How to manage a patient with chronic cough and epigastric hernia, considering their complex medical history and current medications?

Management of Chronic Cough with Epigastric Hernia

The patient's chronic cough requires intensive treatment of suspected GERD with a proton pump inhibitor twice daily, dietary modifications, and prokinetic therapy, while the symptomatic epigastric hernia should be referred for surgical evaluation due to its size and impact on quality of life.

Chronic Cough Assessment and Management

Likely Diagnosis and Approach

The patient presents with a chronic cough (3 weeks duration) that occurs annually around seasonal changes, with green-yellow sputum production. Given the clinical profile (non-smoker with normal chest examination except for mild crackles), the most likely causes include:

1. GERD-related cough (exacerbated by epigastric hernia)
2. Lower respiratory tract infection
3. Possible allergic/seasonal component

GERD-Related Cough Management

The patient's epigastric hernia and cough pattern strongly suggest GERD as a contributing factor. GERD is one of the three most common causes of chronic cough in non-smokers with normal chest X-rays 1.

Recommended Treatment:

• Optimize PPI therapy: Increase omeprazole to 40mg twice daily before meals for at least 8 weeks 2, 1
• Add prokinetic therapy: Metoclopramide 10mg three times daily 2, 1
• Implement strict antireflux diet:
  • Limit fat intake to <45g/24 hours
  • Avoid coffee, tea, soda, chocolate, mints, citrus products, tomatoes, alcohol
  • Avoid vigorous exercise that increases intra-abdominal pressure 2

Important Considerations:

• The patient is already on omeprazole but likely needs dose optimization
• A normal esophagoscopy (if performed) would not rule out GERD as a cause of cough 2
• If cough persists after 3 months of intensive therapy, consider 24-hour esophageal pH monitoring 2, 1

Infectious Component Management

Given the productive green-yellow sputum:

• Consider a short course of antibiotics targeting common respiratory pathogens
• A 5-day course of moxifloxacin 400mg daily or azithromycin (500mg day 1, then 250mg daily for 4 days) would be appropriate 3

Allergic/Seasonal Component

Since the cough occurs annually around seasonal changes:

• Consider a trial of second-generation antihistamine
• If upper airway symptoms are prominent, add a 1-month trial of intranasal corticosteroid 2, 1

Epigastric Hernia Management

Assessment

The patient has a large epigastric hernia (12cm × 7cm) that:

• Is symptomatic during coughing episodes
• Causes significant pain
• Impacts daily activities
• Is reducible and non-tender when not coughing

Recommendations:

• Surgical referral is indicated due to:

  • Large size (12cm × 7cm)
  • Symptomatic nature
  • Impact on quality of life
  • Potential for complications with chronic cough 4, 5

• Surgical approach: A tension-free repair using polypropylene mesh is the preferred approach for epigastric hernias, with lower recurrence rates than traditional techniques 5

• Pre-surgical optimization:

  • Control cough to reduce strain on the hernia
  • Avoid heavy lifting (patient already aware of hernia worsening with bench press)

Additional Considerations

Medication Review

• The patient is on multiple medications that could impact management:
  • Sotalol (recently replaced amiodarone) - monitor for respiratory effects
  • Dabigatran - will need to be managed perioperatively if hernia surgery is planned
  • No ACE inhibitors noted (which could cause cough)

Special Considerations

• Upcoming ablation surgery: Coordinate hernia management with cardiac team
• Hyperthyroidism: Ensure thyroid function is optimized as this can affect cough
• Diabetes management: Monitor during any antibiotic therapy

Follow-up Plan

1. Initiate intensive GERD therapy immediately
2. Review in 4 weeks to assess cough response
3. If no improvement after 8 weeks of intensive therapy, consider:
   • 24-hour esophageal pH monitoring
   • High-resolution CT chest to exclude other pathologies
4. Surgical consultation for the epigastric hernia repair
5. Coordinate timing of hernia repair with cardiac ablation procedure

Pitfalls to Avoid

• Inadequate duration or dosing of PPI therapy (minimum 8 weeks at twice daily dosing)
• Failing to address all components of treatment (medication, diet, lifestyle)
• Delaying surgical referral for symptomatic hernia that impacts quality of life
• Not considering the interaction between chronic cough and hernia symptoms

The combination of chronic cough and epigastric hernia creates a vicious cycle where each condition exacerbates the other. Breaking this cycle requires aggressive management of the cough while planning definitive treatment for the hernia 4, 6.