What is the recommended treatment for chronic gastritis?

Treatment of Chronic Gastritis

The recommended first-line treatment for chronic gastritis is Helicobacter pylori eradication therapy for H. pylori-positive cases, combined with proton pump inhibitors for symptom relief, as this approach reduces gastric cancer risk and improves symptoms. 1

Diagnosis and Classification

Before initiating treatment, proper diagnosis and classification of chronic gastritis is essential:

• Chronic gastritis can be classified into three main types: type A (autoimmune, affecting proximal stomach), type B (H. pylori-associated, affecting distal/antral region), and type C (chemical/reflux-induced) 2
• Common symptoms include epigastric pain/discomfort (especially after eating), nausea, vomiting, early satiety, bloating, and heartburn 3
• H. pylori infection is the most important causative factor in 71-95% of gastric cancers and is strongly associated with chronic gastritis 1
• Diagnostic tests should include endoscopy with biopsy for histopathological examination and H. pylori testing 1

Treatment Algorithm

Step 1: Test for H. pylori and Determine Gastritis Type

• Test for H. pylori using endoscopic biopsy, urea breath test, or stool antigen test 1
• Assess for atrophic changes and intestinal metaplasia, which are risk factors for gastric cancer 1

Step 2: H. pylori Eradication (if positive)

• First-line treatment should be H. pylori eradication therapy using antibiotic combinations based on local resistance patterns 1
• Eradication therapy significantly reduces the risk of gastric cancer development 1
• The antibiotic regimen should be chosen according to local H. pylori antibiotic resistance patterns 1

Step 3: Acid Suppression Therapy

• For symptom relief, acid suppression with proton pump inhibitors (PPIs) is recommended 1
• H2-receptor antagonists like ranitidine may be used for treatment of GERD symptoms associated with gastritis 4
• In patients with chronic cough due to GERD associated with gastritis, acid suppression therapy should be initiated before testing 1

Step 4: Lifestyle and Dietary Modifications

• Implement dietary modifications including limiting fat intake to no more than 45g in 24 hours 1
• Avoid coffee, tea, soda, chocolate, mints, citrus products (including tomatoes), and alcohol 1
• Smoking cessation is recommended as smoking is associated with increased gastric cancer risk 1
• Limit vigorous exercise that increases intra-abdominal pressure 1

Step 5: Follow-up and Monitoring

• Confirm H. pylori eradication 4-8 weeks after completion of therapy 1
• For patients with atrophic gastritis or intestinal metaplasia, endoscopic surveillance is recommended due to increased gastric cancer risk 1
• Monitor for vitamin B12 and iron deficiency, particularly in patients with autoimmune gastritis or severe atrophic gastritis 3, 5

Special Considerations

Atrophic Gastritis and Cancer Risk

• Patients with severe atrophic gastritis are at increased risk for gastric cancer and require closer monitoring 1, 5
• H. pylori eradication is most effective for cancer prevention when performed before the development of preneoplastic conditions 1
• First-degree relatives of patients with gastric cancer should receive H. pylori eradication therapy due to their 2-3 times increased risk 1

Refractory Symptoms

• For patients with persistent symptoms despite standard therapy, consider:
  • Prokinetic therapy in addition to acid suppression 1
  • Evaluation for other causes of symptoms such as functional dyspepsia 3
  • Assessment for bile reflux, especially in patients with history of gastric surgery 2

Nutritional Deficiencies

• Monitor and treat nutritional deficiencies, particularly:
  • Vitamin B12 deficiency in autoimmune gastritis 3, 5
  • Iron deficiency anemia in chronic gastritis with bleeding 3, 5
  • Calcium, magnesium, and zinc deficiencies in severe atrophic gastritis 5

Common Pitfalls and Caveats

• Failure to test for H. pylori before initiating empiric PPI therapy can mask the infection and lead to false-negative test results 1
• PPIs should be discontinued 10-14 days before H. pylori testing to avoid false-negative results 1
• Chronic gastritis may be asymptomatic in early stages but can still progress to atrophy and increase cancer risk 3, 5
• Intestinal metaplasia is generally considered irreversible, highlighting the importance of early H. pylori eradication 1
• Not all patients with H. pylori infection develop symptoms, but eradication should still be considered due to cancer risk 1