What is the recommended treatment for a patient with gastritis?

Management of Gastritis

Proton pump inhibitors (PPIs) are the first-line treatment for gastritis, with higher potency agents such as esomeprazole or rabeprazole (20-40 mg twice daily) recommended over pantoprazole. 1

Diagnostic Approach

• Test for Helicobacter pylori using non-invasive methods:
  • Urea breath test (UBT)
  • Monoclonal stool antigen tests
  • Validated serological tests 2
• Consider endoscopic evaluation if symptoms persist despite 4-8 weeks of therapy 1

Treatment Algorithm

Step 1: Initial PPI Therapy

• First-line: High-potency PPI (esomeprazole or rabeprazole 20-40 mg twice daily) 1
• Duration: 2-4 weeks for mild cases; 4-8 weeks for severe cases 1
• For hemorrhagic gastritis: Higher dose PPI therapy (omeprazole 40 mg twice daily) 1

Step 2: H. pylori Testing and Eradication (if positive)

• Triple therapy (10-14 days):
  • PPI (omeprazole 20 mg twice daily)
  • Clarithromycin 500 mg twice daily
  • Amoxicillin 1000 mg twice daily 1
• Alternative in areas with high clarithromycin resistance:
  • Bismuth quadruple therapy 1

Step 3: Symptom Reassessment

• Evaluate response after 2-4 weeks of therapy 1
• If symptoms persist despite 4-8 weeks of therapy, consider endoscopic evaluation 1

Special Considerations

NSAID-Induced Gastritis

• Discontinue NSAIDs if possible
• PPIs are more effective than H2-receptor antagonists and better tolerated than misoprostol 3

H. pylori-Associated Gastritis

• H. pylori eradication is essential if infection is present, as it significantly reduces recurrence risk 1
• H. pylori eradication in patients with functional dyspepsia provides long-term relief in approximately 1 in 12 patients 2
• H. pylori eradication is particularly beneficial before starting NSAID treatment and mandatory in patients with a history of peptic ulcer 2

Long-term PPI Use

• Long-term PPI treatment in H. pylori-positive patients can accelerate progression to atrophic gastritis 2, 1
• Eradication of H. pylori in patients receiving long-term PPIs heals gastritis and prevents progression to atrophic gastritis 2

Important Cautions

• Avoid pantoprazole when possible due to lower relative potency compared to other PPIs 1
• For patients with severe hemorrhagic gastritis requiring fluid resuscitation, hydroxyethyl starch fluids should be avoided 1
• Monitor patients on glucocorticoids for blood pressure changes, particularly if they have systemic sclerosis, due to risk of scleroderma renal crisis 2

Follow-up

• Reassess symptoms after 2-4 weeks of therapy 1
• If symptoms persist despite adequate therapy (4-8 weeks), endoscopic evaluation is warranted 1
• For chronic gastritis, especially with atrophic changes, consider monitoring for vitamin B12, iron, calcium, magnesium, and zinc deficiencies 4