DYSPEPSIA AND HOMEOPATHY TREATMENT BYDR.V.Karunakar
SPECIAL THANKS TO
PREFACE This book was originally written for the use of my own students.It is the general tendency of mankind todrift towards easy solutions. The common reader is baffled and lost in the lyberinth when he is out to search for a simillimum in the vast ocean of homeopathic therapeutics. Many people were not cured even by taking homeopathic drugs and the problem is even turned into serious disable state. I thought they were not selected simillimum, not atleast similar remedy as they miss important content in the case thinking that the content is simple expressed by patient. In reality those simple things make much matter as it is the important concept in case. For eg. Stomach is deranged after taking cheese if we neglect the word cheese and consider vomitings,pain etc.,its of no use. So remedies for these simple things are listed and primary way of digestion and its process is being dealt in this book. Not only this but also homeopathic approach of dyspepsia is also being dealt here. This book contains the teachings of great authors which are verified in my clinical experience.
3 Through century s food has been recognized as important factor for human being in maintaining the health and causing the disease. Food helps us to grow well and enjoy the good health. The digestion process is one of the most important and one which is easily deranges. In the present society human beings are ingesting foods in large quantities, Which are not that essential for proper growth and normal development of the body. Things like coffee, tea alcohol, gutka, tobacco beetle nut, and narcotic drug substances taken frequently with some many side effects. These substances powerfully affect the digestion. If the digestive organs are good the rest of the systems are active. The digestive system (esp. the stomach)is the primary organ affected reflexely and expressed its manifestations outwardly when other systems are in disorder . Eg:- if the mind is disturbed the stomach is affected and it is expressed as nausea and vomiting., in all fevers and acute inflammations the digestion is more or less interfered with, though the stomach may not be originally at fault. It doesn t matter how wholesome the food may be if there is not enough of it, or if is too much, the stomach will resent it, or if the quantity as well the quality be right and if it be given irregularly, at improper intervals, allowing on time for the stomach to recover it self after all its last digestive effort, indigestion will result. A large number of the cases of indigestion will meet arise from violation of these three cardinal rules Dyspepsia is a major gastrointestinal manifestation. This is one of the most common compliant met with in general practice. It is a collective term for many symptoms thought to originate from upper gastrointestinal tract. Dyspepsia is extremely prevalent, affecting up to 80% of the abnormality is discovered during investigations esp. in young adults. Dyspepsia is major functional disease. People of any age and either sex can suffer from dyspepsia. About 1 out of every 4 persons presents with symptoms of dyspepsia. Dyspepsia includes heart burn, pain, distention, nausea, an acid feeling occurring after eating or drinking, the symptoms are subjective, frequent and usually benign in origin although some times associated with peptic ulceration. Even though dyspepsia is a highly prevalent condition on definite studies have yet established the guidelines for the work up of dyspeptic patients in the primary care setting. In the present industrialized society dyspepsia is thought to be caused by more of mental stress and strain so it is considered as psycho somatic in nature. Psychological factors such as nervous stress in nature. Psychological factors such as nervous stress in job and progress of Dyspepsia. Dyspepsia
4 interferes with patients comfort and daily activities. Persons who develop nausea and pain after eating may skip break fast or lunch. The interference with daily activities also can lead to problems with inter personal relationships especially at domestic and as well as work environment. Dyspepsia may be precipitated by several food items such as fried things, beer, spices or onions. Most of the sufferers have no demonstrable cause and lead to economic, domestic and personality difficulties. Transient frank indigestible food is eaten or over indulgence in food or alcohol Conventional system of medicine treats dyspepsia in one sided manner by considering one or two symptoms like burning in the stomach treated by antacids etc., for obtaining temporary relief and it suppress the problem, acts as palliative rather than curative. Repeated suppression may lead to structural cahnes leading to Peptic ulcer and several other complications.
Homoeopathy has a great scope in the treatment of dyspepsia because of its dynamic, individual and holistic concept where individual is considered for the treatment and not the disease. Homoeopathy treats the psychosomatic disease. More effectively and successfully than any other systems. Homoeopathic treatment is more advantageous in cases of functional disturbances like dyspepsia and effective in preventing and treating e complications associated with dyspepsia
ANATOMY & PHYSIOLOGY OF DIGESTIVE SYSTEM
There are 2 major groups of organs in the digestive system: Alimentary Canal - Organs thru which food actually passes (in order they are the: oral cavity, pharynx, esophagus, stomach, small intestine, and large intestine). Accessory Organs - They assist in digestion, but no food actually passes through them. Includes the teeth, tongue, salivary glands, pancreas, liver, and gallbladder.
The human digestive canal is a long muscular tube consisting of the following parts from above downwards the mouth (guarded by lips and teeth), tongue, pharynx oesophagus, stomach, small intestine, rectum and anal canal. The ducts of the salivary glands open into the mouth. The proximal end of the stomach is guarded by the cardiac sphincter. The distal end of the stomach is guarded by pyloric sphincter. The small intestine begins after the pyloric sphincter and consists successively of the following subdivisions; duodenum, jeiunum and ileum. The duodenum receives food from the stomach. The bile duct and pancreatic duct jointly open in it through armpula of vater. The small intestine is very long and
7 is roughly about 76 metres (25 feet). The great length of the small intestine provides enough time and surface area so that digestion and absorption of food stuff may be complete. The small intestine opens into the next part the large intestine. The opening between them is guarded by ileo -Colic sphincter. In the large intestine opens into the last part rectum and anal canal. The latter opens outside through the anal orifice. Peritoneum is a serous membrane and lines the interior of abdominal cavity.
The Abdominal Cavity The majority of digestive organs are located Peritoneum Visceral peritoneum Parietal peritoneum Peritoneal cavity Mesenteries
Retroperitonium Duodenum Pancreas Colon
The parietal outer layer is in contact with the body and the visceral layer envelops the abdominal organs. The mesentery is the continuation of the peritoneum and extends to the small and large intestines from dorsal body wall. The lesser omentum hangs from the greater curvature of the stomach over the intestine to the colon as an apron.
Functions Ingestion Mastication Propulsion
8 Mixing Secretion Digestion Absorption Elimination Movements : certain types of movements are to facilitate admixture of food onwards, to help blood and lymphatic circulation through the intestinal wall. Defecation is also due to the movements of the large intestine. Erythropoiesis : Stomach manufacturers a substance called the intrinsic factor. The extrinsic factor is Vitamin B12 the intrinsic factor interacts with it an helps in the absorption of the extrinsic factor. The extrinsic factor promotes the maturation of the erythroids cells. Regulates blood reaction The alimentary canal takes part in the regulation of blood reaction. Regulates blood sugar It takes part in the regulation of blood sugar. Maintains water balance the phenomenon of thirst is an important function of the digestive
tract by which the fluid balance of the body is maintained.
Histology 1. Mucosa - innermost tunic, consists of three layers. Mucosa epithelium, stratified squamous epithelium Lamina propria, loose connective tissue. Muscularis mucosae, outer thin smooth muscle. 2. Submucosa thick connective tissue layer containing nerves blood vessels and small glands. 3. Muscularis inner layer of circular smooth muscle and an outer layer of longitudinal smooth muscle.
10 Exceptions superior esophagus has striated muscle, and the stomach has three muscular layers. 4. Serosa or Adventitia connective tissue.
Innervation of the digestive tract : The nerve supply consists of I) an intrinsic part which is represented by nerve cells and fibres originating and located in the intestinal wall it self. II) an extrinsic portion which is represented by vagal fibres and post ganglionic fibres of the sympathetic. The intrinsic mechanism consists of a series of plexures i.e., myentric plexus of Auerbach, Submucous plexus of meissiener. The sympathetic fibres which are branches of the splanchnic nerves originating the coeliac ganglion.
