What is the recommended treatment for gastritis?

Gastritis Treatment

High-potency proton pump inhibitors (PPIs) such as esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily are the first-line treatment for gastritis, taken 30 minutes before meals for optimal effectiveness. 1, 2, 3

Initial Assessment

All patients with gastritis must be tested for H. pylori infection using non-invasive methods:

• Urea breath test (UBT) or monoclonal stool antigen test are the recommended diagnostic approaches 1, 3
• Avoid serological testing for confirming eradication as antibodies remain positive after successful treatment 3
• If atrophic gastritis is present on histology, check antiparietal cell antibodies and anti-intrinsic factor antibodies to identify autoimmune etiology 3

Treatment Based on Etiology

H. pylori-Positive Gastritis

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

• PPI (high-potency) + bismuth + metronidazole + tetracycline for 14 days 1, 3
• Concomitant 4-drug therapy (PPI + amoxicillin + clarithromycin + metronidazole for 5-14 days) is an alternative when bismuth is unavailable, achieving ~90% eradication rates 1, 4
• Sequential therapy (amoxicillin for 5 days, then clarithromycin + metronidazole for 5 days) shows similar efficacy to simultaneous administration 4

Higher-potency PPIs significantly improve H. pylori eradication rates: 1, 5

• Esomeprazole 20-40 mg twice daily 1, 2
• Rabeprazole 20 mg twice daily (equivalent to 36 mg omeprazole) 1
• Lansoprazole 30 mg twice daily (equivalent to 27 mg omeprazole) 1
• Avoid pantoprazole when possible - 40 mg pantoprazole equals only 9 mg omeprazole 1

Critical: Confirm eradication 4-6 weeks after completing therapy using non-serological testing (urea breath test or stool antigen test). 3

NSAID-Induced Gastritis

Discontinue NSAIDs immediately if possible. 2, 3

If NSAIDs must be continued:

• Add high-potency PPI therapy for gastroprotection 1, 2
• Use the lowest effective NSAID dose for the shortest duration 1, 2
• Test and treat H. pylori before initiating long-term NSAID therapy, especially in patients with prior peptic ulcer history 1, 3

Misoprostol (synthetic PGE1) reduces NSAID-associated gastric ulcers by 74% and duodenal ulcers by 53%, but side effects (diarrhea, abdominal pain, nausea) limit its use. 1

Autoimmune Gastritis

Screen for nutritional deficiencies and associated autoimmune conditions:

• Evaluate for vitamin B-12 and iron deficiencies in all patients 1, 3
• Screen for concomitant autoimmune thyroid disease 1, 3
• Consider surveillance endoscopy every 3 years for advanced atrophic gastritis 1, 3

H. pylori-Negative Gastritis or Post-Eradication Symptoms

For patients with residual symptoms after confirmed H. pylori eradication:

• Full-dose PPI therapy (esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily) is first-line treatment 1
• Antacids provide rapid, temporary relief for breakthrough symptoms and can be used on-demand 1, 2, 3
• Gradual improvement with fluctuations is expected 1

PPI Dosing Optimization

PPIs must be taken 30 minutes before meals for maximum effectiveness - inadequate timing is a common pitfall that reduces efficacy. 1, 2

Recommended high-potency PPI regimens:

• Rabeprazole: 20 mg twice daily 1, 2
• Esomeprazole: 20-40 mg twice daily 1, 2
• Lansoprazole: 30 mg twice daily 1, 2

Critical Pitfalls to Avoid

Antibiotic therapy duration: Never use less than 14 days for H. pylori eradication - shorter courses significantly reduce eradication rates 1, 2, 3

Confirmation of eradication: Relying solely on symptom resolution without confirming H. pylori eradication leads to persistent infection and complications 1, 3

PPI dosing errors: Inadequate PPI dosing and premature discontinuation are common mistakes 1, 2

Long-term PPI use in H. pylori-positive patients: This accelerates progression to corpus-predominant and atrophic gastritis - eradicate H. pylori first 1

Failure to evaluate nutritional deficiencies: In atrophic gastritis, not checking vitamin B-12 and iron levels leads to inadequate management 1, 3