Clinical Roundup

How Do You Treat Indigestion in Your Practice?

Homeopathy
Indigestion, also known as dyspepsia, is a functional disorder of the gastrointestinal tract, characterized by epigastric pain/ burning, postprandial fullness, flatulence, belching, and, in some cases, idiopathic nausea and vomiting.1 Nonulcer or functional dyspepsia is the diagnosis made when no underlying pathology is found on investigation. About 50% of reported dyspepsia cases have a functional diagnosis.2 The etiology of functional dyspepsia is poorly understood and is considered to be a multifactorial disorder, of which environmental factors, such as smoking and alcohol consumption, poor dietary habits, psychosocial factors, and stress are major contributors.3 Homeopathy is a holistic form of medicine in which the person as a totality is considered. A comprehensive case history is taken, which considers the patients intrinsic response to the environment and life world, both physically and emotionally, and the unique way that patient manifests the disease. The totalities of the most characteristic symptoms are the guide to finding the patients specific homeopathic remedy. Although further research is needed to understand the efficacy of homeopathic remedies, examples of remedies commonly used in homeopathy for acute indigestion include Nux vomica for nausea and vomiting after overindulgence of rich food and alcohol, and Antimonium crudum for bloating and discomfort after overeating. Lycopodium clavatum is wellindicated for easy satiety, bloating, and heartburn after meals.4 A study on the effect of Natrum phosphoricum 6X in nonulcer dyspepsia found a significant decrease in the severity, duration, and frequency of dyspeptic episodes in the treatment group when taken daily for 4 weeks (Patel J. The efficacy of Natrum phosphoricum 6X in the treatment of non-ulcer dyspepsia. Unpublished. University of Johannesburg, Johannesburg, South Africa, 2005). Lifestyle and dietary changes are also essential for managing indigestion. Patients are given standard advice that includes: exercising; eating in a relaxed atmosphere; chewing food well; eliminating junk foods/drinks; consuming a diet with increased fresh fruit and vegetables; and replacing wheat-based bread with alternative grains such as rye bread. Anecdotally, patients attest that a portion of papaya (with pips if desired), eaten before meals improves digestion and

acid reflux symptoms. Swedish Bitters are a particularly popular herbal home remedy for indigestion, and I frequently recommend this remedy. References
1. Tack J, Talley NJ, Camilleri M, et al. Functional gastroduodenal disorders. Gastroenterology 2006;130:14661479. 2. Fisher RS, Parkman HP. Management of non ulcer dyspesia. New Engl J Med 1998;339:13761381.

3. Louw J, Pinkney-Atkinson V. Diagnosis and management of dyspepsia clinical guidelines. South Africa Med J 1999;89:895906.

4. Vermeulen F. Concordant Materia Medica. Haarlem, The Netherlands: Emryss Publishers, 2000.

Elizabeth Margaret Solomon, HD, ND, DO, BA Department of Homoeopathy, University of Johannesburg, Doornfontein, South Africa

Traditional Chinese Medicine

The symptoms of indigestion include acute, chronic, or recurrent pain or discomfort centered in the upper abdomen.1 Indigestion in Traditional Chinese Medicine (TCM) includes terms such as Cold invading the Stomach, Spleen Qi Deficiency, and Liver Qi Stagnation. These are three common diagnoses associated with indigestion in TCM, and each is allocated a standard formula for treatment. One classical formula for indigestion caused by overeating is called Bao He Wan, which dates back to the fourteenth century.2 In clinical practice, standard formulas are prescribed and are usually modified if prescribed in loose or granular form to suit the patient. If the practitioner is using pill form, several formulas may be used simultaneously to best match the patients TCM diagnosis. As a scientist with 10 years of TCM clinical experience, I treat indigestion using standard formulas coupled with the latest scientific research. Li Zhong Tang is an effective formula for treating Warming of the Middle Burner and consists of loose herbs Dang Shen, Gan Jiang, Bai Zhu, and Zhi Gan Cao. Research has shown that herbs commonly used
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in TCM for indigestion, such as Bo He and Xiang Cai Zi, used in combination were more effective than placebo for reducing pain and discomfort associated with indigestion.3 Acupuncture has proven to be effective for treating indigestion.4 When treating patients, I focus on using standard acupuncture points: Sp 4 (Gong Sun); St 36 (Zu San Li); LI 4 (He Gu); PC 6 (Nei Guan); and CV 12 (Zhong Wan). For indigestion or malnutrition problems in children, I use Si Feng. Si Feng corresponds to the Extra Points category. These are 4 points (as the name implies Si meaning 4 and Feng means cracks in Chinese) located on the palmar surface of the hand in the midpoint of the transverse crease of the proximal interphalangeal joints of the index, middle, ring, and little fingers. References
1. McQuaid KR. Gastrointestinal disorders. In: McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis & Treatment, 50th ed. New York: McGrawHill Companies, 2011;540638. 2. Li F, Chai R-J, Fan Q-L. Formulas for dispersing food and stagnation. In: Iong D, Garran TA, Deasy L. Applications of Chinese Formula Compatibility, 2nd ed. Beijing: Peoples Medical Publishing, 2008;1:365:363372.

