What is the best treatment for gastritis?

Treatment of Gastritis

The best treatment for gastritis is eradication of Helicobacter pylori (if present) using bismuth quadruple therapy as first-line treatment, along with proton pump inhibitors (PPIs) for symptom relief and healing of gastric mucosa. 1

Diagnostic Approach

Before initiating treatment, determine the type of gastritis:

1. Test for H. pylori infection using:

   • Urea breath test (UBT)
   • Monoclonal stool antigen test
   • Validated serological tests 1

2. Identify potential causes:

   • NSAID use
   • Alcohol consumption
   • Autoimmune factors
   • Stress-related factors

Treatment Algorithm

H. pylori-Positive Gastritis:

1. First-line therapy (14-day regimen):

   • Bismuth quadruple therapy consisting of:
     • PPI (high-potency: esomeprazole or rabeprazole 20-40mg twice daily)
     • Bismuth
     • Tetracycline
     • Metronidazole 1

2. Alternative first-line (if bismuth unavailable):

   • Concomitant 4-drug therapy with:
     • PPI (high-potency)
     • Amoxicillin
     • Clarithromycin
     • Metronidazole 1

3. Second-line options (if first-line fails):

   • Levofloxacin-based triple therapy (if no previous exposure)
   • Different bismuth quadruple regimen 1

4. Confirm eradication 4-8 weeks after therapy completion using UBT or stool antigen test 1

H. pylori-Negative Gastritis:

1. PPI therapy:

   • High-potency PPI (esomeprazole or rabeprazole 20-40mg twice daily) 1
   • Duration: 4-8 weeks for healing 2

2. Eliminate aggravating factors:

   • Discontinue NSAIDs if possible
   • Reduce alcohol consumption
   • Manage stress

Choice of PPI

PPIs vary in potency and should be selected carefully:

• Preferred options: Esomeprazole or rabeprazole (20-40mg twice daily)
• Avoid: Pantoprazole (has lower relative potency)
• Relative potency: 20mg esomeprazole = 32mg omeprazole; 20mg rabeprazole = 36mg omeprazole 1

Special Considerations

NSAID-Associated Gastritis:

• For NSAID users: H. pylori eradication is beneficial before starting NSAIDs 1
• For ongoing NSAID users: Continue PPI therapy for gastroprotection 1

Functional Dyspepsia with H. pylori:

• H. pylori eradication produces long-term relief in 1 of 12 patients with functional dyspepsia 1
• PPI therapy may provide additional symptom relief 3

Duration of Treatment

• H. pylori eradication: 14 days (optimal duration) 1
• PPI therapy for healing: 4-8 weeks 2
• Maintenance therapy: May be required in severe or recurrent cases

Common Pitfalls to Avoid

1. Inadequate duration of therapy: 14-day regimens are superior to 7-10 day regimens for H. pylori eradication 1

2. Inappropriate PPI selection: Low-potency PPIs or inadequate dosing reduces efficacy 1

3. Not considering antibiotic resistance: Local resistance patterns should guide therapy choice 1

4. Failure to confirm eradication: Always confirm H. pylori eradication after treatment 1

5. Continuing PPIs long-term unnecessarily: Long-term PPI use in H. pylori-positive patients may accelerate development of atrophic gastritis 1

By following this structured approach to gastritis treatment, focusing on H. pylori eradication when present and appropriate acid suppression, most patients will experience symptom relief and healing of gastric inflammation.