How should gastritis and GERD be treated?

Treatment of Gastritis and GERD

Proton pump inhibitors (PPIs) once daily are the first-line treatment for both gastritis and GERD, with PPIs being more effective than other acid-suppressing medications for healing and providing symptomatic relief. 1

Differentiating Gastritis vs. GERD

Symptoms and Diagnosis

• GERD: Characterized by heartburn, acid regurgitation, and non-cardiac chest pain
• Gastritis: Often presents with upper abdominal pain, nausea, and sometimes vomiting
• Proper diagnosis is crucial for treatment planning:
  • For typical GERD symptoms without alarm features: Initial PPI trial
  • For persistent symptoms or alarm features: Endoscopy is warranted 2

First-Line Treatment Approach

PPI Therapy

• Initial treatment: Standard dose PPI once daily for 4-8 weeks
  • Examples: omeprazole 20 mg, lansoprazole 30 mg, pantoprazole 40 mg, or rabeprazole 20 mg 1
• Take PPI 30-60 minutes before a meal for optimal effect 2, 3
• Assess response after 4-8 weeks of therapy 2

Response Assessment

• If symptoms resolve: Wean to lowest effective dose
  • Continue at lowest effective dose or convert to on-demand therapy 2
• If partial or no response:
  • Verify compliance
  • Increase to twice-daily dosing or switch to a more effective PPI 2

Adjunctive Therapies

For Breakthrough Symptoms

• Alginate antacids: For immediate symptom relief 2
• H2 receptor antagonists (e.g., ranitidine): Can be added for nighttime symptoms 2, 4
• Baclofen: For regurgitation or belch-predominant symptoms 2
• Prokinetics: Consider for coexistent gastroparesis 2

Special Considerations

For Gastritis

• PPIs are preferred over H2RAs 1
• If H. pylori infection is present:
  • Triple therapy (PPI + two antibiotics) is recommended 5
  • H. pylori eradication may actually improve GERD treatment response 6

For Chronic Management

• Evaluate appropriateness of long-term PPI therapy within 12 months 2
• Consider endoscopy with prolonged wireless reflux monitoring off PPI therapy to establish need for long-term treatment 2
• Monitor vitamin B12 levels in patients on long-term PPI therapy, especially those who develop atrophic gastritis 7

Lifestyle Modifications

• Elevate head of bed for nighttime symptoms
• Avoid meals within 3 hours of bedtime
• Avoid specific trigger foods (alcohol, coffee, spicy foods)
• Weight loss if overweight or obese
• Incorporate stress-reducing activities 2, 1

When to Consider Advanced Interventions

• For proven GERD with inadequate response to medical therapy:
  • Laparoscopic fundoplication
  • Magnetic sphincter augmentation
  • Transoral incisionless fundoplication 2
• For obese patients with GERD:
  • Roux-en-Y gastric bypass (not sleeve gastrectomy, which can worsen GERD) 2

Common Pitfalls to Avoid

1. Failing to confirm GERD diagnosis before long-term PPI therapy
2. Not tapering to lowest effective dose after symptom resolution
3. Missing H. pylori infection in patients with gastritis
4. Continuing ineffective therapy without objective testing
5. Not considering functional disorders in patients with persistent symptoms despite therapy

Remember that both gastritis and GERD often require long-term management strategies, with the goal of using the lowest effective dose of medication to control symptoms and prevent complications.