If the aforementioned treatments do not release the organ, I put my hand on the abdomen and ask the patient to relax the abdomen and inhale, letting the abdomen rise up, then hold and exhale very slowly. Typically, the abdomen will release on the second or third breath. If the organ tension still persists, I push down on the organ and ask the patient to inhale, relaxing the abdomen, while applying downward pressure with my finger. The lung pressure causes my finger to rise as the abdomen rises. Then on the exhalation, continuing the pressure on the abdomen, which now is lowering, halfway down, I quickly release my finger, as if it were a hot surface. If the organ still does not release, then I go to the Back Shu point for that organ and apply acupuncture near the corresponding transverse process, spinning the needle back and forth for 90 seconds. If none of the above treatments are successful, I repeat the treatment in 1 week and reassess the patients condition. There is often a major change within 2 days. Phillip Shinnick, PhD, MPA, LAc Research Institute of Global Physiology, Behavior and Treatment, Inc., New York, NY

3. May B, Kohler S, Schneider B. Efficacy and tolerability of a fixed combination of peppermint oil and caraway oil in patients suffering from functional dyspepsia. Aliment Pharmacol Ther 2000;14:16711677. 4. Park Y-C, Kang W, Choi S-M, Son C-G. Evaluation of manual acupuncture at classical and nondefined points for treatment of functional dyspepsia: A randomized-controlled trial. J Altern Complement Med 2009;15:879 884.

Acupuncture, Homeopathy, and Osteopathy

The symptom of indigestion is very commonly seen in the practice of Western medicine. The main issues are epigastric pain or discomfort, reflux or waterbrash, and belching. Each discipline of complementary and alternative medicine will approach the problem from its own individual perspective. The therapies in which I am qualified to practice are acupuncture, homeopathy, and osteopathy. Why do I use these modalities? Each of them has a healing paradigm that is completely different from that used by Western medicine. Acupuncture theory states that indigestion involves a dysfunction caused by an imbalance or blockage of flow of qi (energy). This may be corrected by acupuncture applied to points on the Stomach Channel (e.g., St 36) or to points of the channel, which crosses the epigastrium (e.g., PC 6).1 Homeopathy uses the Principle of Similars (i.e., like cures like). Samuel Hahnemann, MD (17551843), found that small doses of a medicine, which, in large physical doses, would cause a similar symptom picture that resembled the patients condition, rendered a healing stimulus.2 For dyspepsia and belching, remedies such as Lycopodium, Argentum nitricum, and Nux vomica may be used.3 The exact remedy will be tailored to the overall patient picture and individualized to each patient. Osteopathic treatment works on the premise that some so-matic dysfunction or musculoskeletal pain may be caused by viscerosomatic referred pain. This means that visceral pain can be referred to, and cause dysfunction of, superficial structures.4 In the case of the stomach, this pain is referred via the sympathetic plexus to the midthoracic region, T4T7. Manipulation of this area will often give a patient relief from epigastric pain or discomfort.
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Patricia L. Diaz, BAppSc, BBioSc Jiangsu Provincial Hospital of TCM, Nanjing, Peoples Republic of China and Holiclinicstic Australia, Sydney, New South Wales, Australia

Electroacupuncture
I palpate the abdomen for organ tension and spasm, noting the Front Alarm (Mu) points that are in spasm. Common somatic stress is typically present in patients with gastrointestinal disorders including abdominal, neck, and shoulder pain. If tension and/or spasms are found around the neck and shoulders, I treat GB 20 and GB 21 bilaterally with electroacupuncture at 2 Hz for 10 minutes to increase blood flow to the brain. This will relax the patient and help regulate the organs. If the mid-back is still in spasm, I treat all the Back Transport (Shu) points, from T5 to T11, with bilateral electroacupuncture at a low frequency for 10 minutes. Then, I turn the patient over and palpate the viscera again to see which organs have not released. If the abdomen is in spasm, I then use surface electrodes across the abdomen for 10 minutes. I examine the patient again to see which organ remains in spasm and needle the corresponding Mu points for that organ 12 cm in depth with a pecking action.

