What is the treatment for severe gastritis?

Treatment for Severe Gastritis

The treatment for severe gastritis should focus on eradicating H. pylori infection if present, using acid suppression therapy with proton pump inhibitors, and addressing underlying causes to prevent complications such as gastric cancer, bleeding, and nutritional deficiencies. 1

Definition and Classification of Severe Gastritis

Severe gastritis refers to advanced inflammation of the gastric mucosa characterized by:

• Loss of gastric glands (atrophic gastritis) with or without metaplasia
• Significant mucosal damage that may be visible endoscopically
• Risk for complications including bleeding, ulceration, and progression to gastric cancer
• May be acute (hemorrhagic) or chronic (atrophic)

Two main etiologies:

• Helicobacter pylori infection (most common)
• Autoimmune gastritis

Diagnostic Approach

1. Endoscopic evaluation with biopsies:

   • Obtain biopsies from both body and antrum/incisura in separate containers
   • Look for endoscopic features: pale mucosa, increased visibility of vasculature, loss of gastric folds
   • Target any abnormal mucosal areas for additional biopsies 1

2. H. pylori testing:

   • All patients with atrophic gastritis should be assessed for H. pylori
   • Use non-serological testing methods (urea breath test or stool antigen test)
   • Stop proton pump inhibitors (PPIs) 2 weeks before testing to avoid false negatives 2

3. For suspected autoimmune gastritis:

   • Check antiparietal cell antibodies and anti-intrinsic factor antibodies
   • Evaluate for vitamin B-12 and iron deficiencies 1

Treatment Algorithm

1. Eradication of H. pylori (if positive)

• First-line therapy (in areas with low clarithromycin resistance):

  • Triple therapy: Amoxicillin + Clarithromycin + PPI for 14 days 2

• First-line therapy (in areas with high clarithromycin resistance ≥15%):

  • Bismuth quadruple therapy: Bismuth salts + PPI + Tetracycline + Metronidazole for 14 days 2

• Confirm eradication using non-serological testing at least 4 weeks after completing therapy 1, 2

2. Acid Suppression Therapy

• Proton Pump Inhibitors (PPIs):

  • Omeprazole 20-40 mg daily before meals
  • For healing of erosive esophagitis: up to 8 weeks of treatment 3
  • For maintenance therapy: lowest effective dose to minimize side effects

• H2 Receptor Antagonists (alternative if PPIs not tolerated):

  • Ranitidine 150 mg twice daily 4
  • Can be used during the 2-week PPI washout period before H. pylori testing 2

3. Management of Complications

• For acute hemorrhagic gastritis:

  • Supportive measures and acid suppression therapy
  • Endoscopic therapy for active bleeding
  • Surgery as last resort for uncontrolled bleeding 5

• For severe atrophic gastritis:

  • Surveillance endoscopy every 3 years for advanced atrophic gastritis 1
  • For autoimmune gastritis: individualized surveillance based on risk factors 1

• For nutritional deficiencies:

  • Evaluate and treat iron and vitamin B-12 deficiencies 1
  • Particularly important in corpus-predominant atrophic gastritis

4. Special Considerations

• Neuroendocrine tumors in autoimmune gastritis:

  • Screen with upper endoscopy
  • Remove small tumors endoscopically
  • Follow with surveillance every 1-2 years 1

• Autoimmune comorbidities:

  • Screen for autoimmune thyroid disease in patients with autoimmune gastritis 1

Pitfalls and Caveats

1. Medication interference with diagnosis:

   • PPIs should be stopped 2 weeks before H. pylori testing to avoid false negatives
   • H2 antagonists have less impact and can be substituted during this period 2

2. Incomplete eradication:

   • Failure to confirm H. pylori eradication can lead to persistent disease
   • Use different antibiotic regimen after first treatment failure 2

3. Missed surveillance:

   • Severe atrophic gastritis requires ongoing surveillance due to increased gastric cancer risk
   • Patients with pernicious anemia need endoscopy to rule out gastric neoplasia 1

4. Overlooking nutritional deficiencies:

   • Iron and vitamin B-12 deficiencies are common in severe gastritis and require treatment
   • Acid-free stomach can impair absorption of essential vitamins and micronutrients 6

By following this treatment algorithm, the morbidity and mortality associated with severe gastritis can be significantly reduced, particularly by preventing progression to gastric cancer and managing complications effectively.