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Suggest Treatment For Dyspepsia
Question: Hello Dr Narsi. I am 68 male. Pacemaker replaced in Apr 14. Hypertension past 30 yrs. Taking CTD 12.5, Telmasartan 80 + Amlodepine 5 daily. Have BPH. Am Hep B past 10yrs post angiography. LFT normal. Having headaches past 21/2 yrs. CT scan showed - prominent vessel in left frontal lobe suggesting underlying incidental venous angioma. There is prominent perivascular space in left basal ganglia & mild cerebal atrophy changes. Am on 25 mg Protheiden since 06th April 14. Still get them but not so severe. Having severe burping/belching past 6 months. Feel lightheaded too. Acidity problems are there past number of years. Took Pantop-D and Itopride for 2 months (doctors advise). Ultrasound of abdomen all good except for BPH and some post void retention. Felt much better but is back again . Motions regular & normal. No stomach pain as such. Any dietery related? Am veg. Stopped wheat. Please advise.
Brief Answer:
Dyspepsia
Detailed Answer:
Hi,
Thank you for your query. I can understand your concerns.
It seems that you are having dyspepsia most likely NUD (non ulcer dyspepsia ). Irritable bowel syndrome often co-exist.Unspecified excessive belching is a sub classifiication(B2) under Functional dyspepsia (NUD).
Since USG(ultrasonography) abdomen has ruled out pancreatic diseases and gall stones , you need to undergo Upper GI endoscopy with or without biopsy-based testing for H-pylori .
Quit smoking/tobacco in any form.
Stop / reduce alcohol. Immoderate alcohol consumption should be avoided.
Avoid foods and other factors that precipitate symptoms.
Idiosyncratic and restrictive diets are of little help but fat restriction may help . Avoid what you can’t tolerate is better advice than blanket ban on food items.
Simple dietary precautions may go a long way in alleviating symptoms.
Better eating habits.
Regular meal timings: Don’t eat late.
Having unhurried meals.
Not habitually sipping fluids/carbonated beverages during meals.
Avoidance of excessively spicy and fatty foods.
Not to chew gum.
Powerful acid-suppressants like Pantoprazole (proton pump inhibitor/PPI) are seldom required.
H2-receptor antagonists /H2RA (ranitidine,famotidine) may be substituted. H2RA is especially used if night pain or heart burn is troublesome.Take prokinetic medication either domperidon or itopride.if nausea,vomiting & bloating suggestive of gastro-duodenal dysmotility is prominent .
Prothiaden (Dothiepin) 25 mg is advised at bedtime only.
Avoiding flatogenic foods, exercising, losing excess weight, and taking activated charcoal are safe but unproven remedies.
Pancreatic enzymes reduce bloating, gas, and fullness during and after high-calorie, high-fat meal ingestion.
Regards
Dr. T.K. Biswas M.D. XXXXXXX
Dyspepsia
Detailed Answer:
Hi,
Thank you for your query. I can understand your concerns.
It seems that you are having dyspepsia most likely NUD (non ulcer dyspepsia ). Irritable bowel syndrome often co-exist.Unspecified excessive belching is a sub classifiication(B2) under Functional dyspepsia (NUD).
Since USG(ultrasonography) abdomen has ruled out pancreatic diseases and gall stones , you need to undergo Upper GI endoscopy with or without biopsy-based testing for H-pylori .
Quit smoking/tobacco in any form.
Stop / reduce alcohol. Immoderate alcohol consumption should be avoided.
Avoid foods and other factors that precipitate symptoms.
Idiosyncratic and restrictive diets are of little help but fat restriction may help . Avoid what you can’t tolerate is better advice than blanket ban on food items.
Simple dietary precautions may go a long way in alleviating symptoms.
Better eating habits.
Regular meal timings: Don’t eat late.
Having unhurried meals.
Not habitually sipping fluids/carbonated beverages during meals.
Avoidance of excessively spicy and fatty foods.
Not to chew gum.
Powerful acid-suppressants like Pantoprazole (proton pump inhibitor/PPI) are seldom required.
H2-receptor antagonists /H2RA (ranitidine,famotidine) may be substituted. H2RA is especially used if night pain or heart burn is troublesome.Take prokinetic medication either domperidon or itopride.if nausea,vomiting & bloating suggestive of gastro-duodenal dysmotility is prominent .
Prothiaden (Dothiepin) 25 mg is advised at bedtime only.