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I have found all the above methods useful in my practice for treating indigestion. References
1. Xinnong C. Chinese Acupuncture and Moxibustion, 1st ed. Beijing: Foreign Languages Press, 1987.

During the visit, I usually discuss with patients their daily water consumption, and their food and dietary choices. I then provide recommendations to help patients improve their digestion. Sometimes patients sleep is affected too, and they need additional recommendations. References
1. Goodacre SW, Angelini K, Arnold J, et al. Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain. Q J Med 2003; 96:893898. 2. DiGiovanna EL, Schiowitz S, Dowling DJ. An osteopathic approach to diagnosis and treatment, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2005:404,217,620. 3. Standring S. Grays Anatomy, 39th ed. London: Churchill Livingstone, 2005. 4. Hruby RJ. The rib cage. In: Ward RC, ed. Foundations for Osteopathic Medicine, 2nd ed. London: Lippincott Williams & Wilkins, 2003:719720.

2. Academic Unit. Foundation Course in Medical Homeopathy. London: Royal London Homeopathic Hospital, 2006.

3. Pratt N. Homepathic Prescribing, rev. ed. Bucks, England: Beaconsfield Publishers, 1985. 4. Sammut EA, Searle-Barnes PJ. Osteopathic Diagnosis. Cheltenham, UK: Stanley Thornes Publishers, 1998.

John M.H. Gillett, MBBS, MFM, DMSMed Palliative Medicine Consultant to St. Andrews Hospital, Toowoomba, Queensland, Australia

Breathing Techniques and Diaphragmatic Relaxation

In my physiotherapy and osteopathic clinic, I usually combine manual treatment options, such as myofascial and osteopathic techniques, for patients presenting with indigestion. Depending on the symptomatology and individual status of the patient, I vary my techniques. First, I find it very important to make the difference between two kinds of patients. These include patients who usually have symptoms of indigestion (symptoms that persist longer than 2 weeks) and patients who do not usually have symptoms of indigestion and who have a very acute symptomatology. In the latter case it is fundamental to exclude a cardiac problem such as angina pectoris before deciding on a treatment.1 In the former case, I usually use an evaluation sequence, as follows, to determine which techniques to use: (1) Evaluate the status of the diaphragm: Level of tension and pain in every hemidiaphragmatic cupola2 Level and area of referred pain Innervation of the diaphragm from the phrenic nerve originating from cervical spine segments C3C53 Level of movement segment 13 lumbar vertebrae.4 Number of active trigger points (2) Evaluate related dorsal segment (D6, D12)5: Movement and methameric level alterations (3) Evaluate breathing pattern and chest movement: Evaluate synchronicity, rhythm and amplitude. I usually combine stretching and myofascial release techniques for the diaphragm,6 manipulative techniques for the dorsal segment5 and low-force techniques for chest movement.7 To finish the session, I work with relaxation techniques combined with breathing. This is highly therapeutic, and patients feel deeply relaxed.

5. Hein T. Some effects of chiropractic manipulation on reflux oesophagitis: A case report. Br J Chiropract 1999;3:5961. 6. Anders J. Myofascial release techniques and connective tissue massage. Integr Sports Massage Ther 2011:139160

7. Young MF, McCarthy PW, King S. Chiropractic manual intervention in chronic adult dyspepsia: A pilot study. Clin Chiropract 2009;12:2834.

Marie Carmen Valenza, MSc, PT Physiotherapy Department, Faculty of Health Sciences, Granada University, Granada, Spain

Yoga
Indigestion is a broad term that covers functional dyspepsia and bowel-motility disorders that affect digestion of a meal or cause abdominal discomfort. Motility abnormalities, visceral hypersensitivity, anxiety, excessive gastric-acid secretion, Helicobacter pylori, genetics, environment, diet, a sedentary lifestyle, and infections have been implicated in the pathogenesis of indigestion.1 Psychologic stress and anxiety have been found to be important predictors for overlapping symptoms of dyspepsia and irritable bowel syndrome that predominantly cause indigestion.2 Yoga is an ancient mindbody intervention that has shown benefits in various clinical conditions in which stress is believed to play a role.3 Yoga defines indigestion as a psychosomatic problem with its origin being imbalances in the mind. Increased emotional sensitivity and anxiety causes increased visceral sensitivity, abnormal intestinal tone and motility, faster gastric emptying, and increased acid secretions.4 This is compounded by infections that further compromise the gut barrier and increase visceral sensitivity, setting off a vicious cycle. In yoga texts, indigestion is referred to as stagnated Prana and Samana energy that leads to a building up of bile and acidic secretions (Pitta dosha). Yogasanas, such as Trikonasana, Uttanapadasana, Pawanamuktasana, Sarvangasana, Bhujangasana, Dhanurasana, Shashankasana, Paschimottanasana, and

