Treatment of Chronic Gastritis
Eradication of Helicobacter pylori is the cornerstone of chronic gastritis treatment, as it heals gastritis, prevents progression to atrophic gastritis, and significantly reduces the risk of gastric cancer development. 1
Diagnosis and Initial Assessment
Before initiating treatment, proper diagnosis is essential:
- Test for H. pylori infection using non-invasive methods (urea breath test, stool antigen test) or invasive methods (endoscopy with biopsy)
- Assess for atrophic changes and intestinal metaplasia if endoscopy is performed
- Consider checking antiparietal cell and anti-intrinsic factor antibodies if autoimmune gastritis is suspected 1
- Evaluate for anemia, vitamin B12 and iron deficiencies, especially in corpus-predominant gastritis 1
Treatment Algorithm
First-line H. pylori Eradication Therapy
Triple therapy regimen (in areas with low clarithromycin resistance):
Quadruple therapy (preferred in areas with high clarithromycin resistance):
- Proton pump inhibitor (standard dose)
- Bismuth subsalts
- Tetracycline
- Metronidazole
- Duration: 10-14 days
Second-line Treatment (if first-line fails)
- Use antibiotics not included in the first treatment attempt 4
- Options include:
- Levofloxacin-based triple therapy
- Bismuth-containing quadruple therapy
- Consider antibiotic susceptibility testing to guide therapy 4
Special Considerations
Atrophic Gastritis
- All patients with atrophic gastritis must be assessed for H. pylori and treated if positive 1
- Confirm successful eradication using non-serological testing 1
- Consider endoscopic surveillance every 3 years for patients with advanced atrophic gastritis 1
Autoimmune Gastritis
- Evaluate for concomitant autoimmune disorders, particularly thyroid disease 1
- Screen for vitamin B12 and iron deficiencies and provide supplementation as needed 1
- Monitor for development of gastric neuroendocrine tumors 1
High-Risk Populations
H. pylori eradication should be prioritized in patients with:
- First-degree relatives with gastric cancer
- Previous gastric neoplasia
- Severe pan-gastritis or corpus-predominant gastritis
- Severe atrophy
- Long-term acid suppression therapy (>1 year)
- Strong environmental risk factors for gastric cancer 1
Common Pitfalls and Caveats
- Antibiotic resistance: The main cause of treatment failure, particularly clarithromycin resistance. Choose antibiotic combinations based on local resistance patterns 1, 4
- Acid suppression: Adequate acid suppression is critical for antibiotic efficacy. In patients with corpus atrophy and hypochlorhydria, bismuth-based regimens may be more effective 5
- Confirmation of eradication: Always confirm successful eradication at least 4 weeks after completion of therapy and at least 2 weeks after PPI discontinuation 1
- Long-term PPI use: In H. pylori-positive patients, long-term PPI treatment accelerates the development of atrophic gastritis. Consider H. pylori eradication before starting long-term PPI therapy 1
Benefits of Successful Treatment
- Healing of gastritis and prevention of peptic ulcer recurrence
- Halting progression to atrophic gastritis and intestinal metaplasia
- Significant reduction in gastric cancer risk, especially when eradication occurs before development of preneoplastic conditions 1
- Improved absorption of certain medications (thyroxine, L-dopa) 1
The evidence clearly demonstrates that H. pylori eradication is the most effective strategy for treating chronic gastritis and preventing its progression to more serious conditions, including gastric cancer.