What are the treatment guidelines for acute gastritis?

Treatment Guidelines for Acute Gastritis

First-line treatment for acute gastritis should include proton pump inhibitors (PPIs) such as esomeprazole or rabeprazole at 20-40 mg twice daily, which are preferred over pantoprazole due to their higher potency. 1

Diagnostic Considerations

• Distinguish between different types of gastritis:
  • Helicobacter pylori-associated
  • NSAID-induced
  • Stress-related
  • Alcohol-induced
  • Autoimmune
  • Hemorrhagic

Treatment Algorithm

Step 1: Initial Management

• Acid Suppression Therapy:

  • PPI therapy: Omeprazole 20-40 mg once or twice daily for 4-8 weeks 1, 2
  • Alternative: H2-receptor antagonists (e.g., ranitidine) if PPIs are contraindicated 3
  • Antacids may be used concomitantly with PPIs for immediate symptom relief 2

• Fluid Management:

  • Goal-directed fluid therapy for patients with significant bleeding 1
  • Avoid hydroxyethyl starch fluids in patients with hemorrhagic gastritis 1

Step 2: H. pylori Testing and Eradication (if positive)

• Test for H. pylori using urea breath test, stool antigen test, or endoscopic biopsy
• If H. pylori positive, initiate eradication therapy:
  • Triple therapy: PPI (omeprazole 20 mg) + clarithromycin 500 mg + amoxicillin 1000 mg, all twice daily for 10-14 days 2
  • Bismuth quadruple therapy is preferred in areas with high clarithromycin resistance 4

Step 3: Specific Interventions Based on Etiology

• NSAID-induced gastritis: Discontinue NSAIDs if possible
• Alcohol-induced gastritis: Alcohol cessation
• Stress-related gastritis: Address underlying cause of physiological stress
• Hemorrhagic gastritis: Higher dose PPI therapy (omeprazole 40 mg twice daily) 1

Step 4: Follow-up and Reassessment

• Reassess symptoms after 2-4 weeks of therapy 1
• Consider endoscopic evaluation if symptoms persist despite 4-8 weeks of therapy 1
• For H. pylori-related gastritis, confirm eradication 4 weeks after completing treatment 5

Special Considerations

Hemorrhagic Acute Gastritis

Early eradication therapy for H. pylori-associated hemorrhagic gastritis has shown efficacy in achieving rapid healing. Treatment should be initiated as soon as possible after disease onset 5.

Long-term PPI Use

Caution should be exercised with long-term PPI use in H. pylori-positive patients, as it can accelerate progression to atrophic gastritis 1, 6. Studies have shown that both omeprazole and lansoprazole can aggravate gastritis parameters in the corpus while improving them in the antrum 6.

Treatment Duration

Most cases of acute gastritis respond to 4-8 weeks of PPI therapy 2. For H. pylori-associated gastritis, eradication therapy followed by PPI treatment results in faster healing compared to PPI therapy alone 5.

Common Pitfalls and Caveats

1. Failure to test for H. pylori: H. pylori infection is a common cause of acute gastritis and should be tested for in all cases.

2. Inadequate PPI dosing: Higher doses may be needed for severe or hemorrhagic gastritis.

3. Premature discontinuation of therapy: Complete the full course of treatment to ensure healing and prevent recurrence.

4. Overlooking medication-induced gastritis: Always review patient's medication list for potential gastric irritants.

5. Misdiagnosis: Acute gastritis can sometimes mimic more serious conditions like gastric carcinoma or lymphoma, requiring histological confirmation 7.

By following these guidelines, most patients with acute gastritis should experience significant symptom improvement and healing of gastric mucosa.