Innervation of GI tractLocatedIn the submucosa (submucosal or Meissners plexus ) and between circular and longitudinal muscle layers (myenteric or Auerbachs plexus).Excitatory Acetylcholine
ControlMotility Myenteric plexus Secretion Submucosal plexus Through release of neurotransmitters
Inhibitory VIP , nitric oxide
Excitatory - Acetylcholine
Summary of DigestionDIGESTION OF FOOD STUFFS: DEFINITIONSummary of DigestionORGAN ACTIVITY NUTRIENTS DIGESTED ACTIVE SECRETIONS
Chews food and mixes it with saliva; forms into bolus for swallowing
Moves food by peristalsis into stomach
_Stomach Stores food, churns food, and mixes it with digestive juices
Hydrochloric acid, pepsin
Secretes enzymes, neutralizes acidity, receives secretions from pancreas and liver, absorbs nutrients and water into the blood or lymph
Fats, proteins, carbohydrates, nucleic acids
Intestinal enzymes, pancre-atic enzymes, bile from liver
Reabsorbs some water; forms, stores, and eliminates stool
12 The term digestion may be defined as the process of biochemical transformation of complex and larger food particles in the gut enzymatically into a simple form suitable for absorption and assimilation, the complex and higher molecules being unsuitable for absorption. If brief survey is made of the whole process of digestion the following broad facts are seen. 1) There are four digestive juices : Saliva, gastric juice pancreatic juice and succusentericus be taken as the fifth one. 2) Digestion is carried out by enzymes various other factors help the enzymes to carry out their functions. 3) Excepting the milk coagulating enzyme all the other digestive enzymes perform their functions by a process of hydrolysis. 4) One digestive juice does not possess all the enzymes necessary for the digestion of all the varieties of food stuffs completely. 5) One digestive juice digests up to a certain stage, further digestion is carried out by the next one and in this way the process goes on the completion. 6) It should be further noted that simultaneous absorption along with digestion is an essential factor for compete digestion. Because, if not removed by absorption the end products of digestion will accumulate and set up a reversible enzyme action. Thus complete digestion will not be possible. Digestion of Carbohydrates : digestion of carbohydrates includes the digestion of polysaccharides and oligosacharides. Digestion of polysaccharides or olisosacharides starts in the saliva and is completed in the succusentericus. Digestion of Proteins : Proteins digestion starts in gastric juice and is finished in the succusentericus. Digestion of Lipids : Starts in t he stomach and ends in the succusentricus. Absorption : Absorption is the process by which the end products of digestion pass through the intestinal epithelium and enter the blood stream. Bile may
The process of digestion commences immediately as the food is taken into the mouth. Before food can be converted into blood, it is necessary that it be reduced to a liquid or semi-liquid state. All solid foods, therefore, must be broken down in the first instance to fine particles, and for this purpose the teeth are
13 provided. Solids may be swallowed unmasticated, it is true, and the strong digestive juices are capable of digesting them, but this power is made much more certain and easy if the food has been first finely ground by the teeth. But the teeth have another function. In the cheeks and under the tongue are the salivary glands and the ducts of which convey the saliva into the mouth, and one function of the teeth is to mix the food thoroughly with saliva at the same time that they grind it small. The leading action of the saliva is on the starchy elements of the food, which are converted by it from insoluble starch into soluble grape-sugar. In this way solid food is prepared for its passage into the stomach, which is the organ of digestion par excellence. The stomach may be defined as an organ for the reception, at proper intervals, of food and water. I say "water," rather than "drink," because whatever drink is taken, it is the water which is the essential thirstquenching part of it. The stomach, when it has received the food, does not complete the digestion of it, as many people imagine, but it does by far the largest share of the work in liquefying the food and reducing it to a condition in which it can be absorbed. It is lined with a mucous membrane richly supplied with glands of a special kind, which secrete a very powerful acid fluid. This fluid acts chemically on the food taken, breaking it up and reducing it to a pulp. It also contains the substance "pepsin," which acts in a peculiar way like a ferment, converting all the albuminous foods, such as meats of all kinds, into "peptones" which can be absorbed, in the same way that saliva converts starch into grapesugar. Besides the mucous coat there is a muscular coat, with fibres running in two directions-- from end to end, length ways of the organ, and circularly, all round it. By these two sets of fibres the food is moved about when the stomach is full, until it has all come in contact with the mucous membrane and been submitted to the action of the gastric juice. When thoroughly mixed with this, the whole being reduced to a grey, semi-fluid mass, it is ready to be passed on into the bowels. There it meets with the bile, the pancreatic juice, and the secretions of the intestinal glands and mucous membrane; and as each different secretion acts on it, some portion of it is rendered ready to be taken up by the absorbent vessels called lacteals which abound in the intestines. In the lacteals it is a fluid and looks like milk. After passing through the abdominal glands, where it under goes some further preparation, the fluid is at last collected from all the lacteals into one large duct (the thoracic duct) and poured into the current of the blood.
This is the primary digestion, and that alone with which I concern myself in the present treatise; but there is also a secondary digestion, to which I will briefly refer. All the tissues of the body are in a state of ebb and flow. Where life is there is no standing still; everything is in a state of motion
14 and change. The tissues once built up from the food no sooner reach their perfection and perform their function than they begin to decay and make room for more. Some tissues change more rapidly than others--the soft tissues more rapidly than the hard, but all change and break down into their elements. The secondary digestion consists in the absorption of these decomposed elements by the lymphatic vessels and glands, the elimination of those elements which are entirely waste, and the recomposition of those that are still utilisable into blood and new tissues. This process is one of vast importance, and one which is easily deranged. Some people naturally have a more active secondary digestion than others, and these are generally thin. Tissue-change goes on rapidly, and it matters little how much they eat, they can never fatten. In spite of their spareness they have generally great vital heat, and are of an active, nervous, and restless temperament. Others, on the contrary, eat little, but grow constantly fat. With them the process is slow; the tissues bum away (for it is essentially a burning process) less rapidly, and they are of a quieter, more easy-going dispositionlymphatic or phlegmatic. But when there is not merely slow tissue-change, but, in addition to this, a defect in the carrying off of the effete matters from the tissues, then we have various kinds of diseases arising as the effete matters accumulate in the system. If it is lactic acid, we have rheumatism; if the predominating substance is uric acid, we have gout. These are, in general, diseases of the secondary digestion.
DyspepsiaThe word meaning :
15 Dyspepsia word is delivered from the Greak Peose meaning digestion.32 B-
hard or difficult and
Dyspepsia means painful, difficult or disturbed digestion not associated with a definitive pathologic condition.32 C
Definition of Dyspepsia: The common manifestation of GIT are Dyspepsia, Heart burn, indigestion, Flatulence, Hiccups, Vomiting, Constipation, Diarrhoea, Abnormal Stools, Abdominal Pain, Abdominal Distension weight loss, Bleeding , Haematemesis, Rectal bleeding and malaena.18 Dyspepsia is defined as pain or discomfort related to meals most patients have symptoms like Post Prandtrial fullness, bloating, nausea and vomiting.2 Dyspepsia or indigestion includes heart bun, pain distension, nausea or an acid feeling occurring after eating or drinking.18 Dyspepsia : refers to a host of upper abdominal or epigastric symptoms such as pain, discomfort Fullness, bloating, Safiety , belching, hear burn, regurgitation or simply indigestion.32D Dyspepsia (indigestion) is a collective term for any though to originate from the upper GI Tact. It encompasses many different symptoms and disorders including some arising out side the digestive system. Heart burn and other reflux symptoms are separate entities and are considered else where.12 The definition of dyspepsia is as follows Recurrent or persistent abdominal pain or abdominal discomfort centered in the upper abdomen.32 A The discomfort is an uncomfortable feeling but does not reach the level of pain 32 A The discomfort is mainly concentrated in upper abdomen although a person may also have pain in other areas. 32 A Dyspepsia is chronic or recurrent pain or discomfort centered in the upper abdomen. Discomfort in this context, includes mill pain, upper abdominal fullness and feeling full earlier than expected with eating. It can be accompanied by bloating / belching / nausea or hear burn. 32 G Dyspepsia is one of the most common ailments of the bower / affecting and estimated 20% of persons an acute attack of indigestion, deathly nausea, and vomiting. But habitual over-indulgence in tobacco
16 causes dyspepsia of a different kind. In the most aggravated form it is characterised by perpetual sickness; no food can be retained, and at this time, smoking, and even the smell of tobacco, is intolerable. In the less severe cases it takes the form of acidity, heartburn, pain after taking food, sinking sensation at the pit of the stomach, and generally constipation.32 B DESCRIPTION : Dyspepsia is extremely prevalent, affecting up to 80% of the population at some, and very often no abnormality a discovered during investigation, especially in younger patients. Patients with alarm symptoms, those over 55 years old with new dyspepsia and younger patients. Unresponsive to empirical to exclude serious gastrointestinal disease.12 Many people get dyspepsia. It is often caused by life style factors, such as smoking and diet, but here are some serious causes such as cancer of the stomach. Peptic ulcer disease and some medications. When people have dyspepsia but no risk factors for any of the serious causes. It can be labeled indifferntiated dyspepsia and treated with out further investigation. When people have been investigated for dyspepsia but no cause has been found it can be labeled as functional dyspepsia.32 G Dyspepsia often called indigestion is a common malady that many associate with TV ads for antacids. While dyspeptic symptoms are often causes by overeating or eating the wrong foods, the disorder can be associated with a more serious problem.32A The chronic recurrence and persistence of crippling dyspeptic symptoms disrupt the lives of many Americans. People suffering from the most severe symptoms can become disabled enough to miss work. Frequent doctors visits and expensive diagnosis procedures can create a financial drain in addition, many unnecessary operations are performed in an attempt to relieve the painful symptoms. Unfortunately, despite the surgery many patients continue to suffer from the symptoms of dyspepsia.32A The causes of dyspepsia are many and some of them are not clearly understood too often, dyspepsia has been dismissed as a psycho somatic disorder. However in recent years doctors have begun to realize that dyspepsia is often the result of a malfunctions of either nervous system or the muscular activity of the stomach or small intestine.32A The delicate motions of the stomach and small intestine are regulated by the brain and a network of nerves embedded in the muscle wall of the digestive tract. The co-ordination between these nerve endings that secrete a variety of chemical substances (Called neurotransmitter s), hormones and the muscle fibres in the wall of the digestive tract regulate the movement of the track and thereby promote
17 the digestion, absorption, and elimination of food we eat. Any disruption in the normal functioning of the nervous system or the muscular activity of the digestive tract can cause dyspepsia. 32A Dyspepsia is experienced by up to 1 in 10 people and 14 quiet common. It has many possible causes, some of which are more easily detected than others.32 C Persistent pain in the upper abdomen that lasts for more than 4 weeks is a good indication of dyspepsia. Up to 15% of people with dyspepsia may actually have gastro esophageal reflux disease (GERD). For most people there is no identifiable cause of their dyspepsia, though for some, the use of medicines like aspirin can cause similar pain in which case they should be avoided. Dyspepsia is best described as a functional disease. The concept of functional disease. Is particularly useful when discussion disease of the gastrointestinal tract. The concept applies to the muscular organs of the gastrointestinal treat - esophagus, stomach, small intestine, gallbladder and colon. Some gastrointestinal diseases can be seen and diagnosed with the naked eye, such as ulcers of the stomach. Thus, ulcers can be seen at surgery, on x-rays, and at endoscopy. Other diseases cannot be seen with the naked eye, but can be seen and diagnosed under the microscope. For example, gastritis (inflammation of the stomach) is diagnosed by microscopic examination of biopsies of the stomach. In contrast, gastrointestinal functional diseases cannot be seen with the naked eye or with the microscope. In some instances, the abnormal function can be demonstrated by tests (e.g., gastric emptying studies or antro-duodenal motility studies). However, the tests often are complex, are not widely available, and do not reliably detect the functional abnormalities. Accordingly, and by default, functional gastrointestinal diseases are those that involve the abnormal function of gastrointestinal organs in which the abnormalities cannot be seen in the organs with either the naked eye or the microscope. Occasionally, diseases that are thought to be functional are ultimately found to be associated with abnormalities that can be seen. Then, the disease moves out of the functional category. An example of this would be Helicobacter pylori infection of the stomach. Some patients with mild upper gastrointestinal symptoms who were thought to have abnormal function of the stomach or intestines have been found to have stomachs infected with Helicobacter pylori. This infection can be diagnosed under the microscope by identifying the bacterium. When patients are treated, with antibiotics, the Helicobacter and symptoms disappear. Thus, recognition of infections with Helicobacter pylori has removed some patients' diseases from the functional category.
