What is the initial approach to treating gastritis?

Initial Approach to Treating Gastritis

The initial approach to treating gastritis should include H. pylori testing and eradication if positive, followed by proton pump inhibitor therapy for symptom relief, with appropriate dosing and duration based on the specific type and severity of gastritis. 1

Diagnosis and Classification

Before initiating treatment, proper diagnosis is essential:

1. Endoscopic evaluation with biopsies:

   • Obtain biopsies from both body and antrum/incisura in separately labeled jars
   • Target any suspicious areas for metaplasia or atrophy
   • Look for endoscopic features: pale mucosa, increased visibility of vasculature, loss of gastric folds 2

2. Determine etiology:

   • H. pylori testing: Use non-serological methods like urea breath test (95% sensitivity and specificity) or stool antigen test (88-90% sensitivity, 91-100% specificity) 1
   • Autoimmune markers: Check antiparietal cell antibodies and anti-intrinsic factor antibodies if autoimmune gastritis is suspected 2
   • Other causes: Medications, alcohol, stress, bile reflux

Treatment Algorithm

Step 1: H. pylori Eradication (if positive)

• First-line regimen: 14-day triple therapy with:
  • Proton pump inhibitor (e.g., omeprazole 20mg twice daily)
  • Amoxicillin (1g twice daily)
  • Clarithromycin (500mg twice daily) 1
• Confirm eradication: Using urea breath test or stool antigen test at least 4 weeks after treatment completion (stop PPIs 2 weeks before testing) 1

Step 2: Acid Suppression Therapy

• PPI therapy: Omeprazole 20mg daily before a meal for 4-8 weeks 3
  • Take at the lowest effective dose for the shortest time needed
  • For erosive gastritis: 8 weeks of therapy
  • For non-erosive gastritis: 4 weeks of therapy

Step 3: Address Nutritional Deficiencies

• For autoimmune gastritis or atrophic gastritis:
  • Vitamin B12 supplementation if deficient
  • Iron supplementation if iron deficiency anemia is present 2

Step 4: Lifestyle Modifications

• Avoid gastric irritants (alcohol, NSAIDs, spicy foods)
• Smoking cessation
• Stress reduction techniques

Special Considerations

Atrophic Gastritis

• Surveillance: Endoscopy every 3 years for advanced atrophic gastritis (OLGA/OLGIM stage III/IV) 2
• Risk stratification: Consider family history of gastric cancer, immigration from high-risk regions, persistent H. pylori, and smoking 1

Autoimmune Gastritis

• Surveillance: Endoscopy every 3-5 years 2
• Screen for:
  • Type 1 gastric neuroendocrine tumors
  • Autoimmune thyroid disease
  • Vitamin B12 and iron deficiencies 1

Monitoring and Follow-up

• Short-term: Assess symptom improvement after 2-4 weeks of therapy
• Medium-term: Repeat endoscopy for patients with:
  • Persistent symptoms despite therapy
  • Atrophic changes
  • Intestinal metaplasia
• Long-term: Surveillance based on risk stratification

Potential Complications and Pitfalls

1. Medication side effects:

   • PPIs can cause kidney problems (tubulointerstitial nephritis)
   • Risk of C. difficile infection
   • Bone fractures with long-term use
   • Lupus erythematosus in susceptible individuals 3

2. Common pitfalls:

   • False negative H. pylori testing: Can occur if patient recently used antibiotics or PPIs
   • Incomplete eradication: Always confirm successful H. pylori eradication
   • Overlooking atrophic changes: These increase gastric cancer risk and require surveillance 2
   • Misdiagnosing lymphocytic gastritis or other specific forms of gastritis that require different management 4

By following this systematic approach to gastritis management, you can effectively treat symptoms, address underlying causes, and reduce the risk of complications including gastric cancer.