Avoiding flatogenic foods, exercising, losing excess weight, and taking activated charcoal are safe but unproven remedies.
Pancreatic enzymes reduce bloating, gas, and fullness during and after high-calorie, high-fat meal ingestion.
Regards
Dr. T.K. Biswas M.D. XXXXXXX
Above answer was peer-reviewed by :
Dr. Raju A.T
Dear Doctor Biswas,
Thank you very much for your prompt and detailed reply.
I am a bit confused with so much in your reply. I am non smoker & stopped social alchol since past 10 yrs (since detection of Hep B) & take Protheiden at night only. I don't take any carbonated drinks or spicy food. Maybe some chutney once in a while.
I have been having this "dyspesia" for a very long time - 10 yrs. I am not too keen of an Endoscopy unless you feel its very essential. It has its side effects too.
Can Amlodepine or CTD cause this? I read Amlodepine does have such side effects. I was on Amlodepine for a number of years but it was stopped to see if it causd my headaches (which have been diagnosed as Migraine/Vascular/Muscle Tension since CT scan (June 12) did not show up any major findings. The headaches are much better but its in the background.
How does one eliminate diet related issues? What are the gas forming foods to avoid? My meals may be irregular at times. I have not been able to identify what food precipitates this - I have been trying for a while.
You feel I can Ranatidine/Zintac or fomatidine instead of Pantaprazole/Rabaprazole? Is Domperidone 10 mg OK or add Itopride too? Can these be taken on SOS basis or for short durations?
I will certainly make lifestyle changes as suggested by you. My Physcian here thinks I am a hypocondriac !! I am a worrying type and should start doing meditation.
Please advise. Thank you
Thank you very much for your prompt and detailed reply.
I am a bit confused with so much in your reply. I am non smoker & stopped social alchol since past 10 yrs (since detection of Hep B) & take Protheiden at night only. I don't take any carbonated drinks or spicy food. Maybe some chutney once in a while.
I have been having this "dyspesia" for a very long time - 10 yrs. I am not too keen of an Endoscopy unless you feel its very essential. It has its side effects too.
Can Amlodepine or CTD cause this? I read Amlodepine does have such side effects. I was on Amlodepine for a number of years but it was stopped to see if it causd my headaches (which have been diagnosed as Migraine/Vascular/Muscle Tension since CT scan (June 12) did not show up any major findings. The headaches are much better but its in the background.
How does one eliminate diet related issues? What are the gas forming foods to avoid? My meals may be irregular at times. I have not been able to identify what food precipitates this - I have been trying for a while.
You feel I can Ranatidine/Zintac or fomatidine instead of Pantaprazole/Rabaprazole? Is Domperidone 10 mg OK or add Itopride too? Can these be taken on SOS basis or for short durations?
I will certainly make lifestyle changes as suggested by you. My Physcian here thinks I am a hypocondriac !! I am a worrying type and should start doing meditation.
Please advise. Thank you
Brief Answer:
Dyspepsia-various issues
Detailed Answer:
Hi,
Since you have stopped taking alcohol since 10 years,most likely cause of dyspepsia is functional.
Prolonged course of powerful antacid like Pantaprazole/Rabaprazole(proton pump inhibitors/PPI) has its own problem-it produces achlorhydria-consequent Vit B12 malabsorption and megaloblastic anemia and even iron absorption is impaired. Particularly older patients are thought to be at risk of developing B12 deficiency with PPI usage.
Domperidone 10 mg can be taken as prokinetic drug whereas Itopride is not currently approved by the U.S. Food and Drug Administration (FDA) for use in the United States, nor is it yet approved in the United Kingdom.
Amlodepine and CTD can cause dyspepsia but not to the extent of discontinuation of these drugs which are mostly well tolerated.
Cauliflower, Beans,legumes , eggs, and meat produce a greater quantity of gas,
Functional dyspepsia refractory to standard therapies may respond to low-dose antidepressants in tricyclic ( Prothiaden) classes.
Psychological treatments (meditations etc ) may be offered for refractory functional dyspepsia, but no convincing data suggest their efficacy.
Dyspepsia-various issues
Detailed Answer:
Hi,
Since you have stopped taking alcohol since 10 years,most likely cause of dyspepsia is functional.
Prolonged course of powerful antacid like Pantaprazole/Rabaprazole(proton pump inhibitors/PPI) has its own problem-it produces achlorhydria-consequent Vit B12 malabsorption and megaloblastic anemia and even iron absorption is impaired. Particularly older patients are thought to be at risk of developing B12 deficiency with PPI usage.
