If tests are normal but heartburn recurs — The story of Cheongwisan

After meals, my epigastrium feels heavy. I feel full even after eating a small amount. Some days, my epigastrium burns, waking me from sleep. I had an endoscopy, but the results stated "no specific findings."

This condition has a name: functional dyspepsia. There are diagnostic criteria and clinical guidelines. What remains unclear is what comes next. We've addressed how long acid suppressants should be taken, why symptoms worsen again after stopping them, and how Korean medicine views the condition.

What the "No abnormalities" result means

Rome IV criteria define functional dyspepsia as the presence of one or more of postprandial fullness, early satiety, epigastric pain, or epigastric burning that started at least 6 months ago and has persisted for the last 3 months. If fullness is present 3 or more days a week, it is postprandial distress syndrome (PDS); if pain or burning is present 1 or more days a week, it is epigastric pain syndrome (EPS).

In a telephone survey of 5,000 people aged 20-69 in Korea, the prevalence of undiagnosed dyspepsia was 7.7%. Conversely, among 2,700 people who underwent endoscopy for dyspepsia, 23% were found to have organic diseases.

The 2020 revised clinical guidelines list weight loss, dysphagia, signs of bleeding (melena, anemia), persistent vomiting, and family history of gastric cancer as warning signs, recommending additional examinations regardless of age if any one is present (strong recommendation grade). If such signs are present, medical consultation takes precedence over any other method, including Korean herbal medicine.

The sequence set by guidelines

Proton pump inhibitors (PPIs) have a 'strong' recommendation grade and 'high' evidence level. In a meta-analysis of 8 randomized controlled trials involving 2,216 people, 36% of the treatment group and 30% of the placebo group improved, with a relative risk of 1.41 and an NNT of 9 people. Since there was no difference from placebo in less than 4 weeks, 8 weeks of administration is recommended.

The findings differ by subtype. The relative risk of PPIs in EPS was significant at 1.22, but not significant in PDS at 1.56 (0.91–2.70). For those whose main symptom is postprandial fullness, gastrointestinal prokinetics are considered first, and dopamine receptor antagonists are limited to a few days to 1 week of use.

What happens when you stop, and Helicobacter

H2 blockers are recommended only for short periods due to tachyphylaxis. What about PPIs? A 2009 double-blind study in 『Gastroenterology』 administered esomeprazole 40mg to 120 healthy volunteers for 8 weeks, then switched them to placebo for 4 weeks. The proportion of new acid-related symptoms reported 9-12 weeks after discontinuation was 44% (26/59 people) in the PPI group and 15% (9/59 people) in the placebo group. The key point is not that PPIs are harmful, but that discomfort at the time of discontinuation is not necessarily a sign that the disease remains unchanged.

Helicobacter eradication showed a relative risk of 1.18 (1.07–1.31) and an NNT of 14 people in 18 studies followed for 6 months or more. However, in Asia, it was not significant at 1.10. The recommendation grade for dietary control is also 'weak'. Society data reports that high-fat diets triggered symptoms in up to 80% and flour-based foods in up to 93%, but adds that excessive restriction can reduce nutrition and quality of life.

Korean medicine distinguishes between stomach heat and spleen-stomach weakness

Korean medicine also does not view indigestion as a single entity. Those who experience epigastric burning, dry mouth, and seek cold things are seen as having stomach heat (Wi-yeol) and are treated with methods that clear heat. Those who feel full after eating little and experience fatigue after meals are seen as having spleen-stomach weakness (Biwi-heoyak) and are treated with methods that support and strengthen. The directions are opposite, so reversing the order would be incorrect.

In a retrospective chart review of 192 patients, the pattern differentiation types were in the order of Spleen Qi Deficiency (Bi-gi-heo) 33.3%, Damp-Phlegm Syndrome (Seup-dam-jeung) 24.0%, Spleen Deficiency with Qi Stagnation (Bi-heo-gi-che) 17.7%, and Liver Qi Stagnation (Gan-ul-gi-che) 14.1%. These names are not disease diagnoses but frameworks for categorizing body conditions.

A 2023 Cochrane review compiled 41 relevant studies involving 4,477 people and reported symptom improvement for some herbal medicines, but concluded that the certainty of evidence varied widely and some herbs could worsen symptoms. Safety is not guaranteed simply because something is a natural product.

The place of Cheongwisan

Cheongwisan (淸胃散) is a Korean medicine prescription formulated directly by jaimdang Korean Medicine Clinic. It combines Coptis (Hwangnyeon) used for stomach heat, Peony (Jak-yak) and Licorice (Gamcho) to soothe cramping sensations, Citrus Peel (Jinpi) and Magnolia Bark (Hubak) used for qi stagnation and bloating, and Atractylodes (Baekchul) and Poria (Bokryeong) to support the foundation of digestion, based on the Jun-Sin-Jwa-Sa (君臣佐使) principle. It does not share the same mechanism as acid-suppressing drugs, nor is it designed to replace PPIs.

Preparation takes place at an off-site herbal dispensary in Paju, Gyeonggi Province. Standardized herbal ingredients are quantified for marker compounds by HPLC, undergo self-inspection for heavy metals and residual pesticides, and are then decocted through a process with controlled temperature, time, and pressure. After batch-specific quality control, lot numbers are affixed to stick pouches. The process is detailed in [Off-site Herbal Dispensary and Herbal Medicine Quality](/en/journal/wonoe-tangjeon-quality).

The decision to take it and for how long is determined after consultation and review by a Korean medicine doctor. If you are taking antacids or PPIs, please inform us. The procedure is outlined in [Non-face-to-face Korean Herbal Medicine Prescription Guide](/en/journal/bidaemyeon-hanyak-guide).

Four things to prepare before your consultation

• Note the type and frequency of symptoms — whether it's more about fullness or pain. 3 days a week and 1 day a week, and 6 months and 3 months are the baselines.
• Keep a 2-week food diary — see if symptoms coincide with high-fat foods, flour-based foods, coffee, or alcohol.
• List all medications you are taking, including ingredient names — including the dosage and duration of PPIs/H2 blockers, and whether you are taking NSAIDs or anticoagulants.
• Check for warning signs first — if you have weight loss, dysphagia, melena, anemia, or persistent vomiting, immediate medical consultation is a priority.

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References

• Oh JH et al., 「기능성 소화불량증의 임상 진료 지침 개정안 2020」(Revised Clinical Practice Guidelines for Functional Dyspepsia 2020), 『대한내과학회지』 96(2), 2021
• Chung KW, 「로마 기준 IV 이해하기: 위십이지장 질환」(Understanding Rome IV Criteria: Gastroduodenal Disorders), 『대한내과학회지』 92(4), 2017
• Park JK et al., 「기능성 소화불량증의 최근 동향」(Recent Trends in Functional Dyspepsia), 『대한소화기학회지』 64(3), 2014
• Reimer C et al., PPI therapy induces acid-related symptoms after withdrawal, 『Gastroenterology』 137(1), 2009
• Báez G et al., Non-Chinese herbal medicines for functional dyspepsia, 『Cochrane Database Syst Rev』, 2023

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*This article is for informational purposes only and does not guarantee the diagnosis or treatment efficacy of specific diseases. The decision to take Cheongwisan is made through consultation and prescription by a Korean medicine doctor, and responses may vary by individual. If warning signs such as weight loss, dysphagia, melena, anemia, or persistent vomiting are present, immediate medical consultation is required.*