Rapid alleviation of severe epigastric pain associated with gastroesophageal reflux disease through the addition of orengedokuto to standard treatment: A clinical letter

Severe epigastric pain caused by gastroesophageal reflux disease (GERD) may result in patients experiencing difficulty eating due to discomfort. Orengedokuto (OGT), described in Wai Tai Mi Yao Fang [1], alleviates epigastric discomfort due to its inclusion of Scutellaria root and Coptis rhizome. Moreover, Otsuka et al. reported that shishishito containing Gardenia fruit demonstrates significant efficacy in treating esophagitis [2]. This report presents a case in which OGT promptly alleviated symptoms in a patient experiencing difficulty eating due to severe epigastric pain. The patient was a 45-year-old male who had been experiencing common cold for five days until admission. He took only one tablet of loxoprofen sodium at the beginning of the cold. Four days prior to admission, the patient developed a burning epigastric pain during food ingestion, subsequently resulting in near-complete cessation of dietary intake. One day before admission, he was prescribed amoxicillin hydrate, tranexamic acid, and vonoprazan fumarate 20 mg. He was admitted to our hospital for treatment of severe epigastric pain. His body temperature was 35.6°C, blood pressure was 118/70 mm Hg, and pulse rate was 60/min. His height was 177 cm, and he weighed 90 kg. At age 44, he had a history of right ureteral stones without other medical history. For the past 10 years, he had often experienced heartburn after meals without seeking medical consultation. He had no history of drinking alcohol, but smoked 20 cigarettes a day for 25 years. Physical examination revealed weak bowel sounds, and spontaneous pain and tenderness were noted in the epigastric region. Laboratory findings showed a white blood cell count of 6700/μL. C-reactive protein was elevated at 4.43 mg/dL. Emergency upper gastrointestinal endoscopy revealed continuous circumferential erosion from the esophagogastric junction to the lower esophagus, with partial erosion in the mid-esophagus. A hiatal hernia was also observed. The patient was diagnosed with GERD, classified as Los Angeles grade D (Figure 1). Further examination revealed a slightly weak, sunken, and string-like pulse. The patient's tongue was red with slight teeth marks and mild sublingual vein dilation. The tongue coating was white-yellow. Abdominal examination showed a strong abdomen with epigastric stuffiness, discomfort and distension in the left hypochondriac region without other abnormalities. Intravenous therapy of omeprazole 20 mg twice a day (Day 0 of the admission) with continuous drip hydration was initiated; however, the pain persisted. Subsequently, ecabet sodium hydrate 1.5 g twice a day was added (Day 2). On Day 3, as the pain had not subsided, a Kampo medicine treatment was implemented. OGT extract (TJ-15; 2.5 g each, three times daily; Tsumura & Co., Tokyo, Japan) was administered starting in the morning. The patient took OGT and immediately exhibited a twisting motion of the body due to severe pain (Visual Analog Scale [VAS]: 10), which was the same in the second administration. In the evening, however, he reported that his pain had diminished compared to pre-treatment levels, and he experienced minimal discomfort upon taking the third OGT dose (VAS: 0). The patient commenced nutritional intake in the evening following the day of admission; however, prior to the initiation of OGT, he either abstained from food consumption entirely or ingested only two or three bites. Finally, although he experienced moderate pain during eating, he was able to consume half of his dinner (VAS: 5) and was discharged the following day (VAS: 2 at breakfast). He was prescribed vonoprazan fumarate 20 mg, changed from the omeprazole injection, and OGT as discharge medication. Orengedokuto is applied for excess heat pattern, which is characterized by fever, strong physique, red face, red tongue, yellow tongue coating, strong pulse, epigastric stuffiness, and other symptoms. Additionally, the redness, burning pain, and hot sensation in the lesion are indicative of OGT use. The headnote of daiseiryuto in Ruijuhokogi states, “in case that a patient complains vexing heat in its chest and diaphragm, OGT should be added” [3]. In the current report, the patient exhibited an almost typical OGT pattern, and his esophagitis presented as red-colored inflammation with burning pain. Takamura et al. reported that multiple Kampo medicine treatments, including OGT, improved symptoms of gastroesophageal reflux disease. The symptoms resolved within three weeks after OGT addition [4]. Conversely, in our case, the patient's epigastric burning pain diminished immediately following the second OGT administration. Considering these two cases, OGT might be effective in relieving pain caused by esophageal mucosal disorders. Limitations of this study include the absence of a follow-up endoscopy immediately after symptom amelioration, as the patient requested discharge soon after recovery, and the inability to rule out the possibility of an acute esophageal mucosal lesion. Nevertheless, his recurrent episodes of heartburn over the past decade and esophageal hiatus hernia led to the consideration of an acute exacerbation of chronic GERD. We observed a case in which epigastric pain was promptly alleviated with OGT. The combination of OGT with conventional therapy, i.e., a combination of Kampo and Western medicine [5], suggests potential for symptom improvement. T. Nogami received lecture fees from Tsumura & Co. The authors declare no conflicts of interest regarding the reported facts or findings of this study. N/A. Informed consent was obtained from the patient for the publication of this case report. N/A. N/A.