What is the treatment for non-Helicobacter pylori (H. pylori) gastritis?

Treatment for Non-H. pylori Gastritis

For non-H. pylori gastritis, proton pump inhibitors (PPIs) are the first-line treatment, with the lowest effective dose that controls symptoms being recommended. 1

Diagnostic Approach

Before initiating treatment for non-H. pylori gastritis, it's important to:

1. Confirm the absence of H. pylori infection through:

   • Urea breath test
   • Monoclonal stool antigen test
   • Endoscopic biopsy with histology if endoscopy is performed

2. Rule out other causes of gastritis:

   • Medication-induced (NSAIDs, aspirin)
   • Autoimmune gastritis
   • Chemical/bile reflux gastritis
   • Stress-related gastritis

First-Line Treatment Options

Acid Suppression Therapy

• PPIs: First-line therapy for symptom control

  • Examples: omeprazole 20mg daily, pantoprazole 40mg daily, esomeprazole 20mg daily
  • Use the lowest effective dose that controls symptoms 1
  • Duration: 4-8 weeks initially, then reassess

• H2-receptor antagonists: Alternative option if PPIs not tolerated

  • Examples: ranitidine 150mg twice daily, famotidine 20mg twice daily
  • May be effective but evidence is of lower quality than for PPIs 1

Lifestyle Modifications

• Regular aerobic exercise (strongly recommended despite limited evidence) 1
• Avoidance of gastric irritants (alcohol, spicy foods, caffeine)
• Smoking cessation
• Stress reduction techniques

Second-Line Treatment Options

Neuromodulators

• Tricyclic antidepressants (TCAs): For refractory symptoms
  • Start with low dose (e.g., amitriptyline 10mg once daily)
  • Titrate slowly to maximum of 30-50mg once daily
  • Requires careful explanation of rationale and side effect counseling 1

Antipsychotics

• Options include sulpiride 100mg four times daily or levosulpiride 25mg three times daily
• Consider for refractory cases with careful explanation and monitoring 1

Special Considerations

Autoimmune Gastritis

• If autoimmune gastritis is suspected (pernicious anemia, vitamin B12 deficiency):
  • Test for anti-parietal cell and anti-intrinsic factor antibodies
  • Consider vitamin B12 supplementation

Chemical/Bile Reflux Gastritis

• Often occurs post-gastric surgery
• Consider bile acid sequestrants (cholestyramine)
• Prokinetics may provide additional benefit

MALT Lymphoma

• For gastric MALT lymphoma without H. pylori:
  • Radiation therapy (30-40 Gy to stomach and perigastric nodes) for stage I-II disease 1
  • Systemic chemotherapy and/or immunotherapy with anti-CD20 monoclonal antibodies for advanced disease 1

Management of Severe or Refractory Cases

1. Refer to gastroenterology specialist clinic 1
2. Multidisciplinary support team involvement 1
3. Avoid opioids and surgery to minimize iatrogenic harm 1
4. Consider endoscopic re-evaluation to exclude other pathologies

Treatment Pitfalls and Caveats

• Avoid empiric antibiotic treatment in the absence of confirmed H. pylori infection
• There is insufficient evidence to recommend dietary therapies including low FODMAP diets 1
• Probiotics have unproven benefit and should be considered experimental 1
• Prolonged PPI use may be associated with adverse effects (bone fractures, C. difficile infection, micronutrient deficiencies)
• Regular monitoring for symptom improvement is essential, with treatment adjustment as needed

By following this treatment algorithm for non-H. pylori gastritis, focusing on acid suppression with PPIs as first-line therapy, clinicians can effectively manage symptoms and improve quality of life for affected patients.