What is the treatment for chronic gastritis?

Treatment for Chronic Gastritis

The treatment for chronic gastritis should primarily focus on eradication of Helicobacter pylori using proton pump inhibitor (PPI) triple therapy, consisting of a PPI (such as omeprazole 20 mg or esomeprazole 20-40 mg) plus clarithromycin 500 mg plus amoxicillin 1000 mg, all twice daily for 10-14 days. 1

Diagnostic Approach

Before initiating treatment, confirm the diagnosis and etiology of chronic gastritis:

• Test for H. pylori using non-invasive methods:

  • Urea breath test
  • Monoclonal stool antigen tests
  • Validated serological tests 1

• Consider endoscopy with biopsy if:

  • Symptoms persist despite 4-8 weeks of therapy
  • Patient has alarm symptoms (weight loss, bleeding, anemia)
  • Age >45 years with new-onset symptoms 1

Treatment Algorithm

Step 1: Identify the Type of Gastritis

Different types of chronic gastritis require specific approaches:

• H. pylori-associated gastritis (most common)
• NSAID-induced gastritis
• Autoimmune gastritis
• Alcohol-induced gastritis
• Stress-related gastritis 1

Step 2: First-line Treatment

For H. pylori-positive Gastritis:

• First-line regimen: PPI triple therapy

  • PPI (omeprazole 20 mg) + clarithromycin 500 mg + amoxicillin 1000 mg, all twice daily for 10-14 days 1
  • Consider using esomeprazole or rabeprazole instead of pantoprazole due to higher potency 1

• Alternative in areas with high clarithromycin resistance: Bismuth quadruple therapy 1

For H. pylori-negative Gastritis:

• PPI therapy (esomeprazole or rabeprazole 20-40 mg twice daily) for 4-8 weeks 1
• Avoid pantoprazole when possible due to lower relative potency 1

Step 3: For Hemorrhagic Gastritis

• Higher dose PPI therapy (omeprazole 40 mg twice daily) 1
• Goal-directed fluid therapy for significant bleeding
• Avoid hydroxyethyl starch fluids in patients requiring fluid resuscitation 1

Step 4: Follow-up and Second-line Treatment

• Reassess symptoms after 2-4 weeks of therapy 1
• If H. pylori eradication fails (up to 20% of cases), consider:
  • Levofloxacin-based triple therapy
  • Bismuth-containing quadruple therapy
  • Use antibiotics not included in previous treatments 2

Special Considerations

Long-term Management

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

Clinical Benefits of H. pylori Eradication

• Prevents recurrence in patients with peptic ulcer disease (>90% cure rate) 3
• Provides long-term relief in approximately 1 in 12 patients with functional dyspepsia 1
• Particularly beneficial before starting NSAID treatment 1
• Mandatory in patients with a history of peptic ulcer 1
• Associated with decreased recurrence rate of early gastric cancer after endoscopic resection 3

Common Pitfalls to Avoid

1. Failing to test for H. pylori before initiating treatment
2. Using inadequate antibiotic regimens (single or dual therapy) for H. pylori eradication
3. Not considering antibiotic resistance patterns in your region
4. Continuing long-term PPI therapy in H. pylori-positive patients without eradication
5. Using pantoprazole instead of more potent PPIs like esomeprazole or rabeprazole 1

The discovery that H. pylori is the primary cause of chronic antral gastritis has revolutionized our understanding and treatment approach to this condition, with eradication therapy now being the cornerstone of management for H. pylori-positive chronic gastritis 3, 1.