What is the treatment for gastritis?

Treatment of Gastritis

The treatment of gastritis should focus on proton pump inhibitors (PPIs) as first-line therapy, with the addition of antibiotics for H. pylori eradication when infection is present. 1

Diagnostic Approach

• Determine gastritis type: H. pylori-associated, NSAID-induced, stress-related, alcohol-induced, autoimmune, or hemorrhagic
• Testing for H. pylori is essential through breath test, stool antigen, or endoscopic biopsy

First-Line Treatment Algorithm

Non-H. pylori Gastritis

1. Acid Suppression Therapy

   • High-potency PPI (esomeprazole or rabeprazole 20-40 mg twice daily) 1
   • Avoid pantoprazole due to lower relative potency 1
   • Take PPI before meals for optimal effect 2

2. Lifestyle Modifications

   • Eliminate triggering factors (NSAIDs, alcohol, spicy foods)
   • Smaller, more frequent meals
   • Avoid lying down within 3 hours after eating

3. For Hemorrhagic Gastritis

   • Higher dose PPI therapy (omeprazole 40 mg twice daily) 1
   • Goal-directed fluid therapy for significant bleeding 1

H. pylori-Associated Gastritis

1. Triple Therapy (first-line) 3, 1

   • PPI (omeprazole 20 mg twice daily)
   • Clarithromycin 500 mg twice daily
   • Amoxicillin 1000 mg twice daily
   • Duration: 14 days (preferred over shorter courses) 3

2. Bismuth Quadruple Therapy (alternative first-line or for clarithromycin resistance) 3, 1

   • PPI twice daily
   • Bismuth subsalicylate
   • Tetracycline 500 mg four times daily
   • Metronidazole 500 mg three times daily
   • Duration: 10-14 days

Treatment Duration and Follow-up

• Non-H. pylori gastritis: 4-8 weeks of PPI therapy 1
• H. pylori gastritis: 14-day eradication therapy 3
• Reassess symptoms after 2-4 weeks 1
• Consider endoscopic evaluation if symptoms persist despite 4-8 weeks of therapy 1

Special Considerations

Antibiotic Selection

• Use "Access group" antibiotics (amoxicillin, tetracycline, metronidazole) when possible 3
• "Watch group" antibiotics (clarithromycin, levofloxacin) have higher resistance potential 3
• Antimicrobial resistance is a major cause of treatment failure 3, 4

Treatment Failures

• For H. pylori eradication failure, consider:
  • Levofloxacin-based triple therapy (10 days) as second-line treatment 5
  • Rifabutin-based regimen as third-line treatment 5
  • Susceptibility testing when available 3

Medication Interactions

• Monitor carbamazepine levels when using clarithromycin (may increase serum levels) 6
• Check for potential drug interactions with PPIs, especially with clopidogrel, methotrexate 2

Common Pitfalls to Avoid

1. Inadequate treatment duration: 14-day therapy achieves higher eradication rates than 7-day regimens 3
2. Ignoring antibiotic resistance: Consider local resistance patterns when selecting therapy 3
3. Long-term PPI use without H. pylori eradication: Can accelerate progression to atrophic gastritis 1
4. Poor patient compliance: Emphasize the importance of completing the full course of treatment 4
5. Failure to confirm eradication: Consider testing to confirm H. pylori eradication after therapy 3

The treatment approach should be tailored based on gastritis type, with H. pylori eradication being essential if infection is present to prevent recurrence and reduce the risk of complications such as peptic ulcer disease and gastric cancer.