Rationale:
The rationale behind this possible diagnosis is that patients with a Hiatal Hernia will often present with epigastric pain, as noted for this patient. Additionally, patients can sometimes develop gastritis and peptic ulcer disease secondary to an existing Hiatal Hernia, as the protrusion of the stomach into the thoracic cavity could cause irritation of the stomach lining. The clinical presentation describes both epigastric pain and symptoms of gastritis, so it is possible that this patient has developed inflammation or ulcer of the stomach lining in tandem with a pre-existing Hiatal Hernia.
However, in this case it does not appear likely that this patient has Peptic Ulcer disease secondary to the presence of a Hiatal Hernia. First of all, the most common type of Hiatal Hernia (90-95%) is a sliding Hiatal Hernia (pictured below, middle), in which patients are either asymptomatic or experience symptoms directly in conjunction with factors that increase abdominal pressure. For example, they would experience epigastric pain or discomfort whenever they lay down, cough, or wear tight clothes; as all of these actions cause the stomach to herniate (slide into) the thoracic cavity. Pregnancy and obesity would also have this effect. The female in this case is presenting with epigastric pain that does not worsen with any of these factors, but instead reports being more affected by use of NSAIDs and caffeine. She also does not present with heartburn, dysphagia, or any signs of reflux related to GERD, which is known to be typically associated with Hiatal Hernias.
Figure 8. Normal Esophagus and stomach compared with Sliding Hiatal Hernia (Memorial Hermann, 2019)
Ruling out the possibility of a Hiatal Hernia, then, might be possible simply based on the clinical presentation, but could be further confirmed with a Barium Swallow study (Figure 9) or X-ray (Figure 10).
Figure 9. Barium Swallow of Hiatal Hernia (ENT USA, 2008)
Figure 10. X-ray of Hiatal Hernia (University of Virginia, 2013)