I am a young adult student diagnosed with NSAID‑induced gastritis four weeks ago, treated with Nexium (esomeprazole) 40 mg daily for three weeks then stopped; after a large fatty dinner I now have heartburn, upper‑abdominal soreness, and intense hunger briefly relieved by Tums (antacid). Could this be rebound acid hypersecretion or stress‑related gastritis, and how should I manage it?

Rebound Acid Hypersecretion After Nexium Discontinuation

Your symptoms are most likely rebound acid hypersecretion (RAHS) triggered by stopping Nexium after 3 weeks of daily use, compounded by stress from your midterms and a high-fat, acidic trigger meal—not a recurrence of your underlying gastritis. 1, 2

Understanding What's Happening

Rebound Acid Hypersecretion Mechanism

• Daily PPI exposure for more than 4 weeks triggers rebound acid hypersecretion approximately 15 days after discontinuation, lasting from a few days to several weeks depending on exposure duration 2
• While you were on Nexium for only 3 weeks (just under the typical 4-week threshold), you had a previous summer episode requiring 4 weeks of treatment, so your cumulative PPI exposure may have primed your system for RAHS 2
• RAHS occurs because PPIs cause compensatory parietal cell and ECL-cell hyperplasia during treatment; when the PPI is withdrawn, these hyperplastic cells produce excessive acid for 2-6 months until they regress 1, 3

Why This Isn't Your Gastritis Returning

• Gastrin and chromogranin A (biomarkers of acid suppression and ECL-cell activity) return to baseline within 2-3 days of PPI withdrawal in controlled studies, but the cellular hyperplasia persists much longer 4
• Your symptom pattern—feeling great for days after stopping, then sudden symptoms after a trigger meal during stress—fits RAHS, not active gastritis 1
• NSAID-induced gastritis typically presents with constant gnawing pain and soreness, not episodic heartburn and hunger triggered by specific meals 5

Immediate Management Strategy

First-Line Approach for Breakthrough Symptoms

• Use H2-receptor antagonists (like famotidine 20 mg) or antacids (Tums, Gaviscon) on an as-needed basis for symptom control rather than immediately restarting continuous Nexium 1, 6
• On-demand PPI use (taking Nexium only when symptoms occur) is an acceptable partial de-prescribing strategy that provides effective symptom control without committing to continuous therapy 1
• The AGA specifically recommends that patients discontinuing PPIs should be advised they may experience upper GI symptoms at least in the short term, and this does not necessarily mean they must immediately return to continuous PPIs 1

Timeline Expectations

• Severe persistent symptoms lasting more than 2 months after PPI discontinuation may suggest a continuing indication for PPI therapy or a non-acid-mediated cause 1
• Since you're only days into your taper, your symptoms are well within the expected RAHS window 2, 3
• Physiologic studies show enterochromaffin-like cells and parietal cell mass can still be present 8 weeks after PPI withdrawal, though they usually regress by 6 months 1

Dietary and Lifestyle Modifications During This Period

Avoid Trigger Foods That Provoke RAHS

• Your dinner (pasta with red sauce, meatballs, bread) contained multiple acid-triggering components: tomato-based red sauce (highly acidic), high-fat meatballs (delay gastric emptying), and refined carbohydrates 1, 6
• Avoid alcohol, coffee, spicy foods, and high-fat meals if they consistently provoke symptoms during this vulnerable period 1

Stress Management

• Your midterm stress is a legitimate contributor—the brain-gut axis amplifies acid-related symptoms during psychological stress 1
• Integrate stress-reducing activities like mindfulness and diaphragmatic breathing, which can improve acceptance of symptoms and reduce their intensity 1

Nighttime and Meal-Timing Strategies

• Elevate the head of your bed and avoid meals within 3 hours of bedtime to reduce supine reflux, especially important during RAHS 1, 7
• Eat smaller, more frequent meals rather than large dinners to minimize postprandial acid surges 6

When to Consider Restarting Continuous PPI Therapy

Red Flags Requiring Restart

• Severe, uncontrolled symptoms lasting beyond 2 months after discontinuation 1
• Alarm symptoms develop: difficulty swallowing, unintentional weight loss, persistent vomiting, or evidence of GI bleeding 1
• Daily symptoms that significantly impair quality of life despite as-needed H2-blockers and lifestyle modifications 1

Appropriate Restart Strategy If Needed

• If you must restart, use the lowest effective dose rather than returning to 40 mg daily—many patients with uncomplicated GERD maintain control on 20 mg daily or every-other-day dosing 1, 8
• Consider on-demand therapy (taking PPI only when symptoms occur) as a middle ground between continuous therapy and complete discontinuation 1

Common Pitfalls to Avoid

• Do not interpret every symptom flare as gastritis recurrence—RAHS is expected and self-limited 1, 2
• Do not immediately restart continuous daily Nexium at the first sign of symptoms—this perpetuates the cycle and makes future discontinuation harder 1, 3
• Do not panic about "undoing all your healing"—one trigger meal during RAHS does not re-injure healed gastric mucosa 5
• Avoid the misconception that you need endoscopy or pH testing at this stage—these are indicated only if symptoms persist beyond 2 months or if alarm features develop 1

Your Specific Situation

Given your timeline (only days into tapering), midterm stress, and clear dietary trigger, continue your current approach: use Tums or consider adding famotidine as needed, avoid trigger foods for the next 2-4 weeks, manage stress around your Monday midterm, and expect gradual improvement over the next month as your parietal cells regress. 1, 2, 3