Domperidone 10 mg can be taken as prokinetic drug whereas Itopride is not currently approved by the U.S. Food and Drug Administration (FDA) for use in the United States, nor is it yet approved in the United Kingdom.
Amlodepine and CTD can cause dyspepsia but not to the extent of discontinuation of these drugs which are mostly well tolerated.
Cauliflower, Beans,legumes , eggs, and meat produce a greater quantity of gas,
Functional dyspepsia refractory to standard therapies may respond to low-dose antidepressants in tricyclic ( Prothiaden) classes.
Psychological treatments (meditations etc ) may be offered for refractory functional dyspepsia, but no convincing data suggest their efficacy.
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Dear Dr. Biswas,
Thank you very much for your reply.
1. In XXXXXXX 2012 when my headaches started, my Vit B12 was checked. It was 198. I was put on Vitcofol injections + Folic acid tablets regimen. I did most of it except maybe last 5 mothly injections I did not take. In Oct 12 the B12 levels were 703.
Maybe the B12 is again down due to my taking Pantop D SOS and also for two months of XXXXXXX & July 14 alongwith Itopride/Ganaton. I do have tingling feelings in my feet specially the left one. Do I need to check B12 again? If its low what is the Vitcofol regimen be or can I take Vit B 12 tabs/capsules 1500 for a nonth or so?
2. In Aug 12, my Vit D total was showing a shocking <3.0 ng/ml. Maybe some error. I was put on Vit D sachets and in Oct 12 the Vit D was 33.3. Do I need to check that too?
3. I did not understand when you said " Functional dyspepsia refractory to standard therapies may respond to low-dose antidepressants in tricyclic ( Prothiaden) classes." Is Protheiden good for dyspepsia too?
4. My headaches were diagnosed as muscle tension/vascular. Anything to do with my regular dyspepsia?
5. Can Coffee, home made Curd or once in a while Dosa/Idli (fermented stuff) aggrevate dyspepsia? I take coffee about 2 cups a day at XXXXXXX Mostly only 1 cup.
6. Fruits like oranges etc should be OK. I believe that apples, bananas, potaoes, onions, even dals barring yellow moong etc also produce gas. Any of them I should avoid in particular? I am a veg. So also my eggs intake maybe 2 per week. What should I avoid?
7. In April/May/June 14 when my dyspepsia was bad, my diet came down. I lost about 4 kgs from 72 kgs to about 68 Kgs which is steady for past 3 months. Appetite is OK. Not too bad. I walk everyday for 40 mts or so. This whole year my physical activity was minimal as I fractured a rib in XXXXXXX 14, then my pacemaker was replaced in Apr 14 and in Aug 14 I sprained my back playing Golf! A bad year indeed.
8. Is my BP medication of CTD 12.5+ Telmasartan 80 in the morning and 5 mg Amlodepine at night ?
9. I have stopped the BPH medicine last two weeks just to see if that caused any dyspepsia.
10. Can I take Rantac + Domperidone 10 mg on SOS basis ?
Sorry I have asked you a number of questions. Will appreciate your advise.
Regards
XXXXXXX XXXXXXX
Thank you very much for your reply.
1. In XXXXXXX 2012 when my headaches started, my Vit B12 was checked. It was 198. I was put on Vitcofol injections + Folic acid tablets regimen. I did most of it except maybe last 5 mothly injections I did not take. In Oct 12 the B12 levels were 703.
Maybe the B12 is again down due to my taking Pantop D SOS and also for two months of XXXXXXX & July 14 alongwith Itopride/Ganaton. I do have tingling feelings in my feet specially the left one. Do I need to check B12 again? If its low what is the Vitcofol regimen be or can I take Vit B 12 tabs/capsules 1500 for a nonth or so?
2. In Aug 12, my Vit D total was showing a shocking <3.0 ng/ml. Maybe some error. I was put on Vit D sachets and in Oct 12 the Vit D was 33.3. Do I need to check that too?
3. I did not understand when you said " Functional dyspepsia refractory to standard therapies may respond to low-dose antidepressants in tricyclic ( Prothiaden) classes." Is Protheiden good for dyspepsia too?
4. My headaches were diagnosed as muscle tension/vascular. Anything to do with my regular dyspepsia?
5. Can Coffee, home made Curd or once in a while Dosa/Idli (fermented stuff) aggrevate dyspepsia? I take coffee about 2 cups a day at XXXXXXX Mostly only 1 cup.
