What is the treatment for gastritis without bleeding?

Treatment for Gastritis without Bleeding

Proton pump inhibitors (PPIs) are the first-line treatment for gastritis without bleeding, with an initial regimen of oral PPI therapy at standard dosing (such as omeprazole 20 mg twice daily) for 4-8 weeks. 1

Pharmacological Management

First-line Therapy

• Proton Pump Inhibitors (PPIs):
  • Initial treatment: Standard dose PPI (omeprazole 20 mg, lansoprazole 30 mg, or equivalent) twice daily for 4-8 weeks 1, 2
  • PPIs work by inhibiting the H+/K+-ATPase in gastric parietal cells, profoundly suppressing acid secretion 3
  • PPIs increase gastric pH above 6, which is necessary for optimal healing of gastric mucosa 3
  • Examples: omeprazole, lansoprazole, pantoprazole, esomeprazole

Second-line Therapy

• H2 Receptor Antagonists:
  • Less effective than PPIs as they do not reliably or consistently increase gastric pH to 6 3
  • Can be used in patients who cannot tolerate PPIs
  • Examples: ranitidine 150 mg twice daily 4

Adjunctive Therapies

• Antacids:
  • For immediate symptom relief while waiting for PPIs to take effect
  • Can be taken as needed for breakthrough pain

H. pylori Testing and Eradication

• Testing for H. pylori is essential in all patients with gastritis 1
• If H. pylori positive, eradication therapy should be provided:
  • Triple therapy: PPI + clarithromycin 500 mg + amoxicillin 1 g, each twice daily for 14 days 2, 5
  • Quadruple therapy may be considered in areas with high clarithromycin resistance

Duration of Treatment

• Initial treatment: 4-8 weeks of PPI therapy 2
• After initial treatment:
  • If symptoms resolve completely: discontinue therapy
  • If symptoms persist: consider extending therapy for additional 4 weeks
  • For recurrent symptoms: consider maintenance therapy with once-daily PPI 1

Special Considerations

NSAID-Associated Gastritis

• If gastritis is NSAID-related:
  • Discontinue NSAIDs if possible
  • If NSAIDs must be continued, PPI therapy is indicated for the duration of NSAID use 2
  • PPIs are more effective than H2 receptor antagonists for healing and preventing NSAID-related gastric injury 5

Refractory Gastritis

• For patients not responding to standard PPI therapy:
  • Ensure medication adherence
  • Consider doubling the PPI dose
  • Evaluate for other causes of symptoms (functional dyspepsia, gastroparesis)
  • Consider endoscopy if not previously performed

Lifestyle Modifications

• Avoid triggers that may exacerbate symptoms:
  • Alcohol
  • Spicy foods
  • Caffeine
  • Smoking
• Small, frequent meals rather than large meals
• Avoid eating within 3 hours of bedtime

Follow-up

• Clinical reassessment after 4-8 weeks of therapy
• If symptoms persist despite appropriate therapy, endoscopic evaluation is recommended if not previously performed
• For H. pylori-positive patients, confirmation of eradication should be performed 4 weeks after completing antibiotic therapy

Common Pitfalls to Avoid

1. Inadequate acid suppression: Using suboptimal doses of PPIs or H2 blockers
2. Failure to test for H. pylori: All patients with gastritis should be tested and treated if positive
3. Premature discontinuation of therapy: Complete the full course of treatment
4. Overlooking NSAID use: Always assess and address NSAID use in patients with gastritis
5. Missing atrophic gastritis: This condition may require longer treatment and surveillance due to increased risk of gastric cancer

The evidence strongly supports the use of PPIs as first-line therapy for gastritis without bleeding, with H. pylori eradication when indicated. This approach effectively reduces symptoms, promotes healing of the gastric mucosa, and prevents complications.