What is the best approach to manage severe gastritis?

Management of Severe Gastritis

For severe gastritis, initiate 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, while simultaneously testing for H. pylori and treating with bismuth quadruple therapy for 14 days if positive. 1, 2, 3

Immediate First-Line Treatment

Acid Suppression Therapy

• Start high-potency PPIs immediately as they are superior to H2-receptor antagonists for both symptom relief and mucosal healing in severe gastritis 1, 2, 4
• Preferred PPI options with equivalent dosing:
  • 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
• Critical timing: PPIs must be taken 30 minutes before meals for optimal effectiveness—this is a common pitfall that reduces treatment efficacy 1, 2
• Avoid pantoprazole when possible due to significantly lower potency (40 mg pantoprazole = only 9 mg omeprazole) 1

Concurrent H. pylori Assessment

• Test all severe gastritis patients for H. pylori immediately using non-invasive methods: urea breath test or monoclonal stool antigen test 1, 3
• Do not use serology for diagnosis or confirmation of eradication as it remains positive after successful treatment 3

H. pylori-Positive Severe Gastritis

Eradication Therapy

• Bismuth quadruple therapy for 14 days is the preferred first-line treatment due to increasing antibiotic resistance to clarithromycin and metronidazole 1, 2, 3
  • PPI (high-potency as above) + bismuth + metronidazole + tetracycline
• Alternative when bismuth unavailable: Concomitant 4-drug therapy 1, 2
• Duration is critical: Antibiotic therapy must be 14 days—shorter durations significantly reduce eradication rates 2, 3
• Higher-potency PPIs (esomeprazole, rabeprazole) improve H. pylori eradication rates compared to standard-potency options 1

Confirmation of Eradication

• Confirm eradication 4-6 weeks after completing therapy using non-serological testing (urea breath test or stool antigen) 3
• Relying solely on symptom resolution without confirming eradication is a critical error that leads to persistent infection and complications 1, 2

NSAID-Induced Severe Gastritis

Immediate Management

• Discontinue NSAIDs immediately if clinically 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 2, 3

Alternative Gastroprotection

• Misoprostol (synthetic PGE1) reduces NSAID-associated gastric ulcers by 74% and duodenal ulcers by 53%, but use is limited by side effects including diarrhea (common), abdominal pain, and nausea 1

Adjunctive Therapy for Severe Symptoms

• Antacids provide rapid, temporary relief and can be used on-demand for breakthrough symptoms while awaiting PPI effect 1, 2, 3
• Antacids work within minutes but do not heal mucosa—they are symptomatic relief only 1

Special Considerations for Severe Gastritis

Atrophic Gastritis Assessment

• If atrophic gastritis is present on histology, check antiparietal cell antibodies and anti-intrinsic factor antibodies to identify autoimmune etiology 3
• Screen for vitamin B-12 and iron deficiencies in all patients with atrophic gastritis, particularly with corpus-predominant disease 3
• Screen for concomitant autoimmune thyroid disease as autoimmune disorders commonly cluster 3

Long-term PPI Considerations

• In H. pylori-positive patients on long-term PPIs, eradication heals gastritis and prevents progression to atrophic gastritis 1, 3
• Long-term PPI treatment in H. pylori-positive patients accelerates progression to corpus-predominant atrophic gastritis 1
• Monitor for potential complications of prolonged PPI use (>3 years): vitamin B-12 deficiency, hypomagnesemia, and increased risk of osteoporosis-related fractures 5

Surveillance and Follow-up

Endoscopic Surveillance

• For advanced atrophic gastritis (extensive anatomic distribution and high histologic grade), perform endoscopy every 3 years due to increased gastric cancer risk 3
• Consider additional follow-up and diagnostic testing in patients with suboptimal response or early symptomatic relapse after completing PPI therapy 5

Persistent Symptoms After H. pylori Eradication

• For residual symptoms following confirmed H. pylori eradication, continue full-dose PPI therapy for epigastric pain or reflux symptoms 1
• Gradual improvement with fluctuations is expected—complete resolution may take weeks 1
• If symptoms persist despite appropriate therapy, consider endoscopic evaluation to rule out other causes including gastric malignancy 2, 5

Critical Pitfalls to Avoid

• Inadequate PPI dosing or incorrect timing (must be 30 minutes before meals) 1, 2
• Premature discontinuation of treatment before adequate healing occurs 1
• Failure to test for and address H. pylori infection when present 1, 2
• Antibiotic therapy duration <14 days for H. pylori eradication 2, 3
• Relying on symptom resolution alone without confirming H. pylori eradication with non-serological testing 1, 2, 3
• Failure to evaluate for vitamin B-12 and iron deficiencies in patients with atrophic gastritis 3
• Using serology to confirm H. pylori eradication—it remains positive after successful treatment 3