What is the treatment for gastritis?

Treatment for Gastritis

Proton pump inhibitors (PPIs) are the first-line treatment for gastritis, with high-potency options like esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily being most effective, and all patients must be tested for H. pylori infection using non-invasive methods (urea breath test or stool antigen test) to guide additional antimicrobial therapy. 1, 2, 3

Initial Assessment and H. pylori Testing

• Test all gastritis patients for H. pylori using urea breath test or monoclonal stool antigen tests—these are the validated non-invasive methods 4, 1, 3
• Avoid serological testing for confirming eradication as antibodies remain positive even after successful treatment 3
• If atrophic gastritis is present on histology, check antiparietal cell antibodies and anti-intrinsic factor antibodies to identify autoimmune etiology 1, 3

Acid Suppression Therapy (All Gastritis Types)

PPI dosing is critical for treatment success:

• Esomeprazole 20-40 mg twice daily (equivalent to 32 mg omeprazole) 1, 2
• Rabeprazole 20 mg twice daily (equivalent to 36 mg omeprazole) 1, 2
• Lansoprazole 30 mg twice daily (equivalent to 27 mg omeprazole) 1, 2
• Avoid pantoprazole when possible due to lower potency (40 mg pantoprazole = only 9 mg omeprazole) 1
• Take PPIs 30 minutes before meals for optimal effectiveness 2, 3

Higher PPI doses significantly improve outcomes—studies show cure rates increase from 45% with omeprazole 20 mg once daily to 82.5% with 60 mg twice daily when combined with antibiotics 5

H. pylori-Positive Gastritis Treatment

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

• PPI (high-potency as above) + bismuth + metronidazole + tetracycline for 14 days 1, 3
• This regimen achieves approximately 90% eradication rates even with clarithromycin resistance 1, 6

Alternative first-line option when bismuth is unavailable:

• Concomitant 4-drug therapy: PPI + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily + metronidazole 500 mg twice daily for 5-14 days 1, 6
• Simultaneous administration for 5 days achieves ~90% eradication vs. ~80% with traditional 7-day triple therapy 6
• Sequential therapy (amoxicillin for 5 days, then clarithromycin + metronidazole for 5 days) shows similar efficacy 6

Critical treatment principles:

• Use antibiotics from the "Access group" (amoxicillin, tetracycline, metronidazole) rather than "Watch group" (clarithromycin, levofloxacin) when possible to minimize resistance 3
• Never use antibiotic therapy <14 days duration—this significantly reduces eradication rates 3
• Higher-potency PPIs improve H. pylori eradication rates beyond their acid suppression effects 1, 2

Confirm eradication 4-6 weeks after completing therapy using non-serological testing (urea breath test or stool antigen)—do not rely on symptom resolution alone 4, 3

H. pylori eradication produces long-term relief in approximately 1 in 12 patients with functional dyspepsia, which is better than any other treatment 4

NSAID-Induced Gastritis

• Discontinue NSAIDs immediately if possible 3
• If NSAIDs must be continued, add PPI therapy for gastroprotection 1, 2
• 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 1, 2
• Misoprostol reduces NSAID-associated gastric ulcers by 74% but causes diarrhea, abdominal pain, and nausea in many patients 1

Autoimmune Gastritis

• Screen for vitamin B-12 and iron deficiencies in all patients, particularly with corpus-predominant disease 1, 3
• Screen for concomitant autoimmune thyroid disease 1, 3
• Consider surveillance endoscopy every 3 years for advanced atrophic gastritis due to cancer risk 1, 3

Adjunctive Treatments

• Antacids provide rapid, temporary relief and can be used on-demand for breakthrough symptoms 1, 2, 3
• For patients with residual symptoms after successful H. pylori eradication (confirmed by negative tests), continue full-dose PPI therapy 1, 2

Critical Pitfalls to Avoid

• Inadequate PPI dosing and premature discontinuation—use high-potency PPIs at appropriate doses for full treatment duration 1, 2
• Failure to address H. pylori infection when present—always test and treat 1, 2
• Insufficient antibiotic duration (<14 days)—this dramatically reduces eradication rates 3, 6
• Relying on symptom resolution without confirming H. pylori eradication—persistent infection leads to complications 1, 3
• Using pantoprazole as first-line PPI—it has significantly lower potency than esomeprazole or rabeprazole 1
• Taking PPIs at the wrong time—must be 30 minutes before meals 2, 3

Long-term PPI treatment in H. pylori-positive patients accelerates progression to atrophic gastritis, making eradication essential before chronic PPI therapy 1