I have NSAID‑induced gastritis that was treated with esomeprazole (Nexium) 40 mg daily for four weeks, then tapered to 20 mg daily, and now I experience post‑prandial dizziness, early hunger, bloating, gas, and occasional nausea—what is the most likely cause and how should I manage these symptoms?

Post-PPI Taper Symptoms in NSAID-Induced Gastritis

Your symptoms—post-prandial dizziness, early hunger, bloating, and nausea—are most likely caused by rebound acid hypersecretion (RAHS) from tapering esomeprazole too quickly, combined with incomplete healing of your NSAID-induced gastritis. 1

What Is Happening Right Now

Your body developed parietal cell hyperplasia during four weeks of high-dose PPI therapy. When you dropped from 40 mg daily to 20 mg daily, you created a sudden gap in acid suppression that triggered rebound hypersecretion. 1 This rebound can persist for 2–8 weeks and sometimes up to 6 months after PPI withdrawal, explaining why your symptoms worsened immediately after the dose reduction. 1

The post-prandial dizziness you describe is likely vagus nerve stimulation from gastric distension and acid irritation of incompletely healed gastric mucosa. 2, 3 The early hunger signals and gas are classic features of acid rebound—your stomach is producing excess acid between meals, triggering hunger-like sensations and fermentation of food residue. 1

Immediate Management Steps

1. Stabilize Your PPI Dose

Return to esomeprazole 40 mg once daily for a full 8 weeks to ensure complete mucosal healing. 2 NSAID-induced gastritis requires a minimum 8-week course at full dose, not the 4 weeks you completed. 2 Taking 20 mg is insufficient for your condition—you need the higher dose to suppress acid adequately and allow the gastric lining to heal completely. 2, 4

2. Critical NSAID Avoidance

Never use NSAIDs (including ibuprofen, naproxen, aspirin) again without gastroprotection. 2 Even with PPI therapy, NSAIDs significantly increase your risk of ulcer recurrence and complications. 2 Use acetaminophen for pain relief instead. 2

3. Essential H. pylori Testing

Get tested for Helicobacter pylori immediately using a ^13C-urea breath test or stool antigen assay (not serology). 2, 3 H. pylori infection increases NSAID-related complications by 2–4 fold. 2 If positive, you need eradication therapy: PPI + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily for 14 days. 2

Proper PPI Tapering Protocol (After 8 Weeks at 40 mg)

The taper you attempted was too rapid. 1 Here is the evidence-based approach:

1. Week 1–8: Esomeprazole 40 mg once daily before breakfast 2, 4
2. Week 9–12: Esomeprazole 40 mg every other day 1
3. Week 13–16: Esomeprazole 20 mg every other day 1
4. Week 17 onward: On-demand PPI (take only when symptoms occur) or H2-receptor antagonist (famotidine 20 mg twice daily) for breakthrough symptoms 1

During tapering, expect some upper GI symptoms for up to 2 months—this does not mean you must immediately restart continuous PPI. 1 Use famotidine 20 mg as needed or antacids (calcium carbonate, magnesium hydroxide) for short-term symptom control without committing to continuous PPI therapy. 1

Managing Your Current Symptoms

Post-Prandial Dizziness

• Remain upright for 2–3 hours after meals to reduce gastric distension and vagal stimulation. 3
• Eat smaller, more frequent meals (5–6 per day) rather than 3 large meals to minimize gastric stretch. 1
• Avoid lying down within 45 minutes of eating. 3

Early Hunger & Gas

• These are manifestations of rebound acid hypersecretion and will resolve once you stabilize on 40 mg for 8 weeks. 1
• DGL (deglycyrrhizinated licorice) can provide symptomatic relief but does not address the underlying acid rebound. 1
• Avoid coffee, citrus fruits, and carbonated beverages, which worsen acid secretion. 3

Bloating & Nausea

• Ondansetron 8 mg sublingual every 4–6 hours as needed for acute nausea. 5
• Famotidine 20 mg twice daily can bridge acid control during the stabilization phase. 1, 6
• Simethicone 80–125 mg after meals for gas relief. 1

Red-Flag Symptoms Requiring Urgent Endoscopy

Seek immediate medical attention if you develop: 2, 3

• Hematemesis (vomiting blood) or coffee-ground emesis
• Melena (black, tarry stools)
• Significant unintentional weight loss (>5% body weight)
• Difficulty swallowing or food sticking
• Recurrent vomiting (>3 episodes per day)
• Severe, unrelenting epigastric pain

These may indicate ulcer complications (bleeding, perforation) requiring urgent endoscopy or surgery. 2, 3

Why Your Symptoms Are Fluctuating

The day-to-day variability you describe (doing great 2–3 days ago, then suddenly worse) is typical of RAHS. 1 Acid secretion fluctuates based on meal timing, stress, sleep quality, and the waxing/waning nature of parietal cell hyperplasia regression. 1 The roast beef and ham dinner likely contained high fat content, which delays gastric emptying and prolongs acid exposure, triggering your bloating and nausea. 1, 3

Common Pitfalls to Avoid

• Do not attempt further tapering until you complete 8 full weeks at 40 mg daily. 2 Your initial 4-week course was insufficient for NSAID-induced gastritis.
• Do not use NSAIDs "just once" for pain—even a single dose can re-injure healing mucosa. 2
• Do not rely on symptoms alone to guide therapy—gastritis healing lags behind symptom improvement. 2, 4
• Do not skip H. pylori testing—co-infection dramatically worsens outcomes. 2

Long-Term Outlook

Once you complete proper healing (8 weeks at 40 mg) and taper correctly, 50% of patients remain off PPIs at 6 months, though 75% of those use H2-receptor antagonists or antacids for occasional symptoms. 1 Your prognosis is excellent if you avoid NSAIDs permanently and complete the full treatment course. 2, 4