18 The distinction between functional disease and non-functional disease may, in fact, be blurry. Thus, even functional diseases probably have associated biochemical or molecular abnormalities that ultimately will be able to be measured. Dyspepsia is and upper abdominal discomfort or pain related to eating. It may be precipitated by particular foods such as Fried, Beer, Spices or onions. 24 This is one of the most common complaint met with in general practice. Most of the sufferers have no demonstrable cause and are therefore functional in nature the contributory factors include stress associated with economic, domestic or personality difficulties. 24 Transient dyspepsia can occur in a healthy individual when an irritant or frank indigestible food is eaten or over indulgence in food or Alcohol. A part from peptic ulceration, which cause upper gastric abdominal symptoms or gastric neoplasm or biliary tract or pancreatic disorder we must the phenomenon of indigestion. Usually the action of the miasm, is quite marked in other parts of the organism before the action is seen in the normal.24 CAUSES OF INDIGESTION [Causes] BEFORE proceeding further I wish to be clear about terms. Medical terms are often confusing to nonmedical readers, who attach differences of meaning to different terms when they are simply two names for the same thing. A familiar instance of this is the case of the terms "scarlatina" and "scarlet fever." The first is supposed to represent a mild forms of the second. But they are used absolutely indifferently by medical men, the most malignant cases being called scarlatina, just as the mildest cases are called scarlet fever, and vice versa. There is the same distinction made by some people between "indigestion" and "dyspepsia." It is a distinction without a difference; both are names (indigestion, Latin; and dyspepsia, Greek) for identically the same condition, and I use them indifferently. I am sorry if I must rob some poor sufferer of the little consolation he has been able to obtain from the supposition that his complaint is not vulgar "indigestion," but a more refined something named "dyspepsia," but it must be done, for they are merely different names for the same thing.6 A great deal might be profitably written on the art of eating. Hurrying over meals, paradoxical as it may sound to say so, is the most extravagant waste of time. The teeth cannot do their proper share of mastication unless they have sufficient time to do it in ; the food is passed into the stomach in an unprepared state, and the lack of mental quiet prevents the stomach from expending a proper amount of energy on its duties. A meal-time should be a time of mental and bodily rest to all but the digestive
19 faculties. Another point in the art of eating is the avoidance of drinking much during a meal. The practice of washing down every mouthful with a drink, whether of water, wine, lemonade, or what not, is exceedingly bad. It dilutes and weakens the action of the digestive juices, and almost certainly leads to dyspepsia. A good drink, if thirsty, shortly before a meal, or a little time after it, is the best arrangement; though a draught in the pauses between the courses need not to be objected to. But food should never be "washed down."6 A healthy stomach is able to digest anything in an ordinary way that is called food. Its power is not strictly limited to the digesting of "wholesome" food, but it has a margin of overpower, which allows it to undertake luxuries like mince-pies, roast pork, and confectionery. The happy possessor of such an organ should enjoy what he eats and be thankful, and think little or nothing about his stomach. Only he must not transgress his margin. For the strongest stomach may be ruined if it is tried beyond its powers, and if its possessor uses it as a receptacle for things that please his palate, rather than for those which sustain his body. But if he makes the latter his main object, and only indulges his palate now and then, his stomach will take it all very good-naturedly, and no harm will be done.6 The three grand requirements of every stomach are-- proper food, proper quantity of food, and proper rest.6 It does not matter how wholesome the food may be if there is not enough of it, or if there is too much, the stomach will resent it. Or, if the quantity as well the quality be right, and if it be given irregularly, at improper intervals, allowing no time for the stomach to recover itself after all its last digestive effort, indigestion will result. A large number of the cases of indigestion we meet with arise from violation of these three cardinal rules. But not all. The stomach may be disordered when there is no complaint to be made whatever as to the treatment of the stomach itself. For instance, in all fevers and acute inflammations the digestion. is more or less interfered with, though the stomach may not be originally at fault.6 Whatever damages the vitality of the blood, either in the way of blood-poisoning, or by its becoming watery and thin, impairs the power of digestion. Working in illventilated offices with gas, or at poisonous trades, as in the case of cardboard boxmakers, paper-hangers and stainers, and artificial florists, who inhale arsenic, and plumbers who work with lead any of these conditions may set up indigestion. Improper habits of body, as neglect of open-air exercise, and excesses of every kind, will bring on a very inveterate form of indigestion. Inherited delicacy of any kind, whether consumptive, rheumatic, or gouty, will sometimes manifest itself in indigestion apart from any want of care on the patient's part. Finally,
20 mental causes must not be omitted from the list. "Laugh and grow fat" is a very old adage and a very true one. When the mind is ill at ease the stomach cannot work as it ought, and the face grows haggard and lean and the muscles lax. Worry is one great cause of indigestion.6 FACTORS CONTRIBUTING FOR INDIGESTION I. From Indigestible Food. WHEN a small boy strays into an orchard before the fruit is quite ripe, and indulges his appetite without staying to reflect, he is apt to experience an attack of indigestion of the simplest kind. The food he has eaten is not digested, but remains in his stomach like an irritating foreign body. If he is discovered in time, the simplest process is to give him an emetic of salt-and water or mustard-and-water, and so get rid of it in this way. But if it has already had time to pass into the bowels, other measures will be needed. The symptoms he experiences are sharp pains in the upper part of the body or about the navel, and even cramp and spasms which may go on to general convulsions. Stone fruit before it is ripe will cause the same symptoms.6 Those who have reached mature years are generally more discriminating in their diet, but every little while they may forget themselves. Perhaps it is some favourite dish which they know does not agree with them, but which they cannot resist, and then they know what to expect. The symptoms very according to the food that has caused the indigestion. Nuts cause pains in the stomach and chest. Fat food, especially fat pork, causes nausea and vomiting, with moist white tongue. This is frequently accompanied by pains in the body and diarrhoea.6 Food may be indigestible under some conditions, and digestible under others. If a person in a state of exhaustion sits down to a hearty meal, even though the food is nothing but what he is used to, he will not be able to digest it. In all such states the very lightest food should be taken until the bodily powers are restored, which usually happens after a sleep. Some people can eat hot meat very well, but not cold meat, and to them cold meat is an indigestible food. The explanation of this is that in cold meat the albuminous and gelatinous parts are set, whereas in hot meat they are fluid, and these are more easily acted on by the digestive juices; moreover, cold meat must become warm in the stomach before it can be digested, and Pains in the chest and intestines, flatulence, and great distress, are the penalty of want of due care of these points.6 Under the same heading of indigestion from indigestible food must come those cases due to defective teeth. When the teeth are faulty and cannot masticate the food properly before it is swallowed, it
21 reaches the stomach ill-prepared, and sets up indigestion which is apt to become chronic. The remedy in this case is to consult a dentist, and if he cannot put matters right, the food that is, the solid part of it will have to be passed through a mincing-machine and so be chewed artificially.6 2. From Excessive Indulgence in good Food. It is just as possible to injure the digestion with good food as with bad, if too much of it is taken. By a process of training, the stomach can become developed out of proportion to the rest of the body, and then large quantities of food can be taken without any active symptoms of indigestion. The stomach becomes to the gourmand what the athlete's limbs are to himcapable of an amount of exertion beyond the powers of other men. But over-development is not good in any part of the body, be it muscle or be it stomach; and the gourmand pays the penalty before long.6 His powerful digestion lays up more pabulum than he requires; he grows in bulk without growing in strength, and is one day seized with a fit of gout--he is fortunate if it attacks his toe and not some vital organ, or the stomach itself. Gouty dyspepsia is one of the most troublesome kinds to treat. Gout may be inherited as well as acquired, so it is not always the sufferer's own fault. There is in cases of gouty dyspepsia much acidity, flatulence, pain, and constipation.6 3. From Alcohol. The man who drinks excessively of beer loses consciousness, and has an acute attack of indigestion and vomiting. The vomiting relieves his stomach, a few hours' sleep restoring his senses, and after a day's indisposition he is well. But one who habitually indulges in beer and not necessarily to such excess, will have chronic dyspepsia of a different kind. Alcohol acts on both the primary and the secondary digestion, and the action of beer is to relax all the tissues of the body. The beer-drinker gradually becomes of the "flabby" or "sodden" type, probably pale and rather fat, and his digestion also becomes flabby and slow, and the tongue is large and yellow-coated, and there is much flatulence. Those who live active lives in the open air in the country do not show the effects as soon as those who live in towns and get little exercise.6 Wine and spirits act somewhat differently. They do not cause so much puffiness as beer, but they redden the skin more, causing dilatation of the small blood-vessels, especially of the nose. Often there is pallor of the rest of the face, leaving the nose only red. There is in general wasting of the tissues of the body.6 One marked symptom of the alcoholic dyspepsia-- and this applies to all kinds, whether from beer, wine, or spirits--is sickness in the morning. There is bad appetite at any time, but in the morning, before
