What is the best course of treatment for a patient with worsening gastritis and symptoms of anxiety and stress?

Management of Gastritis with Anxiety and Stress Components

For a patient with worsening gastritis and symptoms of anxiety and stress, the recommended treatment approach is to optimize PPI therapy to 20mg omeprazole once daily taken 30-60 minutes before a meal, address work-related stress through stress management techniques, and consider referral for psychological support if symptoms persist.

Diagnosis and Assessment

Based on the patient's presentation, this appears to be a case of functional dyspepsia (FD) with significant stress-related components:

• Long-standing history of gastritis worsened over 3-4 weeks
• Symptoms worse on empty stomach and with delayed meals
• Symptoms improved with omeprazole
• Associated anxiety symptoms (panic, poor sleep, claustrophobic feeling)
• Significant work-related stress (long hours, pressure)

Treatment Plan

1. Optimize PPI Therapy

• Standardize omeprazole dosing: 20mg once daily taken 30-60 minutes before breakfast 1
  • The patient has been taking omeprazole PRN but has needed it daily for the past 10 days
  • Higher doses (40mg) previously caused restlessness
  • Current FDA guidelines support 20mg daily for up to 4 weeks for symptomatic GERD 1

2. Patient Education

• Explain the gut-brain connection and how stress can exacerbate gastric symptoms 2
• Validate that both gastrointestinal and psychological symptoms are real and interconnected 2
• Discuss the physiological basis of symptoms to frame expectations about response to treatment 2

3. Lifestyle Modifications

• Dietary adjustments:

  • Continue avoiding trigger foods (spicy, oily, fried foods)
  • Avoid meals within 3 hours of bedtime 2
  • Maintain regular meal times to prevent symptoms from empty stomach

• Stress management:

  • Implement regular aerobic exercise 2
  • Introduce relaxation techniques and mindfulness practices 2
  • Address work-life balance (discuss reasonable working hours)

4. Consider Psychological Support

• If symptoms persist despite optimized PPI therapy and lifestyle changes, consider referral for psychological support 2
• Options include:
  • Cognitive behavioral therapy
  • Stress management techniques
  • Relaxation therapy 2

Monitoring and Follow-up

• Reassess symptoms after 4 weeks of standardized treatment 2
• If inadequate response, consider:
  1. Increasing to twice daily dosing of omeprazole 2
  2. Referral to gastroenterology for further evaluation
  3. Formal psychological assessment for anxiety management

Special Considerations

• Avoid long-term continuous high-dose PPI use: Research shows alternate-day dosing may maintain remission while reducing risk of sustained hypergastrinemia 3
• Watch for psychological comorbidities: Recent research shows high prevalence of anxiety (36.4%) and depression (25.4%) in patients with chronic gastritis 4
• Poor sleep quality is strongly associated with both anxiety and depression in gastritis patients 4, making sleep hygiene an important component of treatment

Caution

• Avoid opioids for pain management in patients with functional GI disorders 2
• Be cautious with restrictive diets that may lead to nutritional deficiencies 2
• If symptoms persist or worsen despite treatment, consider endoscopy to rule out other conditions, especially in patients >55 years 2