When your endoscopy is normal, but your stomach hasn't had a single good day

Stomach troubles that don't show up on tests have reasons, and they have types

Key points in 30 seconds

1. Among people tested for indigestion, in more than three out of four, no lesion is found that explains it. The same goes for reflux: in many cases the symptoms are clear, but no damage to the lining can be seen.
2. An endoscopy is a test that looks at the "structure" of the stomach and esophagus. But for these people, the problem isn't structure. It lies in movement, sensation, and the connection between the gut and the brain.
3. It makes sense that a test for structure doesn't pick up a problem of function. Getting an upset stomach when you're stressed isn't in your head. It's a real mechanism.
4. Within the same "my stomach feels off," there are types. The kind that starts when you eat, the kind that hurts on an empty stomach, and the kind that comes up when you lie down. Different types mean different things to check and different evidence for treatment.
5. However, if you're losing weight, having trouble swallowing, or passing black stools, an endoscopy comes first, not treatment.

What we often hear

• "I've barely had a few bites, and my upper stomach already feels bloated and blocked."
• "My stomach burns when it's empty, and eating a little seems to help for a while."
• "The moment I lie down, sour stuff comes up, so I sleep with my pillows stacked."
• "I'm fine on stomach medicine, but when I stop, it starts again within a week or two."
• "They say my endoscopy is clean, and that makes it even more frustrating. Then why am I like this?"

What people who come to us with digestive symptoms have in common is that the tests and their body are saying different things.

The tests say you're normal, yet your body is uncomfortable every day. Then someone says "it's just nerves," and you start to feel like you're being treated as if you're faking it.

Let's set that straight first. A normal test doesn't mean your symptoms aren't real.

It's not a problem of structure, but of function and sensation

Among people tested for indigestion, in more than three out of four, no lesion is found that explains it. Reflux symptoms are similar: in many cases the symptoms are clear, yet the endoscopy shows no damage to the lining of the esophagus.

An endoscopy is a test that looks at the "structure" of the stomach and esophagus.

But for these people, the problem isn't structure. It lies in movement and sensation, and the connection between the gut and the brain. That means how the stomach receives food and moves it along, and nerves that have become oversensitive.

It makes sense that a test for structure doesn't pick up a problem of function. That's why gastroenterology today sees these problems as disorders of the two-way communication between the gut and the brain.

Getting an upset stomach when you're stressed isn't in your head. It's a real mechanism.

Even "my stomach feels off" comes in types

The kind that starts when you eat. Bloating after meals lasts a long time, and you feel full after eating only a little. We look at how your stomach receives and moves food along, together with how fast you eat.

The kind that hurts on an empty stomach. Your upper stomach aches and burns when you're hungry. We look at stomach acid, oversensitive sensation, and the spacing between meals.

The kind that comes up when you lie down. Sour reflux and heartburn come especially when you lie down or after you eat. We look at the gap between your last meal and bedtime, your weight, and nighttime symptoms.

This sorting alone doesn't define the condition. Many people have overlapping types. But this distinction, one step deeper than "I have indigestion," is the starting point for deciding which evidence to use where. We've written up how to tell them apart separately.

First, we rule out what needs ruling out

Unintended weight loss, trouble swallowing, repeated vomiting, black or bloody stools, anemia, or symptoms appearing for the first time after middle age.

In these cases, an endoscopy comes first, not treatment. The same applies if you've never been tested or your last test was long ago: referring you to a facility that can do the test comes before our treatment.

Our role begins after structural disease has been ruled out.

We won't make you stop your medication

Medicine that suppresses stomach acid is an effective first-line treatment for reflux.

And it has been shown, in a trial of healthy people who had no reflux symptoms at all, that stopping suddenly can cause a rebound that makes symptoms worse. After stopping the medicine, 44% developed acid-related symptoms, compared with 15% of those who took only a placebo.

So for adjusting your medication, we ask you to talk with the place that prescribed it. Rather than competing with medication, we take on what medication doesn't address: function and sensation, rhythm, and lifestyle factors.

We examine what numbers don't show, in a structured way

With abdominal diagnosis, we check where there is tension and tenderness in your upper stomach and abdomen. With tongue and pulse diagnosis we look at your overall condition, and with blood tests and a body composition test we check the metabolic and nutritional factors tied to digestion.

The more normal the tests, the more this structured examination becomes the map for treatment.

We tell you about the evidence at its actual size

There is a clinical trial that compared real and sham acupuncture in 278 patients with the type that starts when you eat. Differences were found in the rate of response to treatment and the rate of symptoms going away, and the effect lasted up to 12 weeks.

For reflux not controlled by medication, there's a trial in which adding acupuncture did better than doubling the medication. It was a small trial, though, with about 30 people.

In a trial comparing Yukgunja-tang (an herbal formula) with a placebo, improvement in symptoms moved in step with improvement in anxiety scores.

We explain separately what these studies showed and what they didn't, including their size and any disappointing results. If you'd like to see them with the literature, we've written them up in the indigestion post and the reflux post.

Treatment follows this order

First, we rule things out. We check for warning signs and your endoscopy history, and sort the type based on when your symptoms happen. We assess your condition with abdominal, tongue and pulse diagnosis, plus blood and body composition tests. If you need a test first, we start by referring you for one.

Second, we treat according to type and write lifestyle changes as a prescription. We build treatment from acupuncture and electroacupuncture, and herbal medicine matched to your abdominal and test findings. Things whose effect has been confirmed in numbers, like the gap between dinner and bedtime, the height of the head of your bed, a weight goal, and eating speed, we set as a prescription, not as advice, and check at your follow-up visit (three things for people whose reflux comes up at night).

If sleep and stress are tangled up in it, we look at both. A stomach whose nights have fallen apart won't recover with daytime treatment alone.

Third, we check with measurement scales. We record your symptom score when treatment begins and measure again at set points. If there's no response, we don't keep repeating the same treatment; we go back and review the diagnosis and type. If needed, we recommend seeing a gastroenterologist.

What changes

A lunch where you choose from the menu by taste, not by symptoms. A night where you sleep lying flat on a single pillow. A dinner table where the nightly "should I take my medicine or not" question is gone.

That ordinary meal and that ordinary night are what we're aiming for.

How people respond to treatment differs depending on the type, how long they've had symptoms, and related factors like weight, sleep and stress.

Just one thing before you come in

Try going one step deeper than "I have indigestion."

Is yours the kind that starts when you eat, the kind that hurts on an empty stomach, or the kind that comes up when you lie down?

If you bring that answer with you, your visit will go much faster. The order in which we examine the stomach is laid out in our treatment guide.

For questions or appointments, message us in English through the messenger at the bottom right of the page, or call +82-53-716-1175.