What is the treatment for antral gastritis?

Treatment of Antral Gastritis

The primary treatment for antral gastritis is H. pylori eradication using bismuth quadruple therapy for 14 days, which addresses the underlying cause in the vast majority of cases and leads to resolution of inflammation. 1

Identify and Treat the Underlying Cause

H. pylori Testing and Eradication (First Priority)

• Test all patients with antral gastritis for H. pylori infection using non-invasive methods such as urea breath test or monoclonal stool antigen tests 2, 1
• H. pylori is present in approximately 90% of patients with antral gastritis and is significantly correlated with the severity of inflammation 3
• Eradication of H. pylori provides significant improvement in symptom resolution with a number needed to treat of 12 for functional dyspepsia 2

First-Line Eradication Regimen

Bismuth quadruple therapy for 14 days is the preferred treatment due to increasing antibiotic resistance 1:

• Bismuth subcitrate 120 mg four times daily
• Plus two antibiotics from the "Access group" (amoxicillin, tetracycline, metronidazole)
• Plus high-potency proton pump inhibitor

Alternative when bismuth unavailable: Concomitant 4-drug therapy for 14 days 1

Why Bismuth-Based Therapy is Optimal for Antral Gastritis

• Bismuth preparations significantly reduce both H. pylori colonization and gastritis severity (p < 0.002) 3
• In atrophic gastritis involving the antrum, reduced gastric acid secretion may make standard PPI-based regimens less effective 4
• Bismuth-based therapy may be particularly attractive in the specific setting of atrophic changes 4

Acid Suppression Therapy

Proton Pump Inhibitors

High-potency PPIs are first-line for symptom relief and mucosal healing 1:

• Esomeprazole 20-40 mg twice daily, OR
• Rabeprazole 20 mg twice daily, OR
• Lansoprazole 30 mg twice daily
• Take 30 minutes before meals for optimal effectiveness 1

Duration and Monitoring

• Continue PPI therapy during and after H. pylori eradication (typically 4-8 weeks total) 1
• Confirm H. pylori eradication 4-6 weeks after completing antibiotic therapy using non-invasive testing 1
• For persistent symptoms after successful eradication, continue full-dose PPI therapy 1

Expected Timeline for Histological Resolution

• Complete or near-complete resolution of mild to moderate gastritis occurs within 4-5 weeks after successful H. pylori eradication 5
• In mild gastritis: 89% show complete resolution of inflammation 5
• In moderate gastritis: 85% show almost complete recovery with only minor residual changes 5
• Severe gastritis may cause irreparable damage with persistent scarring, glandular distortion, and atrophy even after eradication 5

Special Considerations for Atrophic Changes

When Antral Atrophy is Present

• Antral atrophy with intestinal metaplasia indicates H. pylori-associated atrophic gastritis (HpAG) that begins in the antrum and can progress to involve the corpus 2
• All patients with intestinal metaplasia should receive H. pylori eradication (strong recommendation, moderate quality evidence) 6
• The presence of intestinal metaplasia on gastric histology almost invariably implies atrophic gastritis 2, 6

Cancer Risk Stratification

• Extensive atrophy and metaplasia are associated with increased gastric cancer risk 2
• Incomplete (colonic-type) intestinal metaplasia carries 3-fold higher cancer risk than complete type 6
• Extensive intestinal metaplasia involving both antrum and body has approximately 2-fold higher progression risk 6

Surveillance Considerations

• Endoscopic surveillance is not routinely recommended for all patients with intestinal metaplasia (conditional recommendation, very low quality evidence) 6
• Consider surveillance for high-risk individuals: incomplete metaplasia, extensive metaplasia, or family history of gastric cancer 6
• Patients with severe atrophic gastritis should be considered for endoscopic surveillance for early gastric cancer detection 2

Micronutrient Management

• Screen for and treat iron and vitamin B-12 deficiencies, particularly in patients with extensive atrophic changes 2
• These deficiencies are common extragastric manifestations of atrophic gastritis 2

Common Pitfalls to Avoid

• Do not use inadequate PPI dosing or premature discontinuation of treatment 1
• Do not use insufficient duration of antibiotic therapy - must be 14 days, not 7 days 1
• Do not rely solely on symptom resolution without confirming H. pylori eradication 1
• Do not fail to obtain separate antral and corpus biopsies in labeled jars to assess extent of atrophic changes 2, 6
• Cimetidine and standard H2-blockers have no effect on H. pylori or gastritis severity 3

Adjunctive Therapy

• Antacids can be used on-demand for breakthrough symptoms during treatment 1, 7
• Concomitant antacids should be given as needed for pain relief 7