What is the best management for pain in gastritis?

Management of Pain in Gastritis

The best management for pain in gastritis involves optimizing medical therapies that modulate pain from visceral stimuli while incorporating non-pharmacological approaches, avoiding opioids, and establishing a collaborative patient-provider relationship. 1

First-Line Pharmacological Approaches

• Proton pump inhibitors (PPIs) are efficacious first-line treatments for gastroduodenal disorders including gastritis, as they reduce acid production and allow healing of inflamed gastric mucosa 1, 2
• Histamine H2 receptor inhibitors such as ranitidine can effectively relieve symptoms of gastritis pain, with symptom relief commonly occurring within 24 hours of therapy initiation 3
• Antispasmodics rank highly for relief of abdominal pain in gastrointestinal disorders and can be effective for pain management in gastritis 1
• Antacids should be given as needed for pain relief in patients with gastritis 3

Non-Pharmacological Approaches

• Non-pharmacological therapies should be considered routinely as part of comprehensive pain management and ideally introduced early in care 1
• Brain-gut psychotherapies have strong evidence for pain relief and should be incorporated into treatment plans:
  • Cognitive behavioral therapy has been supported by more than 30 randomized controlled trials for gastrointestinal pain 1
  • Gut-directed hypnotherapy focuses on somatic awareness and down-regulation of pain sensations through guided imagery 1
  • Mindfulness-based stress reduction can decrease visceral hypersensitivity and improve cognitive appraisal of symptoms 1

Advanced Pharmacological Options for Persistent Pain

• For persistent pain not responding to first-line therapies, neuromodulators should be considered:
  • Tricyclic antidepressants (TCAs) rank first for relief of abdominal pain in gastrointestinal disorders 1
  • Serotonin-norepinephrine reuptake inhibitors (SNRIs) are effective alternatives for patients who cannot tolerate TCAs 1
  • Mirtazapine may be beneficial for certain patients with persistent gastritis pain 1

Special Considerations

• Opioids should never be prescribed for chronic gastrointestinal pain as they are ineffective and potentially harmful, with risk of developing narcotic bowel syndrome 1
• For gastritis related to H. pylori infection, treatment should include proton pump inhibitors and appropriate antibiotics 4
• Food-based therapies such as probiotics, honey, and certain plant products may provide complementary benefits, though clinical evidence is limited and requires more rigorous studies 5
• In cases of bile reflux gastritis, medical therapy with chelating agents or motility drugs often yields disappointing results, and surgical diversion may be necessary in severe cases 6, 7

Establishing an Effective Treatment Approach

• Develop a collaborative, empathic patient-provider relationship to address management of persistent pain 1
• Educate patients on the pathogenesis of pain, including the role of the gut-brain axis and psychosocial contexts contributing to pain 1
• Set shared goals and expectations for pain management with the patient 1
• Differentiate when gastrointestinal pain is triggered by visceral factors versus centrally mediated factors to guide appropriate treatment selection 1

Common Pitfalls to Avoid

• Avoid pain catastrophizing by refraining from language suggesting the patient "shouldn't be in so much pain" or continuing to order tests to find the "cause" of pain 1
• Recognize that factors that initiate problems (e.g., infection, surgery, stressful event) are not always the same as those that perpetuate the problem 1
• Be aware that psychological inflexibility and overfocusing on a cause or solution can interfere with pain acceptance and response to treatment 1
• Avoid tramadol, which is considered an opioid and has potential for addiction and other opioid-associated adverse events 1