Indigestion 
Diet and lifestyle guidelines

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Indigestion is a feeling of discomfort or pain within the lower chest or abdomen caused by gastric acid irritation within the upper part of the gut namely the oesophagus, stomach or duodenum.  The are many causes of indigestion and abdominal pain but the usual types of indigestion are:-

Heart burn. A burning feeling in the centre of the chest, sometimes combined with an acid taste in the back of the mouth. Usually made worse by eating a large meal, straining or leaning forward. This is caused by acid from the stomach refluxing back into the gullet. If severe the acid can cause marked and chocking coughing.

Classic indigestion comes on shortly after food and is a described as an intermittent burning discomfort in the top of the abdomen. Often helped temporarily by antacid medication (white medicine).   Caused by irritation of the stomach wall (gastritis or an ulcer).  If discomfort starts on an empty stomach (or starts in the middle of the night) it is more likely because of an ulcer or irritation of the section of gut which immediately follows the stomach called the duodenum. 

Indigestion and more often heart burn are common complaints experienced during chemotherapy or after surgery. The cause of pain is stomach acid, the acid that helps to digest your food. Stomach acid increasing normally when you eat, food travels from your mouth down the esophagus through the lower esophageal sphincter. If there’s too much acid, or if the sphincter doesn’t work properly, food and stomach acid can flow up or reflux into the oesophagus. Acid reflux irritates the lining of the oesophagus causing ulceration and often causes heartburn. If left long enough this can lead to bleeding or stricture formation (causing food to stick in the throat). The steroids,  or anti-inflammatory drugs often given during chemotherapy can also aggravate indigestion. Bisphonates (bone hardening drugs) can cause indigestion especially if they are taken lying down. 

If indigestion is marked are persistent, especially if associated with pain then further investigation such as an endoscopy is required and treatments with anti-acids or other drugs some dietary and lifestyle measures can help:

Diet and lifestyle suggestions and foods to avoid:

• Do not overeat and eat slowly
• Smoking is a common cause of indigestion
• Avoid strong coffee on an empty stomach
• Alcohol especially spirits
• Carbonated drinks (with and without caffeine) 
• Fried food or foods high in fat
• Pickled foods
• Acidic foods such as citrus, onions and tomatoes, if these set off your heartburn.
• Fruit should not necessarily be avoided unless they trigger your discomfort but eat the whole fruit 
• Avoid processed juices as these are more acidic
• Chocolate, cakes, biscuits, muffins
• Foods that you have discovered trigger your heartburn
• Small and frequent meals or snacks may be better tolerated
• Do not eat large meals, especially late at night..
• Try a tablespoon of crushed linseeds every morning - fantastic for the digestion (contains fibre, antioxidants, healthy fats)

                                    Lifestyle changes which may help "heart burn":

• Avoid straining if constipated or if lifting keep you mouth open to equalize your abdominal pressure
• Allow two to three hours to pass after eating before you lie down.
• Raise the head of your bed (eg with two bricks) so that chest is higher than your feet.
• Wear looser-fitting clothing.
• Lose weight, if you are overweight.
• Wait at least two hours after eating before exercising.
• When exercising breath out slowly when straining the stomach or lifting.
• Gentle running is better than weight lifting.
• If swimming learn to breath well as there is a tendency to hold the breath and strain, particularly with breast stroke.
• Keep a heartburn journal to track foods or activities that aggravate your symptoms

Other types of abdominal discomfort:

Duodenal ulceration: If discomfort starts on an empty stomach (several hours after food) it is more likely because of an ulcer or irritation of the section of gut which immediately follows the stomach called the duodenum. The steroids which are given with chemotherapy often make this symptom worse or even bring it on in patients who have not previously experienced it. Often medication is prescribed to prevent this symptom.

Small bowel: Interference in the function of the small bowel often leads to colicky pains and blaoting. This means the pain, usually in the centre of the abdomen, starts slowly then build up into a severe spasm then quite quickly resolve only to build up gradually again. This is not usually caused by steroids and may indicate partial obstruction of the small bowel by tumour or fibrous bands caused by previous abdominal surgery. 

Large bowel Problems with the large bowel are often associated with bloating constipation or diarrhoea. 