6. Fruits like oranges etc should be OK. I believe that apples, bananas, potaoes, onions, even dals barring yellow moong etc also produce gas. Any of them I should avoid in particular? I am a veg. So also my eggs intake maybe 2 per week. What should I avoid?
7. In April/May/June 14 when my dyspepsia was bad, my diet came down. I lost about 4 kgs from 72 kgs to about 68 Kgs which is steady for past 3 months. Appetite is OK. Not too bad. I walk everyday for 40 mts or so. This whole year my physical activity was minimal as I fractured a rib in XXXXXXX 14, then my pacemaker was replaced in Apr 14 and in Aug 14 I sprained my back playing Golf! A bad year indeed.
8. Is my BP medication of CTD 12.5+ Telmasartan 80 in the morning and 5 mg Amlodepine at night ?
9. I have stopped the BPH medicine last two weeks just to see if that caused any dyspepsia.
10. Can I take Rantac + Domperidone 10 mg on SOS basis ?
Sorry I have asked you a number of questions. Will appreciate your advise.
Regards
XXXXXXX XXXXXXX
Brief Answer:
Dyspepsia and related issues in elderly
Detailed Answer:
Hi,
Thank you for your query. I can understand your concerns.
!. You can repeat serum Vit B12 level. Injectable Vit B12 is preferable if one is considering achlorhydria as the contributory cause.
2.You can repeat serum 25(OH) Vit D level since it is more than a year. Reduced levels of vitamin D are found in elderly due to reduced dietary intake, decreased sun exposure and less efficient skin conversion.
3.The mechanism of action low-dose antidepressants in tricyclic ( Prothiaden) classes in 'Functional dyspepsia' is unknown but may involve blunting of visceral pain processing in the brain.
4. Dyspepsia is unrelated to headache,except due to fear of cancer.
5.Dyspetic patient should avoid excessive tea,coffee(>4 cups/day),alcoholic drinks and hot spicy foodstuffs.
6.You should avoid onion & garlics.
7.Physical activity/ Exercise is stress-reducing activities.
8.BP medication of CTD 12.5+ Telmasartan 80 in the morning and 5 mg Amlodepine at night seem appropriate,if tolerating well.
9. You have not specified BPH medicine you had been taking.
10.Many patients started on a proton pump inhibitor can be stepped down to an H2 antagonist e.g. ranitidine. Acid suppressants e.g. ranitidine may be taken continuously or on demand depending on symptom severity.Convincing evidence of benefits of prokinetic drugs e.g Domperidone in functional dyspepsia; however, has not been found. Patients with symptoms resembling postprandial distress may respond preferentially to prokinetic drugs.
Hope I have been able to address your concerns & queries.
Regards
Dr. T.K. Biswas M.D. XXXXXXX
Dyspepsia and related issues in elderly
Detailed Answer:
Hi,
Thank you for your query. I can understand your concerns.
!. You can repeat serum Vit B12 level. Injectable Vit B12 is preferable if one is considering achlorhydria as the contributory cause.
2.You can repeat serum 25(OH) Vit D level since it is more than a year. Reduced levels of vitamin D are found in elderly due to reduced dietary intake, decreased sun exposure and less efficient skin conversion.
3.The mechanism of action low-dose antidepressants in tricyclic ( Prothiaden) classes in 'Functional dyspepsia' is unknown but may involve blunting of visceral pain processing in the brain.
4. Dyspepsia is unrelated to headache,except due to fear of cancer.
5.Dyspetic patient should avoid excessive tea,coffee(>4 cups/day),alcoholic drinks and hot spicy foodstuffs.
6.You should avoid onion & garlics.
7.Physical activity/ Exercise is stress-reducing activities.
8.BP medication of CTD 12.5+ Telmasartan 80 in the morning and 5 mg Amlodepine at night seem appropriate,if tolerating well.
9. You have not specified BPH medicine you had been taking.
10.Many patients started on a proton pump inhibitor can be stepped down to an H2 antagonist e.g. ranitidine. Acid suppressants e.g. ranitidine may be taken continuously or on demand depending on symptom severity.Convincing evidence of benefits of prokinetic drugs e.g Domperidone in functional dyspepsia; however, has not been found. Patients with symptoms resembling postprandial distress may respond preferentially to prokinetic drugs.
Hope I have been able to address your concerns & queries.
Regards
Dr. T.K. Biswas M.D. XXXXXXX
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Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Answered by
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