What is the initial treatment for gastritis?

Initial Treatment for Gastritis

The initial treatment for gastritis should be a proton pump inhibitor (PPI) therapy, with full-dose PPI such as omeprazole 20 mg once daily being the first-line treatment for patients with epigastric pain or ulcer-like dyspepsia symptoms. 1

Diagnostic Approach

Before initiating treatment, it's important to determine:

1. Whether the patient has alarm symptoms (bleeding, weight loss, dysphagia)

   • Patients with alarm symptoms should be referred for endoscopy

2. Whether the patient is taking NSAIDs regularly

   • NSAID users may require prophylactic therapy and should be referred for endoscopy

3. Duration of symptoms

   • Symptoms less than four weeks: May be managed with reassurance and over-the-counter medications
   • Symptoms for four weeks or longer: Proceed with treatment algorithm

Treatment Algorithm

Step 1: Test and Treat for H. pylori

For patients with symptoms lasting longer than four weeks without alarm symptoms:

• Perform H. pylori testing using urea breath test or monoclonal stool antigen test 1
• If H. pylori positive, provide eradication therapy
  • Current guidelines recommend bismuth quadruple therapy as first-line treatment due to increasing clarithromycin resistance 1
  • Concomitant 4-drug therapy is an alternative when bismuth is not available

Step 2: Symptomatic Treatment Based on Predominant Symptoms

For H. pylori negative patients or those with residual symptoms after eradication:

• For epigastric pain/ulcer-like dyspepsia:

  • Full-dose PPI therapy (e.g., omeprazole 20 mg once daily) 1
  • Response to therapy confirms acid-related nature of symptoms

• For fullness, bloating, or satiety (dysmotility-like dyspepsia):

  • Consider prokinetic agent therapy 1

Duration of Treatment

• Initial course of 4-8 weeks
• If symptoms are controlled, consider trial withdrawal of therapy
• For recurrent symptoms, repeat therapy or consider on-demand treatment 1

Special Considerations

NSAID-Related Gastritis

• For patients on NSAIDs with gastritis:
  • Consider misoprostol (200 mcg four times daily) to reduce risk of gastric ulcers 2
  • H. pylori eradication is beneficial before starting NSAID treatment and mandatory in patients with peptic ulcer history 1

Long-term PPI Use and H. pylori

• Long-term PPI treatment in H. pylori-positive patients is associated with corpus-predominant gastritis and accelerated progression to atrophic gastritis 1
• Consider H. pylori eradication in patients requiring long-term PPI therapy to prevent progression to atrophic gastritis 1

Treatment Failure

If symptoms persist despite appropriate initial therapy:

1. Consider switching treatment (e.g., from prokinetic to PPI or vice versa)
2. If symptoms still persist, consider high-dose PPI therapy
3. If no response, refer for endoscopy for further evaluation 1

Key Pitfalls to Avoid

1. Underestimating H. pylori resistance: Clarithromycin-based triple therapy now has success rates below 80% due to increasing antibiotic resistance 1

2. Inadequate acid suppression: Using less potent PPIs may result in treatment failure. Higher-potency PPIs like esomeprazole or rabeprazole are preferred over pantoprazole 1

3. Overlooking NSAID use: Failing to identify and address ongoing NSAID use will result in persistent gastritis despite other treatments 1

4. Misclassifying symptoms: Patients with predominant heartburn may have GORD rather than gastritis and should be treated accordingly 1