and treatments

About a third of the adult population of the UK experience heartburn at least once a month, and a smaller number on a weekly or daily basis.

Most people think of indigestion as being the same as heartburn, which is the commonest type of indigestion experienced by people of all ages. Heartburn is a descriptive term for a burning or sharp pain in the upper stomach or chest. It can be associated with various other symptoms such as: food and acid regurgitation, burping gas, nausea, food sticking in the gullet after swallowing, chest pains and coughing and wheezing. Heartburn and its associated symptoms is known medically as GORD (gastro-oesophageal reflux disease), and is due to stomach acid leaking back into the gullet (oesophagus). Heartburn symptoms are most common after eating, but can also be brought on by lying down or stooping.

Other types of indigestion are less common than heartburn, but can be due to a more serious problem, for instance waking at night with indigestion can be a symptom of a duodenal ulcer.

What can cause indigestion?

Recent research has shown that in a large proportion of cases the development of upper gastro-intestinal problems is associated with the presence in the stomach of a bacterium called helicobacter pylori. Depending on the age you are infected, and which part of the stomach is involved, helicobacter can cause increased or decreased amounts of acid production by the cells lining the stomach.

Acid overproduction is related to the development of gastritis and duodenal ulcers. Low acid secretion is associated with an increased risk of gastric ulcers and stomach cancer. Helicobacter can be eradicated by taking a course of antibiotics and acid suppressing medication for a week, prescribed by a doctor.

Lifestyle also plays a part in indigestion, since people on diets low in salt and high in antioxidants (found in fresh fruit and vegetables) are less at risk of developing gastric cancer, and smokers have a much higher risk of developing duodenal ulcers and gastric cancer.

You also risk developing major gastric problems if you are a long-term user of non-steroidal anti-inflammatory drugs (NSAIDs), which are used for the treatment of many painful conditions and are available over the counter in the form of ibuprofen and aspirin. Elderly people are particularly at risk of NSAID-induced stomach irritation.

Too much acid
Everyone has hydrochloric acid in the stomach to aid digestion. Sometimes, acid leaks or refluxes into the oesophagus (gullet). If acid remains in contact with the lining over a long period of time, inflammation develops. This is known as reflux oesophagitis.

Many people can stand on their heads without acid reflux occurring. This is because there is a ring of muscle (a sphincter) at the bottom of the gullet, acting as a valve which relaxes to let food down but tightens to prevent stomach contents refluxing back up again.

Reflux occurs when pressure in the stomach rises higher than the muscle can control, for example during pregnancy, when acid leaks back into the gullet but is not pushed back down again. The pressure problems in pregnancy are compounded by the effect of hormones softening the muscle ring. Other causes of valve failure include obesity and high fat meals. Less commonly, it can also occur when part of the stomach slides up into the lower part of the chest above the diaphragm, making it impossible for the valve to function properly. This is called a hiatus hernia. Some people develop a troublesome cough and even wheezing when acid refluxes all the way up to the throat and larynx. The role of Helicobacter in reflux disease is not yet well known.

Gastritis
This refers to inflammation of the lining of the stomach and can be caused by Helicobacter infection, NSAIDs and also by alcohol excess.

Gastric and duodenal ulcers
An ulcer occurs when the surface lining of the stomach or duodenum becomes raw. This can be caused by Helicobacter infection or taking NSAIDs. Ulcers can give you similar symptoms to indigestion but the pain tends to be more severe. Ulcers can be dangerous if they burst, or perforate, leaking acidic stomach contents into the abdominal cavity. Occasionally they can also bleed. Both these situations are medical emergencies and need hospital treatment. You would recognise these conditions by sudden severe abdominal pain or vomiting blood, or the passage of loose black stools that look like tar.

What can you do to help yourself?

Stop smoking
Acid reflux is more common in smokers. The chemicals from cigarettes can increase acid production and slacken the stomach valve, so if you can stop smoking your symptoms will improve.

Change your diet
Fatty foods, chocolate, oranges, cucumber, peppermints and coffee can relax the oesophageal muscle sphincter and worsen reflux. Some foods such as citrus fruits, spices, tomatoes and coffee can directly affect the inflamed lining of the gullet. Common sense and experience can tell you which foods affect you personally, and small meals are preferable to large ones since they do not provoke such a great outpouring of stomach acid.

Check medication
Some drugs (see above) are closely linked to the development of ulcers, and anyone who develops indigestion whilst taking NSAIDs should stop and consult the pharmacist or their GP.

Lose weight
Being overweight puts extra pressure on the stomach, and encourages reflux. Losing weight can help.

Perfect your posture
An upright posture will help prevent acid reflux. If you have symptoms at night try raising the head of the bed by about 10cm with large books or a brick. You could also try propping yourself up on extra pillows.

Cut down on alcohol
This can cause gastritis and if you stop drinking for a while the symptoms may settle down. Try to stick to less than two units a day, since binge drinking has a far worse effect than regular, moderate amounts.

Try to relax
Stress does not cause reflux or ulcers but it can certainly make things seem worse.

Take the tablets
You can treat indigestion yourself by taking simple antacid preparations. If you have symptoms frequently you should see your GP, who can prescribe stronger drugs that stop acid production in the stomach or help control the muscle involved in acid reflux.

When do I need to consult my GP?
Visit your GP if symptoms persist despite trying self-help, or if they recur frequently. Some symptoms may be caused by a more serious problem, so be sure to see your doctor if you experience indigestion for the first time over the age of 40. Other more serious symptoms include weight loss, difficulty swallowing or a feeling that food is getting stuck. Vomiting and losing blood can also be more serious symptoms. Occasionally it will be difficult to distinguish between stomach pain and heart pain, so you may need to see a cardiologist.