What is the recommended treatment for gastritis?

Treatment of Gastritis

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

Diagnosis and Evaluation

Before initiating treatment, it's important to:

• Test for H. pylori infection using either:

  • 13C-Urea Breath Test (sensitivity 95%, specificity 90%)
  • Monoclonal stool antigen test (comparable accuracy to breath test)
  • Note: Discontinue PPIs, antibiotics, and bismuth products at least 2 weeks prior to testing 1

• Consider endoscopy for patients:

  • Age ≥ 55 years
  • Presenting with alarm symptoms (weight loss, bleeding, anemia)
  • With risk factors for gastric cancer 1

Treatment Regimens

H. pylori-Associated Gastritis

1. First-line therapy:

   • Bismuth quadruple therapy (14 days):
     • PPI (high-potency preferred, such as esomeprazole or rabeprazole 40 mg twice daily)
     • Bismuth subsalicylate
     • Tetracycline HCl
     • Metronidazole 1

2. Alternative first-line options:

   • Concomitant non-bismuth quadruple therapy (14 days) - 80% eradication rate
   • Standard triple therapy (PPI + clarithromycin + amoxicillin) for 14 days - 85% eradication rate 1

3. Salvage therapy (after first-line failure):

   • Ideally guided by antibiotic susceptibility testing
   • For areas with high dual resistance (clarithromycin and metronidazole):
     • 14-day regimen with high-dose PPI + amoxicillin + levofloxacin + bismuth
   • If clarithromycin sensitive:
     • 14-day regimen with PPI + bismuth + tetracycline + clarithromycin 1

Non-H. pylori Gastritis

For gastritis not associated with H. pylori infection, treatment focuses on acid suppression:

• PPI therapy (e.g., omeprazole) for 4-8 weeks
• Omeprazole is indicated for:
  • Treatment of active duodenal ulcer
  • Treatment of active benign gastric ulcer
  • Treatment of symptomatic GERD
  • Treatment of erosive esophagitis 2

Follow-up and Monitoring

• Test for H. pylori eradication at least 4 weeks after completing treatment
• Stop PPI at least 2 weeks before testing
• Use either urea breath test or monoclonal stool antigen test 1

Important Considerations

Patient Education

• Counsel patients about potential side effects:
  • Darkening of stool from bismuth
  • Need to avoid alcohol while taking metronidazole 1

Medication Interactions and Special Populations

• PPIs may have drug interactions - consider this when prescribing
• Most medications for H. pylori treatment are compatible with breastfeeding
• For pregnant patients, avoid invasive diagnostic procedures unless absolutely necessary 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: 14-day regimens are recommended to maximize eradication rates 1

2. Poor patient compliance: This significantly reduces eradication rates; thorough patient education is essential 1

3. Ignoring antibiotic resistance: In areas with high resistance rates, antibiotic susceptibility testing is valuable 1

4. Failure to confirm eradication: Always test for eradication at least 4 weeks after completing treatment 1

5. Overlooking PPI effects on H. pylori testing: False negatives can occur if PPIs are not discontinued before testing 1

PPIs not only reduce acid secretion but also possess some antibacterial activity against H. pylori and may exert anti-inflammatory effects, which can help reduce gastritis symptoms even without complete eradication of the infection 3, 4.