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Ushtrasana help improve the tone of the abdominal wall and intestinal muscles, and may help reduce symptoms of irritable bowel syndrome.57 Pranayama or regulated nostril breathing such as Shitali and Shitakari are especially useful for addressing heartburn and gastroesophageal reflux disease. Suryanadi pranayama (right nostril breathing) is useful for improving sympathetic tone but should not be done when one has gastritis.8 Yogic texts also advocate a vegan diet and lifestyle regimen as being important for managing indigestion. References
1. Miwa H, Watari J, Fukui H, et al. Current understanding of pathogenesis of functional dyspepsia. J Gastroenterol Hepatol 2011;26(suppl3):5360. 2. Lee SY, Lee KJ, Kim SJ, Cho SW. Prevalence and risk factors for overlaps between gastroesophageal reflux disease, dyspepsia, and irritable bowel syndrome: A population-based study. Digestion 2009;79:196201.

3. Ross A, Thomas S. The health benefits of yoga and exercise: A review of comparison studies. J Altern Complement Med 2010;16:312. 4. De la Roca-Chiapas JM, Sols-Ortiz S, Fajardo-Araujo M, et al. Stress profile, coping style, anxiety, depression, and gastric emptying as predictors of functional dyspepsia: A case-control study. J Psychosom Res 2010;68:7381. 5. Taneja I, Deepak KK, Poojary G, et al. Yogic versus conventional treatment in diarrhea-predominant irritable bowel syndrome: A randomized control study. Appl Psychophysiol Biofeedback 2004;29:1933. 6. Kuttner L, Chambers CT, Hardial J, et al. A randomized trial of yoga for adolescents with irritable bowel syndrome. Pain Res Manag 2006;11:217223.

from a motility disturbance, a psychiatric disorder, or some other unknown cause. In a patient with no alarm symptoms, it is important for us to ascertain why he or she, with long-standing symptoms, has presented on this occasion for care. We explain the meaning of the symptoms and their benign nature. We give education about diet. Reassurance and education may help some individuals. We test and treat for Helicobacter pylori. If symptoms do not resolve, an empirical trial of acid suppression with a proton pump inhibitor is prescribed. Prokinetic agents may be helpful for many patients. In addition, we try herbal medicine. For example, we recommend sipping a tea glass of hot water to which is added a teaspoonful of honey and a half of a pressed lemon, after meals. For individuals with postprandial bloating, especially bloating that is aggravated by stress, we offer a cup of anise, balm, fennel, or daisy tea three times a day. Drinking 2 teaspoonfuls of sodium bicarbonate, dissolved in a glass of water, after meals, can relieve symptoms. Also, we recommend yoga, a form of exercise that has been proven to reduce stress.4 n References
1. Metz DC. Dyspepsia. In: Brandt LJ, ed. Clinical Practice of Gastroenterology, vol. 1. Philadelphia: Churchill Livingstone, 1999:226235.

2. Talley NJ, Vakil N. Guidelines for the management of dyspepsia. Am J Gastroenterol 2005;100:23242337. 3. Fisher RS, Parkman HP. Management of nonulcer dyspepsia. N Engl J Med 1998;339:13761381. 4. Bernice CS. Coping with stress. Stress Med 1991;7:6163.

7. Gupta N, Khera S, Vempati RP, et al. Effect of yoga based lifestyle intervention on state and trait anxiety. Indian J Physiol Pharmacol 2006;50:4147.

8. Raghuraj P, Telles S. Immediate effect of specific nostril manipulating yoga breathing practices on autonomic and respiratory variables. Appl Psychophysiol Biofeedback 2008;33:6575.

Raghavendra Mohan Rao, BNYS, PhD Consultant to Institute of Naturopathy and Yogic Sciences Medical Research Society, Bangalore, India

Aye Selda Tekiner, MD, and Aye Glsen Ceyhun Peker, MD Family Medicine Department, Ankara University School of Medicine, Ankara, Turkey

Turkish Practice
Indigestion, or dyspepsia, is a symptom complex of major importance, because it affects a large proportion of the population.1 It accounts for about 15% of our outpatients. After patients are evaluated for typical presentation of dyspepsia, most remain undiagnosed.2,3 These patients are generally labeled as having functional dyspepsia. Functional dyspepsia may result

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