What is the treatment for gastritis?

Treatment for Gastritis

The cornerstone of gastritis treatment is identifying and addressing the underlying cause, with H. pylori eradication therapy being essential for H. pylori-positive gastritis and acid suppression therapy with proton pump inhibitors being the mainstay for symptom management in all types of gastritis. 1

Diagnosis and Classification

• Gastritis should be confirmed by histopathology with biopsies from both the gastric body and antrum/incisura 2
• All patients with gastritis should be assessed for H. pylori infection using non-serological testing modalities 1
• Two main etiologies of gastritis are H. pylori infection and autoimmunity 2

Treatment Algorithm Based on Etiology

H. pylori-Associated Gastritis

• Test for H. pylori using non-serological methods (urea breath test, stool antigen test, or histology) 1
• If H. pylori positive, administer eradication therapy:
  • First-line: Bismuth quadruple therapy (PPI + bismuth + tetracycline + metronidazole) for 10-14 days due to increasing clarithromycin resistance 1, 3
  • Alternative: Concomitant 4-drug therapy (PPI + amoxicillin + clarithromycin + metronidazole) when bismuth is unavailable 1
• Confirm successful eradication at least 4 weeks after therapy completion using non-serological testing 2, 3
• H. pylori eradication can prevent progression to atrophic gastritis and reduce gastric cancer risk 1, 3

Autoimmune Gastritis

• Check antiparietal cell antibodies and anti-intrinsic factor antibodies to confirm diagnosis 2
• Evaluate for vitamin B-12 and iron deficiencies, especially if corpus-predominant 2, 1
• Screen for type 1 gastric neuroendocrine tumors with upper endoscopy 2, 1
• Consider surveillance endoscopy every 1-2 years if neuroendocrine tumors are present 2

Medication-Induced Gastritis (NSAID, alcohol)

• Discontinue or reduce offending agents when possible 4
• Administer PPI therapy (e.g., omeprazole 20-40 mg daily before a meal) 5
• Consider mucosal protective agents like sucralfate or misoprostol for NSAID users who cannot discontinue therapy 4

Pharmacological Management

Acid Suppression Therapy

• Proton pump inhibitors (PPIs):
  • First-line for symptom relief and healing of mucosal damage 5
  • Omeprazole 20-40 mg once daily before a meal for 4-8 weeks 5
  • Take exactly as prescribed at the lowest effective dose for the shortest duration needed 5
• H2-receptor antagonists (if PPIs contraindicated):
  • Ranitidine 150 mg twice daily for symptom relief 6
  • Symptomatic relief commonly occurs within 24 hours 6

Antacids

• Provide rapid but short-term relief of symptoms 6
• Can be used as needed for breakthrough pain in conjunction with other therapies 6

Special Considerations

Atrophic Gastritis

• Consider endoscopic surveillance every 3 years for advanced atrophic gastritis 2
• In patients with autoimmune gastritis, screen for concomitant autoimmune disorders, particularly autoimmune thyroid disease 2
• Bismuth-based therapy may be particularly effective in atrophic gastritis due to reduced gastric acid secretion 3

Acute Hemorrhagic Gastritis

• Requires aggressive management with high-dose PPI therapy (e.g., omeprazole 40 mg twice daily) 4
• Supportive measures including fluid resuscitation and blood transfusion if needed 4
• Endoscopic therapy may be necessary for ongoing bleeding 4

Monitoring and Follow-up

• For H. pylori gastritis: Confirm eradication at least 4 weeks after completing treatment 2, 3
• For atrophic gastritis: Consider surveillance endoscopy every 3 years 2
• For autoimmune gastritis: Monitor vitamin B-12 and iron levels regularly 2, 1
• For patients on long-term PPI therapy: Monitor for potential side effects including bone fractures, kidney problems, and vitamin/mineral deficiencies 5

Pitfalls and Caveats

• False-negative H. pylori tests can occur in patients taking PPIs; ideally, stop PPIs 2 weeks before testing 5, 7
• Long-term PPI use may be associated with increased risk of bone fractures, kidney problems, and C. difficile infection 5
• Incomplete H. pylori eradication can lead to antibiotic resistance; always confirm successful eradication 3, 8
• Non-H. pylori bacterial gastritis (e.g., Enterococcus) may occur, particularly in immunocompromised patients 9, 7