22 anything has been taken, there is vomiting, of mucus generally. The tongue is tremulous, and there is a tremor through the body; flatulence and constipation generally accompany this kind.6 4. From Tobacco. The first attempts to smoke are almost always attended with the process of digestion commences immediately food is taken into the mouth. Before food can be converted into blood, it is necessary that it be reduced to a liquid or semi liquid state. All solid foods, therefore, must be broken down in the first instance to fine particles, and for this purpose the teeth are provided. Solids may be swallowed unmasticated. It is true, and the strong digestive juices are capable of digesting them, but this power is made much more certain and easy if the food has been first finely ground by the teeth. But the teeth have another function. In the cheeks and under the tongue are the salivary glands and the ducts of which convey the saliva into the mouth and one function of the teeth is to mix the food thoroughly with saliva at the same time that they grind it small.6 The leading action of the saliva is on the starchy elements of the food which are converted by it form insoluble starch into soluble grape-sugar. In this way solid food is prepared for its passage into the stomach which is the organ of digestion per excellence. The stomach may be defined as an organ for the reception at proper intervals of food and water.6 The stomach, when it received the food, does not complete the digestion of it. As many people imagine, but it does by far the largest share of the work in liquefying the food and reducing it to a condition in which it can be absorbed. It is lined with a mucous membrane richly. Supplied with glands of a special kind, which secrete a very powerful acid fluid.6 This acts chemically on the food taken, breaking it up and reducing it to a pulp. It also contains the substance Pepsin which acts in a peculiar way like a permanent, converting all the albuminous foods such as meats of all kinds into Peplones which can be absorbed, in the same way that saliva converts starch into grape sugar. Besides the mucous coal there is a muscular coat with fibres running in tow directions from end to end, length ways of the organ and circularly, all round it.6 By these days two sets of fibres the food is moved about when the stomach is full. Until it has all come in contact with the mucous membrane and been submitted to the action of the gastric juice.6 5. From Tea. It would be difficult to say which is the greater cause of indigestion-alcohol or tea. It is true people don't often get drunk with the cup that "not inebriates" (though there has been one case reported, in
23 which a woman who ate tea suffered from delirium tremens in consequence), but they do often get dyspepsia. In the tea dyspepsia the nervous symptoms predominate.6 There is more pain at the stomach than sickness or vomiting, the tongue is not so large and flabby as with beer drinkers, and the subjects of it suffer more from what is called "nerves." They are always on high tension, easily startled, sleep little, and have no appetite for anything but--tea. They want tea always; it is the only thing that relieves the "sinking" they complain of (itself a consequence of the tea). They suffer much from low spirits.6 6. From Cold. Few things stop digestion so soon as lowering the bodily temperature. A cold bath soon after a meal arrests the process completely, and is very apt to cause dangerous symptoms. A drive in cold air with insufficient wraps will cause symptoms of indigestion, chiefly pains in the stomach, and flatulence. The next meal gives great pain, and it takes some time for the stomach to recover from the injury.6 7. From Bad Air. When many hours of the twenty-four are passed in air that is spent, heated by gas, or polluted by the breath of human beings which cannot escape, it is impossible for the digestion to go on properly. The stomach, as well as the rest of the body, loses its proper vitality; the digestive fluids are not able to transform the food eaten; and, for want of proper oxygen in the blood, the secondary digestion is imperfectly performed. The results are wasting and pain.6 8. From Vinegar Some persons who have a tendency to grow fat take to drinking vinegar, in order to prevent such a dreadful, unbecoming calamity falling upon them. Many have succeeded by this means in bringing about "vinegar-consumption," and dying of it.6 Others have gained their object at the price of no worse a disease than ruined digestion. Constant acidity, pain after food, flatulence, flushing of the face, great thinness, are the leading symptoms of vinegar dyspepsia.6 10. From Nervous Debility. Some of the most inveterate cases of indigestion arise from weakness of the nervous system. This may be brought on in many ways. It may be due to nervous strain or worry of business. It may arise from fright, mental shock, or anxiety. Much more frequently it arises from evil habits and abuse of the organs
24 of generation. One vicious boy at school will often corrupt numbers of others, and so the disease will spread like an infection, bearing fruit before long in the loss of all manly qualities, and in sufferings of a most distressing kind connected with the process of digestion. These cases, like most of the others, are curable, but they need much care, and, of course, a sine qua non is the abandonment of the habits that have brought about the disorder.6 11. From Bloodlessness. Young girls between 12 and 20 are very frequently affected with a disease commonly called "greensickness." This is chiefly a fault of digestion, primary or secondary, or both, but it is also a fruitful cause of digestive troubles. There is almost complete loss of appetite, constant nausea, frequent vomiting. Usually, also, there is great weakness and . constipation. When the condition is attended by violent pains at the stomach after all food, it is not easy to distinguish between simple indigestion and ulceration of the stomach. This is usually declared by vomiting of blood in the quantity, which never takes place in ordinary indigestion, and is rarely, if ever, absent at some period of ulceration.6 12. Medicinal. Many a sufferer from indigestion traces his troubles to the prescriptions of his doctor. It is one of the commonest experiences of medical life, to find digestion ruined by strong drugs given for other complaints. Others owe it not to their doctors, but to their own efforts to cure themselves with drugs. Probably, in the first instance, it has been a slight attack of indigestion from indiscretion in diet, for which the offender has purchased a drug according to his own fancy. Then the drug has set up symptoms of its own, for which he has taken more drugs. More symptoms have followed, and the drugging has become a habit which he has not been able to break off. Palliatives, like Bicarbonate of Soda and Bismuth, are responsible for many cases of confirmed dyspepsia, and Iron, Mercury, and acids for many more. The symptoms in these cases vary according to the drugs which have caused them.6 13. Constitutional. A depraved or disordered constitutional state is often answerable for chronic indigestion. Persons who inherit a tendency to skin disease frequently find that when their skin is affected their digestion is good, and vice versa. This is what Hahnemann called psora. In such cases, the only treatment that is of any permanent service is one which is directed to the constitution as a whole. The indigestion is only one symptom of many.6 Indigestion is frequently a manifestation of the consumptive tendency which is one of the branches of
25 Psora, and in such cases Tuberculinum or Bacillinum often greatly assists the cure. Occasional doses may be given inter-currently with the symptomatically indicated remedy.6 in the author's Constitutional Medicine, with especial reference to the Three Constitutions of von Grauvogl. The symptoms of this are an extraordinary sensitiveness to cold, damp, and barometrical changes. The persons are always chilly. Residence by water, in valleys, or forests, passing storms, and changes of weather bring on attacks of illness, which takes various forms. Sometimes it is general malaise, with no definite symptoms, only the patient feels wretched only the patient feels wretched, good for nothing. At other times it is an attack of asthma or ague. Certain kinds of food disagree with them, such as melons, cucumbers, mushrooms, hard-boiled eggs, watery fruits, fish, and sometimes milk. They are generally pale and have cold feet. They are better in summer than in winter, and are relieved when they perspire. This constitution may be inherited or acquired. It often follows malarial poisoning. The particular form of indigestion attending this constitution is marked by pains in the stomach, water-brash, eructations of odourless gas, often brought on by eating watery fruits or vegetables and vegetable acids. There is distaste for animal food, though the appetite is often good. With such patients drinking plain water produces aggravation, and in their case the addition of wine to the water they drink is necessary.6 Vaccination often leaves behind it a depraved state of the constitution with many hydrogenoid symptoms, and the development of abdominal flatulence. Thuja meets most of these cases.6 Causes of Dyspepsia : A wide variety of disorders may cause dyspepsia.12 Upper gastrointestinal disorders : Peptic ulcer disease Acute gastritis Gall stones Motility disorders eg. Esophageal spasm. Functional (non ulcer dyspepsia and irritable bowel syndrome)
Other gastrointestinal disorders : Pancreatic disease (cancer, chronic pancreatitis)
26 Hepatic disease (hepatitis, metastases) Colonic carcinoma
