Morning Stomach Discomfort
Hunger pangs and at times rumbling noises from the stomach are common occurrences in the morning. Most people do not eat within 2 to 3 hours before bedtime and during sleep the body’s energy needs are much lower. By the time the morning arrives, some 10 to 12 hours have passed without eating. The body therefore signals its need for food with hunger pangs and stomach noises. In some cases though there are distinct upper gastrointestinal symptoms involving the food pipe (esophagus), stomach and the first part of the small intestine (duodenum) which may be due to an underlying problem. The signals in these cases are symptoms of a disease and need to be investigated further.
Sometimes these signals are not subtle and the symptoms can be severe and cause distinct discomfort and pain. For the majority of people, however, these symptoms are so mild that it is difficult to isolate it as being due to a disease. Many people with these symptoms pass it off as morning hunger, or even a slight case of minor indigestion, but differentiating these disease symptoms from the normal signals is imperative for seeking early medical attention and having the underlying condition diagnosed. Some of these underlying conditions can actually increase the risk of cancer in the stomach and upper gut in the long term and early diagnosis and rapid treatment is therefore vital.
Types of Morning Symptoms
Waking up in the morning and experiencing hunger pangs and stomach noises (boborygmi) are considered normal to some extent. However, the following needs to be investigated further as a possible cause of upper gastrointestinal problems :
- Hunger pains (not pangs) although stomach pain and nausea are commonly confused with hunger pangs.
- Stomach noises that are excessively loud and constant.
- Stomach ache, burning stomach and/or stomach pain – often felt as left upper abdominal pain.
- Heartburn – burning chest pain or central chest pain
- Extremely offensive morning breath even with good dental hygiene in the morning and night
- Intense nausea that can either cause a loss of appetite or lead to vomiting
Other symptoms such as a morning sore throat, sour taste in the mouth, excessive belching, abdominal distention and cramps may also be present.
Causes of Morning Stomach Symptoms
The various causes of morning stomach symptoms, which may actually involve any part of the upper gastrointestinal tract, is most commonly due to :
- Gastroesophageal reflux disease (GERD)
- Peptic ulcer disease (PUD)
These conditions are largely associated with changes in stomach acid production which tends to peak at night. In severe cases the symptoms of these conditions may disturb sleep but in the large majority of cases it remains unnoticed at night. The only indication thereof is upon waking in the morning and experiencing one or more of the symptoms described above. These possible causes of morning stomach symptoms, or more correctly upper gastrointestinal symptoms in the morning upon waking, are therefore largely related to each other.
Reasons for Morning Stomach Symptoms
It is important to have a basic understanding of the alimentary tract. Food enters through the mouth, passes down the throat and travels through the esophagus (food pipe) to the stomach. Here it is churned and mixed with stomach acid and enzymes. Once the food is partially digested, it is released as a thick fluid (chyme) into the small intestine.
As mentioned above, many of the morning stomach symptoms are associated with stomach acid. This highly corrosive substance is produced by specialized cells in the inner wall of the stomach. Although it is capable of digesting human tissue, the body and in particular the stomach, has different mechanisms to prevent the acid from damaging the gut. The stomach has a thick layer of mucus that coats its inner wall and acts as a barrier against the action of the stomach acid.
Normally the stomach acid is isolated to the stomach cavity, with small amounts being passed out in a controlled manner into the duodenum (first part of the small intestine). The duodenum has its own mechanisms to rapidly neutralize moderate amounts of stomach acid. However, problems arise when the :
- mucus barrier becomes compromised,
- excessive amounts of stomach acid are produced,
- stomach acid flows backward into the esophagus,
- duodenum’s mechanisms cannot rapidly neutralize the incoming acid.
This causes irritation of the inner mucosal lining of the gut known as esophagitis, gastritis and duodenitis when it affects the esophagus, stomach and duodenum respectively. In severe cases and with certain contributing factors, small open sores may form in the inner lining and these are known as ulcers. Various other complications can arise from these disruptions in normal upper gastrointestinal functioning although most of the problem revolves around the stomach acid. In the long term, these complications may give rise to serious and life threatening disorders such as cancer.
- Acid reflux or gastroesopohageal reflux disease (GERD) is the backward flow of stomach acid into the esophagus. It is mainly caused by a weak lower esophageal sphincter (LES) – the part of the lower esophagus that is supposed to prevent this backward flow. Acid in the esophagus leads to esophagitis. Heartburn which is a burning chest pain is the typical symptom. Other symptoms may include water brash where excessive saliva is released to counteract the acid, morning sore throat when the acid reaches as high as the throat and a sour taste in the mouth. Sometimes with silent acid reflux there is no heartburn yet the other symptoms may be present particularly in the morning.
- Esophagitis is inflammation of the wall of the esophagus especially the inner mucosal lining most often caused by the presence of stomach acid due to GERD. Although the inflammation may quickly subside, the recurrent acid reflux particularly at night exacerbates the condition again. Symptoms include a gnawing chest pain sometimes right up to the esophagus with burning after eating, at night and upon waking. Eventually this can cause localized narrowing of the esophagus (esophageal strictures) and the formation of ulcers (esophageal ulcers).
- Esophageal ulcers are a less common feature of peptic ulcer disease. Here open sores form in the lining of the stomach as a result of chronic acid reflux and many of the same causes seen with gastritis (stomach inflammation discussed below). Sharp pain may be felt at the site of the ulcers, which are usually located in the lower esophagus, and this pain is often aggravated at night, when hungry and shortly after eating.
- Gastritis is inflammation of the stomach wall, usually isolated to the inner mucosa but sometimes extending deeper into the middle layers of the wall. The two most common causes are H.pylori infection and excessive use of NSAIDs. The stomach pain varies from a dull gnawing ache to a persistent sharp stabbing pain. Typically the symptoms worsen after eating and there may be changes in the appetite. Other symptoms may include nausea, indigestion and excessive belching. Symptoms tend to worsen at night while sleeping.
- Stomach ulcers are open sores that develop in the inner lining of the stomach wall often as a complication of long term and untreated gastritis. It may therefore arise for the same reasons as gastritis. The pain is usually more intense than with gastritis often leading to appetite changes as the pain tends to worsen after eating and when hungry. Stomach ulcers are a part of peptic ulcer disease with duodenal ulcers also being present at times.
- Duodenitis is inflammation of the duodenum that arises with many of the same causes as gastritis. It may be acute or chronic. Symptoms are largely the same as gastritis including epigastric pain (upper middle abdominal pain), changes in appetite, excessive belching and nausea. Chronic duodenitis often leads to duodenal ulcers. Conditions such as gallstones and pancreatitis may cause symptoms that are similar to duodenitis.
- Duodenal ulcers are open sores that form in the inner lining of the duodenal wall. It is a part of peptic ulcer disease (PUD) and may occur with stomach ulcers. Symptoms are similar to duodenitis with the pain often being more intense, aggravating at night, with eating and when hungry. Duodenal ulcers are more common than stomach ulcers.
Various other causes may be responsible for morning stomach symptoms. However, many of these conditions do not specifically result in an exacerbation of the symptoms in the morning or upon waking. These causes include :
- Barret’s esophagus
- Clostridium difficile infection
- Crohn’s disease (inflammatory bowel disease)
- Gastric outlet obstruction syndrome
- Irritable bowel syndrome
- Liver disease
- Zollinger-Ellison syndrome