Constipation: This is mainly constant on the left lower side of the abdomen, if severe there may be some mild colicky type pains.  We are all familiar with the symptoms of constipation which most commonly include an uncomfortable feeling in the back passage, bloating and abdominal cramps. There are many other symptoms which are not so immediately obvious. A recent survey of patients with regular constipation reported the following symptoms:

• 65% mentioned discomfort, fatigue & apprehension
• 25% reported irritability and increased arguments with their partners
• 51% admitted feeling less attractive, impacting their social lives
• 38% said they cancelled or left a social engagement early
• 68% said it affected sex either because they felt unattractive or in pain
• 70% reported embarrassment with the extra associated flatulence.

There are several reasons why constipation may develop.

• anti-sickness medication (eg ondansetron) and pain killers (codeine or morphine) are additional major culprits

• not eating enough fibre

• not being active enough

• drinking an excessive amount of strong tea or coffee (these can be dehydrating)

• bowel muscles weakness – being frail or recent abdominal surgery

• haemorrhoids, or anal fissure can make it painful to defecate

Ways to prevent constipation:

• Eat plenty of fibre such as bran, wholemeal bread, cereals, fruit, leafy vegetables, potato skins, beans, dried peas (see below).

• Have a regular routine in the morning and allow your bowels time to work. The best time to go is in the hour after breakfast

• Don’t ignore the call to stool – if you want to go – go don’t be embarrassed to keep people waiting while you sit on the loo with the newspaper until you’ve had a good result.

• Exercise shakes up your bowels and reduces the time motion takes to pass through your bowels (transit time) - your stool will be softer by the time it reaches your rectum easier to pass.

• Use ointment, suppositories to relieve a painful anus.

Dietary tips and constipations:

• Crushed or milled linseeds are excellent they contain fibre, antioxidants and healthy oils such as omega 3 and 6 - a tablespoon every morning is a must!
• Try including more fruit in your diet, either tinned, fresh, stewed, pureed or dried.
• Add dried fruit to porridge, cereal or milk puddings
• Slice a banana on your breakfast cereal
• Slice fruit on to desserts such as mousses and cheesecakes
• Try increasing your intakof vegetables including peas, beans and lentils.
• Fresh, frozen, tinned, cooked or raw:-
• Add cauliflower, leeks or broccoli to stews, casseroles, curries, and soups
• Include salad in sandwiches
• Baked beans on toast makes a high fibre snack / meal
• Breads and Cereals
• More wholemeal bread (unless wheat intolerant).
• Cereals such as Branflakes, Weetabix, Porridge, Shredded Wheat or Fruit & Fibre are a good source of fibre.
• Digestive and oat biscuits contain more fibre than plain biscuits such as Morning Coffee or Rich Tea.
• Cereals such as Branflakes, Albran or Fruit & Fibre can be mixed with lower fibre cereals such as cornflakes or Frosties to increase their fibre content

Only if these measures fail there are several laxatives are available from the clinic, GP or over the counter. A number of drugs are available for diarrhoea including Codeine and loperamide although a change in diet may help - see diet & diarrhoea

Lower rectum; A feeling of fullness in the back passage, urgency to open bowels and of severe incontinence of wind or faeces. It may be associated with a blood on the stool or a mucous discharge form the back passage. Often caused by radiotherapy to the lower pelvis can be help with suppositories  such as xyloproct. proctocydul or scheriproct - ask your doctor.

Drug therapy

Zantac (ranitidine) decreases the production of acid from the lining of the stomach.  This protects the stomach, oesophagus and duodenum from irritation and ulceration. It works by blocking a receptor in the stomach call the H2 receptor of the gastric parietal cell - so called H2 antagonist. A tablet containing 150mg of ranitidine twice a day (morning and evening). It doesn't matter exactly what times of day you take it but many people try to take it at the same times each day so its easier to remember. If you forget to take your tablet don’t panic but  try not to miss more than one or two tablets in a row. Zantac is generally very well tolerated. Side effects are rare but include headache and  skin rashes Very rarely breast tenderness in men may occur.

Zoton (Lansoprazole), Protium (pantoprazole) or Losec (omeprazole) are very successful in treating the symptoms caused by acid irritation. Even if you don't already have indigestion it is useful to give Zoton to prevent these symptoms developing when steroids are given with chemotherapy. It  decreases the production of acid from the lining of the stomach.  This protects the stomach, oesophagus and duodenum from irritation and ulceration. They work by blocking an enzyme (hydrogen-potassium adenosine tri-phosphatase) of the gastric parietal cell - so called proton pump inhibitor. Side effects are rare but include headache, diarrhoea and  skin rashes. Your doctor should be aware if you have problems with your liver and the recommended dose should not be exceeded..