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, taken 30 minutes before meals, are the first-line treatment for gastritis, with H. pylori testing mandatory in all patients and bismuth quadruple therapy for 14 days as the preferred eradication regimen when infection is present. 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

First-Line Acid Suppression Therapy

High-potency PPIs are superior to H2-receptor antagonists and should be used as first-line therapy:

• 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
• Critical timing: Take PPIs 30 minutes before meals for optimal effectiveness 1, 2
• Avoid pantoprazole when possible due to lower potency (40 mg pantoprazole = only 9 mg omeprazole) 1

H. pylori-Positive Gastritis Treatment

Bismuth quadruple therapy for 14 days is the preferred first-line regimen due to increasing clarithromycin resistance:

• PPI (high-potency as above) + bismuth + metronidazole + tetracycline for 14 days 1, 2, 3
• Concomitant 4-drug therapy (PPI + amoxicillin + clarithromycin + metronidazole) is an alternative when bismuth is unavailable 1, 2
• Use antibiotics from the "Access group" (amoxicillin, tetracycline, metronidazole) rather than "Watch group" (clarithromycin, levofloxacin) when possible to minimize resistance 3
• Higher-potency PPIs (rabeprazole, esomeprazole) improve H. pylori eradication rates 1, 4

Confirm eradication 4-6 weeks after completing therapy:

• Use non-serological testing (urea breath test or stool antigen) 3
• Common pitfall: Relying on symptom resolution alone without confirming eradication leads to persistent infection and complications 1, 2, 3

Critical duration requirement:

• Antibiotic therapy must be given for 14 days—shorter courses significantly reduce eradication rates 1, 2, 3

NSAID-Induced Gastritis

Immediate NSAID discontinuation is the priority:

• Stop NSAIDs immediately if possible 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 3
• Misoprostol reduces NSAID-associated gastric ulcers by 74% but causes diarrhea, abdominal pain, and nausea limiting its use 1, 2

Autoimmune Gastritis

Screen for nutritional deficiencies and associated autoimmune conditions:

• Evaluate for vitamin B-12 and iron deficiencies in all patients 3
• Screen for concomitant autoimmune thyroid disease 3
• Failure to evaluate for these deficiencies leads to inadequate management 1

Atrophic Gastritis Surveillance

Advanced atrophic gastritis requires regular endoscopic monitoring:

• Surveillance endoscopy every 3 years for advanced atrophic gastritis (extensive anatomic distribution and high histologic grade) 1, 3
• H. pylori eradication in patients on long-term PPIs heals gastritis and prevents progression to atrophic gastritis 1, 3
• Long-term PPI treatment in H. pylori-positive patients accelerates progression to corpus-predominant and atrophic gastritis 1

Adjunctive Therapy

For breakthrough symptoms:

• Antacids provide rapid, temporary relief and can be used on-demand 1, 2, 3

Management of Residual Symptoms After H. pylori Eradication

Many patients continue to have dyspeptic symptoms despite confirmed eradication:

• Full-dose PPI therapy (such as esomeprazole 40 mg twice daily) is first-line for epigastric pain or reflux symptoms after confirmed eradication 1
• Gradual improvement with fluctuations is expected 1
• Absence of alarm symptoms (bleeding, vomiting, weight loss) is reassuring 1

Critical Pitfalls to Avoid

• Inadequate PPI dosing or taking PPIs at the wrong time relative to meals (must be 30 minutes before eating) 1, 2
• Premature discontinuation of PPI treatment 1, 2
• Failure to address H. pylori infection when present 1, 2
• Insufficient duration of antibiotic therapy (<14 days) 1, 2, 3
• Not confirming H. pylori eradication with non-serological testing 1, 2, 3