What is the diagnosis and treatment for a 69-year-old female presenting with epigastric pain, inability to eat, and a computed tomography (CT) scan showing a small hiatal hernia and gastritis?

From the Guidelines

For a 69-year-old female with epigastric pain, inability to eat, and CT findings of a small hiatal hernia and gastritis, I recommend starting a proton pump inhibitor (PPI) such as omeprazole 40mg once daily before breakfast for 8 weeks, as this approach is supported by recent guidelines 1. The patient's symptoms and CT findings suggest acid reflux and gastritis, which can be effectively managed with PPI therapy and lifestyle modifications. Some key points to consider in the management of this patient include:

• The importance of lifestyle modifications, such as elevating the head of the bed 6-8 inches, avoiding eating within 3 hours of bedtime, eliminating trigger foods (spicy, acidic, fatty), and maintaining a healthy weight, as these changes can help prevent acid reflux associated with the hiatal hernia.
• The use of antacids like Maalox or Mylanta for immediate symptom relief, as needed.
• The consideration of further evaluation with an upper endoscopy if symptoms persist beyond 2 weeks of PPI therapy, to better characterize the gastritis and rule out other conditions.
• The potential for tapering the PPI to 20mg daily for 2 weeks before discontinuation if symptoms completely resolve after 8 weeks. It is also important to note that avoiding NSAIDs and alcohol is crucial, as these can worsen gastritis, and that the patient's response to therapy should be closely monitored to determine the best course of action. Additionally, the patient's age and symptoms suggest the need for careful evaluation and management to prevent complications and improve quality of life, as highlighted in recent studies 1.

From the FDA Drug Label

INDICATIONS AND USAGE Ranitidine tablets USP are indicated in: ... 6. Treatment of GERD. Symptomatic relief commonly occurs within 24 hours after starting therapy with ranitidine 150 mg twice daily. Concomitant antacids should be given as needed for pain relief to patients with active duodenal ulcer; active, benign gastric ulcer; hypersecretory states; GERD; and erosive esophagitis.

The patient has a small hiatal hernia and gastritis, which can be associated with GERD. Ranitidine may be used for the treatment of GERD, and symptomatic relief can occur within 24 hours. Additionally, concomitant antacids can be given as needed for pain relief.

• The patient's epigastric pain and inability to eat may be managed with ranitidine and antacids.
• However, the patient's specific condition of gastritis is not directly addressed in the label, but gastric ulcer is, and ranitidine is indicated for the short-term treatment of active, benign gastric ulcer. 2

From the Research

Patient Presentation

• A 69-year-old female presents with epigastric pain and is unable to eat.
• A CT scan reveals a small hiatal hernia and gastritis.

Relevant Studies

• A study from 2006 3 found that proton pump inhibitors (PPIs) were effective in relieving symptoms of hiatal hernia after open heart surgery.
• Another study from 2010 4 compared the efficacy of PPIs, H2-receptor antagonists (H2RAs), and prokinetics in adults with gastro-oesophageal reflux disease (GORD) and found that PPIs were more effective than H2RAs in relieving heartburn.
• A study from 1998 5 investigated the effect of treatment with PPIs on the efficacy of H2RAs in Helicobacter pylori-negative patients and found that treatment with PPIs reduced the effect of H2RAs.

Management of Incidental Findings

• A white paper from 2010 6 provides guidance on managing incidental findings on abdominal CT scans, including those related to the gastrointestinal tract.
• The paper emphasizes the importance of standardizing the approach to managing incidental findings to limit costs and reduce risk to patients.

Helicobacter pylori Infection and PPIs

• A study from 1998 7 discussed the antibacterial activity of PPIs against Helicobacter pylori and their potential anti-inflammatory effects.
• The study found that PPIs, particularly lansoprazole, possess antibacterial activity against H. pylori and may exert an anti-inflammatory effect by interfering with the cellular immune response to infection.