Systemic disease : Renal failure Hyper calcaemia Drugs : Non steroidal ant-infalmmatory drugs (NSAIDS) Iron and potassium supplementary corticosteroids Digoxin. Others: Alcohol Psychological e.g. anxiety, depression, Diabetes, Thyroid disease, myocardial ischemia, auto immune disease, intra abdomial , malignancy Helicobacter pylori in infection of the stomach that can lead to inflammation (gastritis) or ulcers, there may be a relationship between infection with pylori and functional dyspepsia although a clear association has not been established. Types of dyspepsia There are two major categories of dyspepsia Functional dyspepsia refers to the dyspepsia that occurs with no obvious abnormality in
the digestive treat (such as an ulcer)32 A Organic or non functional dyspepsia refers to conditions that have a visible. Abnormality in the digestive track some of Dyspeptic symptoms suggest peptic ulcer disease and it is almost impossible to make an accurate diagnosis. Therefore it is now standard clinical practice to consider them together and labour as either peptic ulcer or non ulcer dyspepsia only after performing upper intestinal endoscopic examination.32A Dyspepsia often called non ulcerative dyspepsia is usually benign condition with out any pathological correlation in about 45-50% of cases but dyspeptic symptoms are often associate with32 A) Ischaemic hear disease (dyspepsia increses on excretions) B) Diffuse oesophaseal spasms
27 C) Peptic ulcer syndrome D) Cholecystitis E) Anxiety with arophagia, Depression, hypochondriasis F) Irritable bowel syndrome and other motility Disorders should be excludes. Functional Dyspepsia : Synonyms: - Idiopathic, essential or non ulcer dyspepsia2 The term dyspepsia (corresponding to the lay term indigestions refers to a symptom complex that has its origin in the upper gastro intestinal track is localized to the upper abdomen and is generally meal related. The symptoms include pain, bloating. Early satiety and nausea. The diagnosis of functional dyspepsia requires that other conditions with similar symptoms (peptic ulcer disease, gastro esophageal reflux disease, giardiases, pancreatic and biliary diseases) be excluded by standard investigative modalities. In clinical practice, however, these investigations are done only when the suspicion of these conditions is strong. Functional dyspepsia is an inhomogeneous syndrome. It is a kind of discomfort often described as indigestion gaseousness, fullness of abdomen or pain that is growing or burning in quality and localized to the upper abdomen. This is defined as chronic dyspepsia (pain or upper-abdomen discomfort) with no evidence of organic disease on investigation. (which must include endoscopy) The pain may resemble that of acid peptic diseases, the bloat that of gastric dysmotility. Based have been described viz. Ulcer like, gastro esophageal reflux like dysmotility like and unspecified. Aetio Pathogenesis: The most common cause of chronic dyspepsia up to 2/3 of dyspeptic patients have no obvious organic or biochemical cause for their symptoms diagnosable by upper endoscopy or abdominal ultrasonography, symptoms may arise from a complex interaction of increased visual afferent sensitivity, delayed gastric emptying psychological stressors. As stated above, functional dyspepsia is a heterogeneous syndrome obviously, no single abnormality can account for all symptoms. Delayed gastric emptying and antral hypo motility may be detected in about one half of patients. Logically these patients would present with bloating and early
28 satiety. In patients with pain suggestive of Acid-Peptic disease no abnormality in acid secretion has been consistently defected. As in patents with peptic ulcer disease. These patients may have increased sensitivity to acid. The role of gastritis or duodenitis and of helicobacter pylori infection is not clear. Many patients with this condition implicate particular article of diet as cause of symptoms. Higher anxiety and neuroticism scores have been described in these patients but these are not specific. The condition of non ulcer dyspepsia probably covers a spectrum of mucosal, motility and psychiatric disorders. Motor or nerve co ordiantion : 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 lead to delayed emptying of the stomach contents into the upper region of the small intestine resulting in nausea and vomiting and early sense of fullness with eating and bloating. Delayed gastric emptying is found in approximately 30% of people with dyspepsia. However, many people with delayed gastric emptying have no symptoms of dyspepsia. 32A About 40 percent of people with dyspepsia have impaired relaxation (also called accommodation) of the upper region of stomach of the meals. This can cause an early sensation of fullness.32A 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.32A Helicobacter pylori infection: There may be a relationship between infection with it Pylori and functional dyspepsia, although a clear association has not been established. Psychological and Social (Psycho Social) 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 a person s pain is in their head or made up although treating the underlying depression or anxiety may improve person s symptoms of abdominal discomfort.32A Clinical features: Patients are usually young (Luo and women are affected twice as commonly as men.) Abdominal pain is associated with a variable combination of other dyspeptic symptoms.12 A person is said to have dyspepsia if he/she suffers from several of a group of symptoms which might include Nausea regurgitation (back wash o stomach contents into the oesophagus of
29 mouth) Vomiting Heart burn Prolonged abdominal fullness or bloating after a meal. Stomach discomfort or pain Often people say that they have a sick feeling in the stomach or indigestion nervous stomach when they are suffering from dyspeptic symptoms.2 Some times people will experience these symptoms after over eating or eating foods that disagree with them. The symptoms may also accompany a disease such as peptic ulcer disease, gall bladder disease, or gastritis.2 Alarm Features in Dyspepsia12: Weight loss Anemia Vomiting Haematemesis and or malaena Dysphagia Palpable abdominal mass. Course of Dyspepsia: Dyspepsia is a chronic disease that usually lasts years, if not a life time. It does, however, display periodicity, which means that the symptoms may be more frequent or severe for days, weeks or months and then less frequent or severe for days weeks or months. the reasons for these fluctuations are unknown. Because of the fluctuations it is important to judge the effects of treatment over many weeks or months to be certain that any improvement is due to treatment and not simply to a natural fluctuation in the frequency or severity of the disease.32C Complications of dyspepsia: The complications of functional disease of the gastro intestinal tract are relatively limited. Since symptoms are most often provoked by eating. Patients who later their diets and reduce their intake of calories may lose weight. However, loss of weight is unusual in functional diseases. Symptoms that awaken patients from sleep also more likely to be due to non functional than functional disease. 32D or may be
30 INVESTIGATIONS: Investigation is mandatory only in the following situation like late age of onset of symptoms.2 Weight loss no response to adequate standard therapy (including antacids, medication and prokinetic drugs) and any abnormality on physical examination. A full Haematocrit, Stool Examination (including test for occult blood in elderly) and liver and renal function profiles are used as screening tests. Diagnostic oesophago gastroduodenoscopy and biopsy of abnormal areas. If any would be the
next step biopsy based testing for H. Pylori is done simultaneously. Ultrasonography for biliary and pancreatic diseases is done when suspicion exists further evaluation by CT Scan or ERCP is reserved for those with abnormality on sonography. Oesophageal PH metry is indicated for confirming the Diagnosis of Gastro oesophageal reflux disease when suspected. The physical examination is rarely helpful signs of serious organic disease such as weight loss/ organomegaly, abdominal mass or fecal occult blood warrant further investigations. In patients over 45 years age initial laboratory work should include a blood count, electrolytes, liver enzymes calcium, Thyroid function tests. Although symptoms often correlate poorly with the underlying diagnosis a careful is important to: A) Elicit symptoms classical of specific disorders as peptic ulcer. B) Detect alarm features requiring urgent investigations. C) Detect optical symptoms more suggestive of other disorders as Myocardial ischemia Dyspepsia is diagnosed primarily on the basis of symptoms and the exclusion of 'non-functional gastrointestinal diseases (including acid-related diseases), non-gastrointestinal diseases, and psychiatric illness. There are tests for identifying abnormal gastrointestinal function directly, but they are limited in their ability to do so.32A Exclusion of other diseases 32A Exclusion of non-functional gastrointestinal disease As always, a detailed history from the patient and a physical examination frequently will suggest the
31 cause of dyspepsia. Routine screening blood tests often are performed looking for clues to unsuspected diseases. Examinations of stool also are a part of the evaluation since they may reveal infection, signs of inflammation, or blood and direct further diagnostic testing. Sensitive stool testing (antigen/antibody) for Giardia lamblia would be reasonable because this parasitic infection is common and can be acute or chronic. Some physicians do blood testing for celiac disease (sprue), but the value of doing this is unclear. (Moreover, if an EGD is planned, biopsies of the duodenum usually will make the diagnosis of celiac disease.)32A There are many tests to exclude non-functional gastrointestinal diseases. The primary issue, however, is to decide which tests are reasonable to perform. Since each case is individual, different tests may be reasonable for different patients. Nevertheless, certain basic tests are often performed to exclude nonfunctional gastrointestinal disease. These tests identify anatomic (structural) and histological (microscopic) diseases of the esophagus, stomach, and intestines.32A Both x-rays and endoscopies can identify anatomic diseases. Only endoscopies, however, can diagnose histological diseases because biopsies (samples of tissue) can be taken during the procedure. The x-ray tests include: 32A y y y y The esophagiogram and video-fluoroscopic swallowing study for examining the esophagus. The upper gastrointestinal series for examining the stomach and duodenum The small bowel series for examining the small intestine The barium enema for examining the colon and terminal ileum.
