Gastritis Treatment
The recommended first-line treatment for gastritis is proton pump inhibitors (PPIs), with eradication therapy for Helicobacter pylori if present. 1, 2
Diagnosis and Initial Assessment
- Determine if H. pylori testing is indicated (especially for patients with dyspepsia)
- Check for alarm symptoms requiring endoscopy:
- Age >45 with severe symptoms
- Anemia, weight loss, dysphagia, palpable mass, malabsorption 1
Treatment Algorithm
Step 1: Proton Pump Inhibitor Therapy
Standard PPI dosing for 4-8 weeks 1, 2:
- Omeprazole 20mg twice daily
- Lansoprazole 30mg once daily
- Pantoprazole 40mg once daily
- Rabeprazole 20mg once daily
- Esomeprazole 20mg once daily
For better efficacy, consider double standard PPI doses (e.g., omeprazole 40mg twice daily) administered 30 minutes before meals 1
Step 2: Test for H. pylori (if not already done)
- Use urea breath test or monoclonal stool antigen test
- If positive, proceed with eradication therapy
Step 3: H. pylori Eradication (if positive)
First-line regimen (14-day course) 1:
- Standard triple therapy: PPI twice daily + amoxicillin 1g twice daily + clarithromycin 500mg twice daily
- For penicillin allergy: Bismuth quadruple therapy (PPI twice daily + bismuth 300mg four times daily + tetracycline 500mg four times daily + metronidazole 500mg three times daily)
Second-line regimen (if first-line fails) 1:
- Levofloxacin-based therapy: PPI twice daily + bismuth 300mg four times daily + levofloxacin 500mg once daily + tetracycline 500mg four times daily for 14 days
Step 4: Confirm H. pylori Eradication
- Perform urea breath test or stool antigen test at least 4 weeks after completing treatment
- Patient should be off PPI for at least 2 weeks before testing 1
Special Considerations
Gastroesophageal Reflux Disease (GERD)
- PPIs are indicated for treatment of heartburn and other GERD symptoms for up to 4 weeks 2
- For erosive esophagitis, treat with PPI for 4-8 weeks 2
Duodenal and Gastric Ulcers
- For active duodenal ulcer: PPI therapy for 4 weeks 2
- For active gastric ulcer: PPI therapy for 4-8 weeks 2, 3
- For NSAID-associated gastritis: PPIs have efficacy advantages over ranitidine and misoprostol 3
Maintenance Therapy
- For erosive esophagitis: Long-term PPI maintenance therapy may be indicated 2
- For uncomplicated duodenal ulcer: Prolonged PPI therapy is not required after successful H. pylori eradication 1
- For complicated duodenal ulcer: Continue PPI until H. pylori eradication is confirmed 1
Patient Education
- Inform patients about potential side effects of PPIs and antibiotics:
- Darkening of stool, metallic taste, nausea, diarrhea (especially with bismuth-containing regimens)
- Skin rash, vomiting, muscle and joint pains 1
- Emphasize importance of completing full course of treatment
- Take medications with meals to improve tolerance and efficacy 1
Clinical Pearls
- H. pylori eradication provides significant improvement in symptom resolution compared to placebo in functional dyspepsia patients 4
- PPIs not only heal ulcers but may also reduce H. pylori colonization and urease activity 5, 6
- H. pylori eradication prevents the increase in corpus gastritis associated with long-term PPI therapy 7
- 14-day regimens are superior to 7-day regimens, providing approximately 5% better eradication rates 1
- In areas with high clarithromycin resistance (>15-20%), avoid clarithromycin-based regimens 1