What is the recommended outpatient treatment for alcoholic gastritis?

Outpatient Treatment for Alcoholic Gastritis

The cornerstone of outpatient treatment for alcoholic gastritis is complete alcohol abstinence, which must be strictly recommended as continued alcohol use leads to disease progression. 1 Alcohol cessation should be combined with proton pump inhibitors (PPIs), thiamine supplementation, and nutritional support for optimal management.

Treatment Algorithm

First-Line Interventions

1. Alcohol Abstinence

   • Complete abstinence is essential for healing of gastric mucosa
   • Brief alcohol intervention during initial evaluation and follow-up visits 1
   • Consider pharmacotherapy for alcohol dependence:
     • Naltrexone 25 mg for 1-3 days, then 50 mg daily (patients must be alcohol-free for 3-7 days before starting) 2
     • Acamprosate as an alternative option 1

2. Acid Suppression Therapy

   • High-potency PPI (preferred over H2 blockers):
     • Esomeprazole 20-40 mg twice daily or
     • Rabeprazole 20 mg twice daily 1
   • Continue for 4-8 weeks or until symptoms resolve

3. Nutritional Support

   • Daily caloric intake target: 35-40 kcal/kg body weight 1
   • Protein intake: 1.2-1.5 g/kg body weight 1
   • Thiamine supplementation: 100-300 mg daily for 3-4 days, then 10 mg daily for maintenance 1
   • Consider calorie-dense, high-protein supplements 1

Second-Line/Adjunctive Therapies

1. Pain Management (if needed)

   • Avoid NSAIDs due to risk of gastric irritation
   • If pain medication necessary, consider acetaminophen (maximum 3g/day) 1

2. Management of Nausea/Vomiting

   • Metoclopramide 10 mg three times daily before meals (strongest evidence) 1
   • Alternative: Ondansetron 4-8 mg every 8 hours as needed

3. Screening for H. pylori

   • Test for H. pylori infection, which is common in alcoholics 3
   • If positive, standard eradication therapy (PPI + two antibiotics)

Follow-up and Monitoring

1. Short-term follow-up (2-4 weeks)

   • Assess symptom improvement
   • Evaluate alcohol abstinence
   • Consider endoscopy if symptoms persist

2. Long-term follow-up

   • Monitor liver function tests every 3 months if on naltrexone 2
   • Reinforce alcohol abstinence at each visit
   • Consider endoscopy to document healing

Special Considerations

• Severe malnutrition: More aggressive nutritional supplementation including B-complex vitamins
• Liver disease: Avoid medications metabolized by liver; monitor liver function tests
• Persistent symptoms: Consider endoscopy to rule out other pathologies (ulcers, malignancy)

Potential Pitfalls

• Failure to address alcohol dependence: Without abstinence, gastritis will likely recur or worsen
• Inadequate nutritional support: Alcoholic patients often have multiple nutritional deficiencies that require correction
• Missing H. pylori infection: Antibiotic treatment for H. pylori-positive patients can result in both histological and symptomatic improvement 3
• Initiating naltrexone too soon: Starting naltrexone before alcohol is fully cleared can precipitate withdrawal symptoms 2

Recent research suggests that pyroptosis (inflammatory cell death) plays a role in alcoholic gastritis pathogenesis, which may lead to new therapeutic targets in the future 4, but current standard treatment remains focused on alcohol cessation, acid suppression, and nutritional support.