The endoscopic tests include: y Upper gastrointestinal endoscopy (esophago-gastro-duodenoscopy esophagus, stomach and duodenum. y y Colonoscopy to examine the colon and terminal ileum Endoscopy also is available to examine the small intestine, but this type of endoscopy is complex, not widely available, and of unproven value in dyspepsia.30 For examination of the small intestine, there is also a capsule containing a tiny camera and transmitter that can be swallowed. As the capsule travels through the intestines, it transmits pictures of the inside of the intestines to an external recorder for later review.32A or EGD) to examine the
32 The capsule is not widely available and its value, particularly in dyspepsia, has not yet been proven. X-rays are easier to perform and less costly than endoscopies. The skills necessary to perform x-rays, however, are becoming rare among radiologists because they are doing them less often. Therefore, the quality of the x-rays often is not as high as it used to be. As noted previously, endoscopies have an advantage over x-rays since at the time of endoscopies, biopsies can be taken to diagnose or exclude histological diseases, something that x-rays cannot do.32A Exclusion of acid-related gastrointestinal diseases Because they are so common, the most important non-functional gastrointestinal diseases to exclude are acid-related diseases that cause inflammation and ulceration of the esophagus, stomach, and duodenum. Infection of the stomach with Helicobacter pylori, an infection that is closely associated with some acid-related diseases, is included in this group. It is not clear, however, how often Helicobacter pylori causes dyspepsia.32A Moreover, the only way of excluding this bacterium as a cause of dyspepsia in a particular patient is by eliminating the infection (if it is present) with appropriate antibiotics. If dyspepsia is substantially improved by eradication, it is likely that the bacterium was responsible. Helicobacter pylori infection can also be diagnosed (or excluded) by blood tests, biopsy of the stomach, urea breath test, or a stool test.32A Endoscopy is a good way of diagnosing or excluding acid-related inflammation. If no signs of inflammation are present, acid-related diseases are unlikely. Nevertheless, some patients without signs of inflammation respond to potent and prolonged suppression of acid, suggesting that acid is causing their dyspepsia. Therefore, many physicians will use potent suppression of acid in dyspepsia as a means to both treat and diagnose. Thus, if dyspepsia improves substantially (more than 50 to 75%) with suppression of acid, it is likely that acid is responsible for the dyspepsia. For this purpose, it is important to use potent acid suppression with proton pump inhibitors (PPIs), such as omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix) or esomeprazole (Nexium). Treatment often is given at higher than recommended doses for 12 weeks or more before a decision is made about the effect of treatment on the symptoms. (A short course for just a few days or weeks is not enough.) If the symptoms of dyspepsia do not improve, it even may be reasonable to check the amount of acid produced by the stomach (and also the reflux of acid into the esophagus) by 24 hour ph monitoring to be certain that the acid-suppressing drugs are effectively suppressing acid. (Up to 10% of patients are resistant to the effects of even the PPls.)32A
33 Another potential cause of dyspepsia is bacterial overgrowth of the small intestine, although the frequency with which this condition causes dyspepsia has not been determined.32A Overgrowth can be diagnosed by hydrogen breath testing and is treated primarily with antibiotics. Exclusion of non-gastrointestinal disease: Patients with dyspepsia often undergo abdominal ultrasonography (US), computerized tomography (CT or CAT scans), or magnetic resonance imaging (MRI). These tests are used primarily to diagnose nonintestinal diseases. (Although the tests also are capable of diagnosing intestinal diseases, their value for this purpose is limited. X-ray and endoscopy are better.) It is important to realize that US, CT, and MRI are powerful tests and may uncover abnormalities that are unrelated to dyspepsia. The most common example of this is the finding of gal1stones that, in fact,' are causing no symptoms. (Up to 50% of gallstones cause no symptoms.) This can cause a problem if the gallstones are assumed to be causing the dyspepsia. Surgical removal of the gallbladder with its gallstones (cholecystectomy) is unlikely to relieve the dyspepsia. (Cholecystectomy would be expected to relieve only the characteristic symptoms that gallstones can cause.) Additional tests to exclude non-gastrointestinal diseases may be appropriate in certain specific situations, although certainly not in most patients.32A Exclusion of psychiatric disease The possibility of psychiatric (psychological or psychosomatic) illness often arises in patients with dyspepsia because the symptoms are subjective and no objective abnormalities can be identified. Psychiatric illness may complicate dyspepsia, but it is unclear if psychiatric illness causes dyspepsia. If there is a possibility of psychiatric illness, a psychiatric evaluation is appropriate.32A Specific tests of gastrointestinal function Esophageal motility study Functional disorders of the esophagus can be identified with esophageal motility studies (manometry). For these studies, a pressure-sensing tube is swallowed and positioned within the esophagus. Contractions of the esophageal muscle normally cause increases in pressure within the esophagus that can be monitored by the catheter during and between swallows of water. Among the abnormalities that can be seen are abnormally high or abnormally low pressures during swallow-associated contractions and/or during spontaneous contractions unassociated with swallows. 32A Gastric emptying study and electrogastrogram
34 Slow emptying of the stomach is a common functional abnormality that can lead to bloating, nausea, and vomiting. Rapid emptying of the stomach is relatively uncommon and can lead to abdominal pain and diarrhea. Both of these abnormalities-slow and rapid emptying-- can be identified by a gastric emptying study.32A The most common type of emptying study is a nuclear medicine study. In this test, patients drink or eat food labeled with radioactive material. A Geiger counter-like device then is placed over the abdomen and the speed with which the radioactive iodide empties from the stomach is monitored.32A The electrogastrogram (EGG) is like the electrocardiogram (ECG) for the heart. Electrodes that are taped to the upper abdomen monitor the electrical activity generated by the muscle of the stomach. Abnormalities of the electrical rhythm of the stomach frequently are associated with dyspeptic symptoms, particularly nausea and vomiting.32A Barostatic study A barostat is an instrument that is used to measure pressure and detem1ine the compliance (flexibility) of a gastrointestinal organ. Compliance is a term that describes the effect that internal stretching has on the organ. The greater the compliance of an organ, the less there is tension (pressure) generated when the organ is stretched from within.32A Compliance is important to the normal function of gastrointestinal organs. For example, as food fills the stomach during a meal, the muscles of the stomach must relax (comply) to accommodate the increasing volume of food. If the stomach does not relax properly, the pressure in the stomach increases abnormally. It is believed that abnormally high pressures within the stomach (due to reduced compliance) can lead to symptoms such as early satiety (the feeling of abdominal fullness or pain after only a small amount of food has been ingested).32A The barostat includes a balloon that is placed within a gastrointestinal organ through the mouth or anus. As the balloon is progressively blown up and stretches the organ, the pressure within the organ is measured by the barostat. In this way, abnormal compliance can be identified. Barostat can be placed in the esophagus, stomach, small intestine or colon. Barostatic studies, however, probably should be considered experimental. In fact, barostat and expertise in their use are available in only a limited number of centers.32A Small intestinal transit study, Small intestinal transit studies measure the speed with which food travels through the small intestine. In the most common type of transit study, a test meal that has been labeled
35 with a radioactive material is ingested.32A A Geiger-counter-like device is placed over the abdomen and is used to follow the radioactive material through the small intestine and into the colon. Rapid transit is associated with abdominal pain and diarrhea. Slow transit also may be associated with abdominal pain. Although transit studies are not difficult to conduct, they are not frequently used because experience with their use is not wide-spread. They probably should be considered experimental.32A Antro-duodenal motility study Antro-duodenal motility studies measure the pressures that are generated by the contractions of the muscles of the antrum (outlet) of the stomach and the duodenum. For these studies, a pressuresensing tube is swallowed or passed through the nose and positioned in the distal (outlet) part of the stomach (the antrum). and the first part of the small intestine (the duodenum). Pressures are measured with the stomach empty and after a test meal. Abnormally high or low pressures as well as uncoordinated contractions can be identified. These abnormalities are believed to be associated with symptoms of dyspepsia. Antro-duodenal motility studies and expertise in their use are not widely available.32A Gallbladder emptying studies Gallbladder emptying studies determine how well the gallbladder empties. Between meals, the gallbladder stores bile that is produced by the liver. After meals, the muscles of the gallbladder contract and squeeze out (empty) most of the bile into the intestine. In the intestine, the bile assists with the digestion of food.32A For a gallbladder emptying study, a radioactive material is injected intravenously. The radioactive material is removed from the blood by the liver and accumulates with the bile in the gallbladder. The gallbladder then is stimulated to contract with either a meal or an intravenous injection of a hormone, called cholecystokinin.32A A Geiger-counter-like device is placed over the abdomen and the speed with which the radioactivity leaves the gallbladder and enters the intestine is monitored. Emptying studies of the gallbladder are widely available since this technology is used for several purposes other than measurement of gallbladder emptying.32A It has been suggested that abnormally slow emptying of the gallbladder may be associated with abdominal pain. Unfortunately, however, the studies that support the association between slow
36 gallbladder emptying and symptoms are weak. Moreover, many people have abnormally slow emptying of the gallbladder but no symptoms. For these reasons, abnormal emptying studies of the gallbladder have not been widely accepted for diagnosing functional disorders of the gallbladder.32A
37 INVESTIGATION OF DYSPEPSIA12 Dyspepsia
Are there alarm features ? Yes No
Endoscopy Test for H. Pylori
H. Pylori eradication
Treat Symptomatically or Consider other Diagnosis Symptoms persist
Symptoms Resolve No follow-up
MANAGEMENT AND TREATMENT: Simple dietary precautions may go along way in alleviating symptoms regular meal timings, having unhurried meals not habitually sipping fluids during meals 2 Avoidance of excessive spice, fatty food items rich in indigestible carbohydrates and milk.
