What is the initial treatment for gastritis?

Initial Treatment for Gastritis

The initial treatment for gastritis should be a proton pump inhibitor (PPI) such as esomeprazole or rabeprazole at 40mg twice daily for 2-4 weeks, with H. pylori testing and eradication if positive.

Diagnosis and Classification

Before initiating treatment, it's important to understand the type of gastritis:

• Acute gastritis: Often caused by NSAIDs, alcohol, stress, or certain medications
• Chronic gastritis: Commonly associated with H. pylori infection, autoimmune conditions
• Erosive vs. non-erosive gastritis: Determined by endoscopic findings

Initial Treatment Algorithm

Step 1: PPI Therapy

• Start with a high-potency PPI (esomeprazole or rabeprazole preferred)
• Dosage: 40mg twice daily
• Duration: 2-4 weeks initially
• Take 30 minutes before meals on an empty stomach for optimal effect 1

Step 2: H. pylori Testing

• Test for H. pylori infection using urea breath test or monoclonal stool antigen test
• If testing while on PPI, discontinue PPI at least 2 weeks before testing to avoid false negatives 1

Step 3: If H. pylori Positive

• Initiate eradication therapy based on local resistance patterns:
  • In areas with low clarithromycin resistance (<20%): PPI + clarithromycin 500mg twice daily + amoxicillin 1000mg twice daily for 14 days 1
  • In areas with high clarithromycin resistance or unknown: Bismuth quadruple therapy (PPI + bismuth subsalicylate + tetracycline + metronidazole) for 14 days 1

Step 4: Follow-up

• Confirm H. pylori eradication at least 4 weeks after completing treatment
• Continue PPI for gastric ulcers until complete healing is achieved 1

Special Considerations

NSAID-Induced Gastritis

• Discontinue NSAIDs if possible
• If NSAIDs must be continued, add misoprostol or continue PPI therapy for gastroprotection 2

Stress-Related Gastritis

• Common in critically ill patients
• PPI therapy is first-line treatment
• Consider H2 receptor antagonists (e.g., ranitidine) as an alternative 3

Refractory Symptoms

• Consider endoscopy if symptoms persist despite 2-4 weeks of PPI therapy
• Rule out other conditions like functional dyspepsia, GERD, or gastric malignancy

Treatment Efficacy and Monitoring

• PPIs effectively reduce gastric acid secretion within 24 hours, with maximum effect after 3-4 days 4
• H. pylori eradication reduces the risk of recurrent gastritis and progression to atrophic gastritis 5
• Long-term PPI use in H. pylori-positive patients may accelerate progression to atrophic gastritis; therefore, H. pylori testing and eradication is recommended before long-term PPI therapy 5

Common Pitfalls

1. Inadequate PPI dosing: Using standard rather than high-dose PPI therapy may result in suboptimal symptom relief
2. Premature discontinuation: Stopping PPI therapy too early can lead to symptom recurrence
3. Failing to test for H. pylori: Missing this common cause of chronic gastritis leads to incomplete treatment
4. Testing for H. pylori while on PPI therapy: Can lead to false-negative results 1
5. Using clarithromycin-based regimens in high-resistance areas: Results in treatment failure and antibiotic resistance 1

Remember that chronic gastritis is often asymptomatic, and upper abdominal complaints may not correlate with the severity of gastritis on histology 6. The goal of treatment is to relieve symptoms, heal mucosal inflammation, and prevent complications like ulceration and progression to atrophic gastritis.