What is the treatment for issues related to the gastric cardio-oxyntic mucosa, such as gastritis or ulcers?

Treatment for Issues Related to Gastric Cardio-Oxyntic Mucosa

Proton pump inhibitors (PPIs) should be used as first-line therapy for gastritis or ulcers affecting the gastric cardio-oxyntic mucosa, with potassium-competitive acid blockers (P-CABs) reserved for PPI treatment failures. 1

First-Line Treatment Options

PPI Therapy

• Standard PPI dosing for gastric ulcers:

  • Omeprazole 20 mg daily
  • Lansoprazole 30 mg daily
  • Pantoprazole 40 mg daily
  • Rabeprazole 20 mg daily
  • Duration: 4-8 weeks 2

• Administration instructions:

  • Take 30-60 minutes before meals
  • Use lowest effective dose for shortest duration needed 2

H. pylori Testing and Eradication

• Test all patients with gastric ulcers for H. pylori 1
• If H. pylori positive: Use bismuth quadruple therapy as first-line treatment
  • PPI + bismuth + two antibiotics for 10-14 days 1
  • Avoid clarithromycin if local resistance rates are high

Treatment Algorithm Based on Etiology

NSAID-Related Gastritis/Ulcers

1. Discontinue NSAIDs if possible
2. If continued NSAID use necessary:
   • PPI therapy (standard dose)
   • Consider lowest-risk NSAID at lowest effective dose 1
   • H. pylori eradication if positive

H. pylori-Associated Gastritis/Ulcers

1. Eradication therapy: Bismuth quadruple therapy preferred 1
2. Confirm eradication after treatment completion
3. Continue PPI for total of 4-8 weeks for complete healing 1

Idiopathic Gastritis/Ulcers

• Standard PPI therapy for 4-8 weeks
• Note: Healing rates are typically lower compared to H. pylori-associated ulcers 1

Management of Bleeding Ulcers

For Active Bleeding

1. Endoscopy: First-line for diagnosis and treatment 1
2. High-dose PPI therapy:
   • IV PPI (e.g., pantoprazole 8 mg/hour for 72 hours)
   • Then oral PPI twice daily for 2 weeks, followed by once daily 1
3. If rebleeding occurs: Repeat endoscopy before considering other interventions 1
4. For refractory bleeding: Consider angioembolization if available 1

Second-Line Therapy Options

For PPI Treatment Failures

• P-CABs (e.g., vonoprazan 20 mg daily) 1
  • More rapid onset of acid suppression
  • May be more effective in PPI non-responders
  • Currently higher cost and limited availability in some regions

For Refractory Ulcers

• Rule out other causes of non-healing ulcers:
  • Cancer
  • Opportunistic infections
  • Vasculitis
  • Ischemia 1
• Consider higher PPI doses or twice-daily dosing 1

Special Considerations

Zollinger-Ellison Syndrome

• High-dose PPI therapy is generally advised 1, 2
• P-CABs may be useful but evidence is currently limited 1

Long-Term Prophylaxis

• For patients requiring long-term NSAID/aspirin therapy with history of PUD:
  • Continue PPI co-therapy
  • H. pylori eradication alone is insufficient for protection 1

Potential Complications of Long-Term PPI Use

• Tubulointerstitial nephritis
• C. difficile-associated diarrhea
• Bone fractures with prolonged use
• Vitamin B12 deficiency
• Hypomagnesemia 2

Monitoring

• Reassess symptoms after 4-8 weeks of therapy
• For long-term PPI users, consider monitoring for:
  • Magnesium levels
  • Vitamin B12 status
  • Bone density if prolonged use 2

Long-term PPI therapy appears safe regarding gastric mucosa changes, with studies showing no increased risk of neoplastic changes in the exocrine or endocrine stomach even after 10 years of continuous use 3.