38 Restricting intake of caffeintated and aerated beverages may all be helpful to individual patients. Avoid what you cannot tolerate is better advice than blanket ban on food items. Tobacco in any form and immoderate alcohol consumption should preferably be avoided despite the absence of firm scientific evidence. The most important elements are explanation and reassurance, possible psychological factors should be explored and the concept of psychological influences on gut functions should be explained. 12 Idiosyncratic and restrictive diets are of little benefit but fat restriction may help. 12 Understanding the condition Being diagnosed to some functional dyspepsia may be a relief to
some people and a frustration to others. It is important to understand that symptoms 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) recommended. 32D Life Style Changes: It is important to educate patients with dyspepsia about their illness.32A Symptoms which can be associated with an identifiable cause of stress (impending marriage or divorce or financial or employment difficulties for examples) resolve the appropriate counseling. 32A How is dyspepsia treated? The treatment of dyspepsia is a difficult and unsatisfying topic because so few drugs have been studied and have shown to be effective. Moreover, the drugs that have been shown to be useful have not been substantially effective. This difficult situation exists for many reasons, as follows: 32Fy
Life-threatening illnesses (e.g., cancer, heart disease, and high blood pressure) are the illnesses that capture the public's interest and, more importantly, research funding. Dyspepsia is not a lifethreatening illness and has received little research funding. Because of the lack of research, an understanding of the physiologic processes (mechanisms) that are responsible for dyspepsia has been slow to develop. Effective drugs cannot be developed until there is an understanding of these mechanisms.32F
39 y Research in dyspepsia is difficult. Dyspepsia is defined by subjective symptoms (such as pain) rather than objective signs (e.g., the presence of an ulcer).32Fy
Subjective symptoms are more unreliable than objective signs in identifying homogenous groups of patients. As a result, groups of patients with dyspepsia who are undergoing treatment are likely to contain some patients who do not have dyspepsia, which may dilute (negatively affect) the results of the treatment. Moreover, the results of treatment must be evaluated on the basis of subjective responses (such as improvement of pain).32F
In addition to being more unreliable, subjective responses are more difficult to measure than objective responses (e.g., healing of an ulcer). 32
Different subtypes of dyspepsia (e.g., abdominal pain and abdominal bloating) are likely to be caused by different physiologic processes (mechanisms). It also is possible, however, that the same subtype of dyspepsia may be caused by different mechanisms in different people. What's more, any drug is likely to affect only one mechanism. Therefore, it is unlikely that anyone medication can be effective in all-even most-patients with dyspepsia, even patients with similar symptoms. This inconsistent effectiveness makes the testing of drugs particularly difficult. Indeed, it can easily result in drug trials that demonstrate no efficacy (usefulness) when, in fact, the drug is helping a subgroup of patients.32F
Subjective symptoms are particularly prone to responding to placebos (inactive drugs). In fact, in most studies, 20 to 40% of patients with dyspepsia will improve if they receive inactive drugs. Now, all clinical trials of drugs for dyspepsia require a placebo-treated group for comparison with the drug-treated group. The large placebo response means that these clinical trials must utilize large numbers of patients to detect meaningful (significant) differences in improvement between the placebo and drug groups.
Therefore, these trials are expensive to conduct.32F The lack of understanding of the physiologic processes (mechanisms) that cause dyspepsia has meant that treatment usually cannot be directed at the mechanisms. Instead, treatment usually is directed at the symptoms. For example, nausea is treated with medications that suppress nausea but do not affect the cause of the nausea.32F On the other hand, the psychotropic drugs (antidepressants) and psychological treatments (such as cognitive behavioral therapy) treat hypothetical causes of dyspepsia (e.g., abnormal function of sensory
40 nerves and the psyche) rather than the symptoms. Treatment for dyspepsia often is similar to that for irritable bowel syndrome (IBS) even though the causes of IBS and dyspepsia are likely to be different.32A Some patients have major chronic psychological disorders resulting in persistent or recurrent symptoms and need behavioral or other formal psycho therapy. 32A Treatment: The treatment of dyspepsia is a difficult and unsatisfying topic because so few drugs have been studied and have shown to be effective moreover the drugs that have been shown to be useful have not been substantially effective. This difficult situation exists for many reasons. Medicines : Certain medications may help to reduce the symptoms of functional dyspepsia 32C 1. Acid reducing medications: - eg. H2 blockers such as Zantac or Proton Pump inhibitors such as prilosec 2. Visceral analgesics 3. Pain medications. Prognosis : Dyspepsia is typically a relapsing condition. In studies 60-90% 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 properly diagnosed, and many will respond to the treatments discussed above.32C
DIET IN DYSPEPSIA
IT is just as easy to give too little food to dyspeptics as too much. When a stomach has once become whimsical. Its whims will have to be disregarded in the process of breaking it into more wholesome habits. Of course, this will mean a certain amount of suffering at first, but the good results of it will soon be apparent.
When there is ulceration of the stomach present. It will be necessary to give only liquid food, and of all liquid foods in this states, Koumiss is the best. In acute attacks of indigestion the best of all remedies is to go without any food at all until the stomach has had time to recover itself.
