What is the initial treatment for gastritis?

Initial Treatment for Gastritis

For patients with gastritis, the initial treatment should include a proton pump inhibitor (PPI) such as esomeprazole 20-40 mg twice daily, taken 30 minutes before meals. 1, 2

Treatment Algorithm

First-Line Treatment

1. Proton Pump Inhibitor (PPI) Therapy

   • Esomeprazole 20-40 mg twice daily (preferred due to higher efficacy)
   • Alternative PPIs: omeprazole 20 mg, rabeprazole 20 mg, lansoprazole 30 mg, pantoprazole 40 mg
   • Take 30 minutes before morning and evening meals
   • Duration: 4-8 weeks depending on symptom resolution

2. If H. pylori infection is confirmed:

   • Bismuth quadruple therapy for 14 days is recommended, especially in areas with high clarithromycin resistance (≥15%) 1:
     • PPI (esomeprazole 20-40 mg) twice daily
     • Bismuth subsalicylate 2 tablets (262 mg each) four times daily
     • Tetracycline 500 mg four times daily
     • Metronidazole 500 mg three to four times daily

Supportive Measures

• Avoid alcohol, NSAIDs, spicy foods, and other gastric irritants
• Smaller, more frequent meals
• Stress reduction techniques

Evidence for PPI Therapy

PPIs are the cornerstone of initial gastritis treatment due to their potent acid suppression properties. Omeprazole and other PPIs are FDA-approved for various acid-related conditions including gastritis 2. They work by reducing gastric acid production, allowing the inflamed gastric mucosa to heal.

The American College of Gastroenterology recommends PPI therapy as first-line treatment for gastritis, with esomeprazole showing superior efficacy compared to other PPIs like pantoprazole (94% vs 82% eradication rates when used in combination therapy) 1.

H. pylori Considerations

If H. pylori is present (a common cause of gastritis), eradication therapy is necessary. Studies show that PPI therapy alone is ineffective for H. pylori eradication, with one study demonstrating only 15% clearance with omeprazole 40 mg/day compared to 83% with triple therapy 3.

Bismuth quadruple therapy for 14 days is currently recommended as first-line treatment in areas with high clarithromycin resistance 1. This regimen achieves eradication rates of approximately 85%.

Important Clinical Pearls

• Timing matters: PPIs should be taken 30 minutes before meals to maximize efficacy 1
• Duration of therapy: Initial treatment is typically 4-8 weeks, with potential extension if symptoms persist 2
• Confirm H. pylori eradication: Test for eradication 4 weeks after completing treatment using urea breath test or stool antigen test (not serology) 1
• Stop PPIs before testing: PPIs should be discontinued 2 weeks before H. pylori testing (except serology) to avoid false negatives 1

Potential Pitfalls

1. Inadequate acid suppression: Using too low a dose or incorrect timing of PPI administration

2. Failure to address H. pylori: Not testing for or inadequately treating H. pylori infection

3. Prolonged PPI use without indication: Long-term PPI use may lead to complications including:

   • Tubulointerstitial nephritis
   • C. difficile-associated diarrhea
   • Bone fractures
   • Certain types of lupus erythematosus 2

4. Inappropriate treatment duration: Too short a course may lead to symptom recurrence; too long without indication may increase risk of adverse effects

By following this treatment algorithm, most patients with gastritis will experience symptom relief and healing of gastric inflammation within 4-8 weeks.