What is the recommended treatment for gastritis?

Treatment of Gastritis

The recommended first-line treatment for gastritis is a 14-day bismuth quadruple therapy consisting of a proton pump inhibitor (PPI), bismuth subsalicylate, tetracycline HCl, and metronidazole, which achieves eradication rates of 85-90% for H. pylori-associated gastritis. 1

Diagnosis and Evaluation

Before initiating treatment, it's important to determine the underlying cause of gastritis:

• For suspected H. pylori infection, use the 13C-Urea Breath Test (sensitivity 95%, specificity 90%) or monoclonal stool antigen test 1
• Discontinue PPIs, antibiotics, and bismuth products at least 2 weeks prior to testing to avoid false negatives 1
• Patients ≥55 years or with alarm symptoms (weight loss, bleeding, anemia) should undergo prompt endoscopy 1

Treatment Algorithm

1. H. pylori-Associated Gastritis

H. pylori eradication is crucial as it reduces the risk of duodenal ulcer recurrence 2:

• First-line therapy: 14-day bismuth quadruple therapy

  • PPI (e.g., omeprazole 40 mg twice daily)
  • Bismuth subsalicylate
  • Tetracycline HCl
  • Metronidazole 1

• Alternative regimens:

  • Triple therapy: Omeprazole + clarithromycin + amoxicillin 2
  • Dual therapy: Omeprazole + clarithromycin (less effective) 2
  • Concomitant non-bismuth quadruple therapy (14 days, 80% eradication rate) 1

• For treatment failures:

  • Perform antibiotic susceptibility testing 1
  • Avoid previously used antibiotics 1
  • For areas with high dual resistance (clarithromycin and metronidazole), use 14-day regimen with high-dose PPI + amoxicillin + levofloxacin + bismuth 1

2. Non-H. pylori Gastritis

• PPI therapy (e.g., omeprazole 20 mg twice daily) for 4-8 weeks 2, 3
• PPIs effectively reduce gastric acid secretion, allowing the gastric mucosa to heal 4
• Higher-potency PPIs (esomeprazole or rabeprazole 40 mg twice daily) may provide better symptom relief 1

Follow-up and Monitoring

• Test for H. pylori eradication at least 4 weeks after completing treatment 1
• Stop PPI at least 2 weeks before testing 1
• Consider surveillance endoscopy every 3 years in patients with risk factors for gastric cancer or atrophic gastritis 1

Important Clinical Considerations

• Patient education is crucial: Inform patients about potential side effects, especially darkening of stool from bismuth and the need to avoid alcohol while taking metronidazole 1

• PPI selection considerations:

  • Rabeprazole has a more rapid onset of action than other PPIs 4
  • Omeprazole and lansoprazole have greater potential for drug-drug interactions compared to pantoprazole and rabeprazole 4
  • Lansoprazole has the strongest antibacterial activity against H. pylori, similar to omeprazole, while pantoprazole is less effective 5

• Caution with long-term PPI use:

  • Long-term PPI therapy in H. pylori-positive patients may cause corpus-predominant gastritis, which is associated with gastric cancer 3
  • Consider H. pylori eradication before starting long-term PPI treatment to reduce hypergastrinemia 6

• Special populations:

  • For pregnant patients, avoid invasive procedures unless absolutely necessary 1
  • Most H. pylori treatments are compatible with breastfeeding 1
  • Consider allergy testing for patients with reported penicillin allergy before prescribing amoxicillin-containing regimens 1

By following this evidence-based approach, gastritis can be effectively treated with high eradication rates for H. pylori and significant symptom improvement for non-H. pylori gastritis.