41 In the chronic cases where the vitality is low, and the general to tone of health not robust, great care will be required in bringing the patient back to ordinary diet. Cold foods must be particularly avoided. Bread only sparingly used. Bread is not nearly so digestible an article as most people imagine, and dyspeptics should never eat bread and butter or hot buttered toast. Dry toast is all they should indulge in. When toast is not tolerated, rusks or biscuits may take its place. Plain water-biscuits are the best; such as Huntley & Palmer s Breakfast biscuits, and Captain s biscuits ; Cracknells ; and for breakfast there is one cold article of diet dyspeptics may take, and that is the fat of very good cold boiled bacon. They may have this with toast. Tea is bad for the digestion and for most people the habit of drinking tea in the afternoon is an exceedingly objectionable one. It breaks up the proper interval between lunch and dinner, and gives the tea its best possible chance of working its evil effects on the stomach. Coffee is not so injurious to the digestion as tea. It rather assists the digestion of fats which tea hinders. Though coffee has more tendency to cause headache, and with some persons flatulence and constipation, with others it assists the action of the bowels, Tea should never be taken without milk or cream, and it should never be strong, or taken after it has been made more than a few minutes. The teas of China are less injurious than those of India and Ceylon. Green teas are especially poisonous, and should never be taken under any circumstances. Cocoa possesses more of the nutrient and sustaining properties, and is less of a pure stimulant than either tea or coffee. Some Object to it on that account, as they say they want a drink rather than a food. This difficulty may be avoided by using and infusion of the nibs ; or the shells, or husks, which contain the nibs, may be used for making the beverage. When meat cannot be taken, beef-tea must be substituted. Mutaton is more digestible than beef, because in beef the fast is mor intermixed with the fibre of the meat, and the fat is more difficult to digest, and the fibre is harder. In cases where there is manifest ulceration of the stomach, Koumiss is the best fool. It may be given alone every hour or every two hous until the pain and vomiting have ceased and other food can be taken. Or one of the forms of soured milk such as Hindley s Bulgolac (II9, Coniston Road,Bromley, Kent) may be substituted. This is an excellent preparation, and is valuable in many forms of dyspepsia. When dyspepsia is constitutional, the particular constitution must be studied. Gouty patients should avoid all rich or highly spiced foods, and eat little butter and milk except with tea or coffee. These should be taken not strond. And the tea only when freshly made. Meat should be taken once a day, never cold, and never cooked a secondd time. The less flatulent kinds of vegetables are good, as French beans, Spinach, yound peas, also stewed celery. Potatoes should be avoided, and cabbage. Malt liquors. Wines and spirits should be avoided. Water is the best drink at meals; Salutaris water or toast-water may be substituted, or Caley s Aerated Distilled water, or Poland water. Hard water should be carefully avoided. Gouty patients should drink freely of liquids. A tumbler of water
42 taken half an hour before meals and at bedtime will supply all that is needed. Vittel and Contrexeville waters are usefull as eliminators. Those who have a tendency to rheumatism should observe most of the rules indicated for the gouty. Excess of meat and milk are not good. Oatmeal porridge should be taken at breakfast; at lunch or dinner. Soup, meat from the joint, with vegetables, plain rice or other farinaceous pudding without eggs, and no fruit. Toast-water should be the drink with the meals. Fresh-water fish, and watery fruits and vegetables, must be avoided. For the psoric no special rules can be laid down. They must be dieted according to their symptoms. The chilly sycotic patients must avoid all cold foods and watery foods, as the rheumatic. They may drink hot water, but never cold water. It will often be found beneficial to the circulation to sponge them every morning all over with spirit of wine before dressing. Fruit, milk, melons, mushrooms, hardboiled eggs must be avoided. Oysters can sometimes be taken when nothing else can, and they contain a considerable amount of nourishment. They may be taken raw or cooked as desired. Pepsine and all the artificial digestives I do not like, except for short periods. The stomach is ready enough to accommodate itself to inaction ; and when it finds the food put into it already peptonised, it will not trouble itself to secrete any pepsine itself. Hence it falls into bad habits, and finally the artificial pepsine ceases to suit the patient, whose stomach is then really weakes than before the pepsine was given. An exception must be made in favour of a preparation I have found very useful, namely, Bullock s Acid Glycerine of Pepsine, a teaspoonful being mixed in half a tumbler of hot water, and drunk at meals as a beverage. This is very pleasant to take, as well as efficient. It must not, however, be used continuously. A still more convenient preparation is Reed & Carnrick s Peptenzyme in tablets, one or two of which may be taken after meals. Vitalia and Vinsip contain nourishment in the most concentrated form. It is valuable as a restorative and stimulant as well as a nutrient. Bovinine is another preparation of beef of great value. It is in a form to be absorbed almost immediately without digestive effort. Brand s beef jelly is the next best thing to good home-made beef-tea. Brand s beef jelly is the next best thing to good home-made beef-tea. Liebig s beef-tea, Lemco, is more of a stimulant than a nutrient. But if taken with biscuit it is nourishing. Among Milk preparations Horlick s Malted Milk is one of the most valuable. It is in dry powdered form, and can be mixed with either hot or cold water, requiring no cooking. The various invalid foods are almost all good. Neave s, Ridge s, Sanvia, Allenbury s and Savory & Moore s foods have obtained well deserved reputations.
43 This is the most convenient place in which to mention the treatment of states of intestinal digestion by lactic bacilli, usually known as the sour-milk treatment of Metchnikoff. The object of the treatment is to introducae into the intestinal canal cultures of the bacillus which multiply there and take the place of less desirable organisms. The methods adopted are the use of milk or cheese soured with the bacilli or the taking of tablets, such as those of Metchnikoff himself, Lactobacillin, or Lacteol. These may be taken plain, after meals, or crushed and mixed ( they do not dissolve) in a little sweetened milk. I have already referred to milk preparations soured with the lactic ferments. The use of these preparations is often of service as an adjunct to homoeopathic treatment in a large number of cases of indigestion, and especially in those associated with neurasthenia. It is sage for any one to try these preparations, but they do not suit everyone and sometimes cause a little inconvenience, in which case they should not be persevered with. In dieting dyspeptics the most important thing is the times of eating; next in importance is the quantity they take most dyspeptics taking either too much or too little; and last, and perhaps less important than either of these two, is the regulation of the quality.
44 DIFFERENTIAL DIAGNOSIS OF DYSPEPSIA Any disease producing epigastria pain must differentiated from peptic ulcer disease, Diseases of Pancreas and gall bladder and functional disease like irritable Bowel syndrome.14 Peptic Ulcer disease : Symptoms of gastric and duodenal ulcers are identical to non ulcer dyspepsia since the diagnosis is essentially the symptoms of pain, discomfort, heart burn or gas bloat, it is necessary to elicit the history in detail. Constipation, haematemesis and malaena are present. A daily clock like recurrence of the pain is diagnosis. Ulcer related pain generally occurs 2 to 3 hours after meals and often awakens the patient at night. Endoscopy reveals ulcer present in GI tract.14 Duodentis: often no pain but nausea & sensation of fullness in upper right part of abdomen. Maximum intensity several hours after ingestion of food. Symptoms are usually not intermittent but continuous.14 Gall bladder disease: Cholecystitis Vague upper abdominal distress & fullness after meals. Belching & Eructations. Intolerance to fat, attacks of epigastric pain with tenderness over gall bladder, No occult blood in stools. Biliary colic & jaundice if complicating gall stones. Symptoms tend to be more irregular & less periodic. Radiological investigation often necessary.14 Pancreatic disease: Pancreatitis: Relief not obtained by food or alkali seldom any pain 2-3 hours after meal. Pain of severe degree persisting with out remission for periods of several days with radiation especially to the left side of abdomen and back, vomiting, often pyrexia during attack. Pain may be relieved by sitting up made worse by lying flat.14 Irritable Bowel Syndrome: IBS is a functional bowel disorder in which abdominal pain is associated with defecation or change in bowel habit. Causative factors are psychosocial factors, altered gastro intestinal motility, visceral hypersensitivity. Main complaint is recurrent abdominal pain usually colicky or cramping felt in lower abdomen & relieved by defecation.12
MIASMATIC PRESENTATION OF DYSPEPSIA:
PSORA All symptoms of acidity and dyspepsia, nausea and vomiting and pains in the liver and stomach are psoric.3 Gastritis oesophagitis with burning and other functional disorders of the gastrointestinal tract are Psoric. The Psoric patient suffers from feelings of dissension due to an accumulation of gas, with flatulence, rumbling and gurgling and sour and bitter eructations, which taste of the food just eaten. There is a sensation of fullness, weight and heaviness as if there is a stone or lump in the stomach. Psora also has acidity, sour eructation heart burn and nausea with a feeling of faintness.
Dyspeptic symptoms are also Psoric in origin.3,16.25
Empty, all gone sensation, especially in the morning as the patient is unable to assimilate any nutritious substances from the food they eat.3 ,16 ,25
Psoric patients mostly eat beyond their capacity of digestion, which causes various types of diarrhea, or the patient may be hungry but a few mouthfuls fill them up to the throat. 3 ,16 ,25
The Psoric patient may have an excessive hunger for unnatural substances like chalk, clay and other indigestible things especially during fever or pregnancy.3,16,25
Hungry especially between 10 A.M and 11 A.M. There may be a constant growing at the pit of the stomach with a cold or hot sensation beating, throbbing constriction and oppression occur especially after eating. In psora-aggravation occurs a few hours after eating. After meals, patient has head aches, flatulence or flatulent dyspepsia, weariness, sleepiness, vomiting, beating of the heart, coughing, pains in different parts of the body especially in the region of the liver. In the hypochondria or epigastrium they have pains of a cutting or colicky nature. Sore bruised, recessive pains in the abdomen are Psoric. In psora there are sensations of heaviness, Fullness with distension of the abdomen, heart burn and water brash. There may also be a bearing down sensation.
46 Rumbling and gurgling occurs in the abdomen as soon as the Psoric patient eats or drinks. All Psoric complaints but especially those of the abdomen are aggravated after eating which causes bloating. The patient cannot bear anything to touch the abdomen. The flatus does not pass off, but moves about causing many ailments of body and of spirit.
Cutting pains in the abdomen as if from obstructed flatus, there is a constant sensation of fullness in the abdomen- the flatus rises upwards.3,16,25
An organ of so complex function as the stomach has of course, many symptoms that acknowledge the presence of Psora in the organism.1
Usually the action of the miasm is quite marked in some other parts of the organism before its action is seen upon the stomach.1
We must look deeper and further than the gastric function for the phenomena of indigestion. Indigestion behind it, as a have all other disturbed functions, a mistuned life force : and a gastric expression is as much a secondary expression as in erysipelas, eczema or any eruption on the skin : or in other words, a gastric disturbance of any nature, whatever, is nothing more or less than the attempt of nature to, in some degree, eliminate the effects of miasmatic influence in the organism. Indigestion begins in the very cell itself, in its molecular movements which is from its periphery to its center, from the vitalizing nucleus to its circumference, and as the vitalized point receives the non vitalized or new food matter, it vitalizes it and projects it outward. Thus, this