What is the treatment for gastritis?

Treatment of Gastritis

All patients with gastritis should be tested for H. pylori infection and treated with eradication therapy if positive, while acid suppression with high-potency proton pump inhibitors forms the cornerstone of symptom management regardless of etiology. 1

Initial Assessment and H. pylori Testing

• Test all gastritis patients for H. pylori using non-invasive methods such as urea breath test or monoclonal stool antigen test 1
• Avoid serological testing for confirming eradication as it remains positive after successful treatment 1
• If atrophic gastritis is present on histology, check antiparietal cell antibodies and anti-intrinsic factor antibodies to identify autoimmune etiology 1

H. pylori-Positive Gastritis Treatment

Bismuth quadruple therapy for 14 days is the preferred first-line treatment due to increasing antibiotic resistance to clarithromycin and metronidazole 1, 2, 3

Bismuth Quadruple Therapy (14 days):

• High-potency PPI (esomeprazole 20-40 mg or rabeprazole 20 mg twice daily) 2, 3
• Bismuth subsalicylate
• Metronidazole
• Tetracycline 1

Alternative First-Line Option (when bismuth unavailable):

• Concomitant 4-drug therapy with PPI plus three antibiotics simultaneously 2, 3

Key Points for H. pylori Eradication:

• Use antibiotics from the "Access group" (amoxicillin, tetracycline, metronidazole) rather than "Watch group" antibiotics (clarithromycin, levofloxacin) when possible to minimize resistance development 1
• Higher-potency PPIs (rabeprazole or esomeprazole) improve eradication rates compared to lower-potency options like pantoprazole 2, 3
• Confirm eradication 4-6 weeks after completing therapy using non-serological testing 1, 2
• Triple therapy should only be used when local clarithromycin resistance is <15% 1

Acid Suppression Therapy (All Gastritis Types)

High-potency PPIs taken 30 minutes before meals are first-line for symptom relief and mucosal healing 2, 3

Recommended PPI Regimens:

• Esomeprazole 20-40 mg twice daily (equivalent to 32 mg omeprazole) 2, 3
• Rabeprazole 20 mg twice daily (equivalent to 36 mg omeprazole) 2, 3
• Lansoprazole 30 mg twice daily (equivalent to 27 mg omeprazole) 2, 3
• Avoid pantoprazole when possible as 40 mg is only equivalent to 9 mg omeprazole 3

Critical Timing:

• PPIs must be taken 30 minutes before meals for optimal effectiveness 2, 3
• Inadequate timing is a common cause of treatment failure 2, 3

NSAID-Induced Gastritis

• Discontinue NSAIDs immediately if possible 2, 3
• If NSAIDs must be continued, add PPI therapy for gastroprotection 2, 3
• Test and treat H. pylori before initiating long-term NSAID therapy in all patients, especially those with prior peptic ulcer history 1, 3
• Use the lowest effective NSAID dose for the shortest duration 2, 3
• Misoprostol (synthetic PGE1) reduces NSAID-associated gastric ulcers by 74% but causes diarrhea and abdominal pain in many patients 2, 3

Autoimmune Gastritis

• Screen for vitamin B-12 and iron deficiencies in all patients, particularly with corpus-predominant disease 1
• Screen for autoimmune thyroid disease as concomitant autoimmune disorders are common 1
• Perform endoscopy with topographical biopsies in patients with new pernicious anemia to confirm corpus-predominant atrophic gastritis and rule out neuroendocrine tumors 1
• Screen for type 1 gastric neuroendocrine tumors with upper endoscopy; remove small tumors endoscopically and perform surveillance every 1-2 years 1

Atrophic Gastritis Management

Risk stratification using OLGA staging determines surveillance intervals and cancer prevention strategies 1

High-Risk Patients Requiring H. pylori Eradication:

• First-degree relatives of gastric cancer patients (2-3 times increased risk) 1
• Previous gastric neoplasia treated by endoscopic or subtotal resection 1
• Severe pan-gastritis or corpus-predominant gastritis 1
• Chronic acid suppression therapy >1 year 1
• Heavy smoking or high occupational dust/quartz/cement exposure 1

Surveillance Strategy:

• Endoscopy every 3 years for advanced atrophic gastritis (extensive anatomic distribution and high histologic grade) 1
• Obtain biopsies from body and antrum/incisura in separately labeled jars at minimum 1
• For autoimmune gastritis, surveillance intervals based on individual risk assessment 1

Adjunctive Therapy

• Antacids provide rapid, temporary symptom relief and can be used on-demand for breakthrough symptoms 2, 3
• For residual symptoms after successful H. pylori eradication, continue full-dose PPI therapy 2, 3

Critical Pitfalls to Avoid

• Never use antibiotic therapy <14 days duration as this significantly reduces eradication rates 2, 3
• Never rely on symptom resolution alone without confirming H. pylori eradication with non-serological testing 2, 3
• Never continue PPIs long-term in H. pylori-positive patients without eradication as this accelerates progression to corpus-predominant atrophic gastritis 3
• Never fail to assess vitamin B-12 and iron status in patients with atrophic gastritis, especially corpus-predominant disease 1
• Never use inadequate PPI dosing or incorrect timing (must be 30 minutes before meals) 2, 3

Expected Treatment Course

• Histological resolution of mild to moderate gastritis occurs 4-5 weeks after successful H. pylori eradication 4
• Severe gastritis may cause irreparable mucosal damage with persistent scarring and atrophy despite eradication 4
• Gradual symptom improvement with fluctuations is expected; persistent symptoms despite appropriate therapy warrant endoscopic evaluation 2
• H. pylori eradication heals gastritis and prevents progression to atrophic gastritis in patients on long-term PPIs 3