What is the care plan for a patient with gastritis?

Care Plan for Gastritis

All patients with gastritis should receive high-potency proton pump inhibitors (PPIs) as first-line therapy—specifically esomeprazole 20-40 mg or rabeprazole 20 mg twice daily, taken 30 minutes before meals—and must be tested for H. pylori infection using non-invasive methods such as urea breath test or stool antigen test. 1, 2, 3

Initial Assessment and Diagnostic Workup

H. pylori Testing (Mandatory for All Patients)

• Perform non-invasive testing with urea breath test or monoclonal stool antigen test 1, 2
• Avoid serological testing as it remains positive after successful treatment and cannot confirm eradication 1
• If atrophic gastritis is present on histology, check antiparietal cell antibodies and anti-intrinsic factor antibodies to identify autoimmune etiology 1, 3

Risk Stratification

• Assess for NSAID use, anticoagulant use, or other risk factors for gastritis 4
• Screen for vitamin B-12 and iron deficiencies, particularly in corpus-predominant disease 1, 3
• Screen for autoimmune thyroid disease in patients with autoimmune gastritis 1, 3

Treatment Algorithm 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:

• High-potency PPI (esomeprazole 20-40 mg or rabeprazole 20 mg) twice daily 1, 2, 3
• Bismuth subsalicylate 1, 2
• Metronidazole 1, 2
• Tetracycline 1, 2

Alternative regimen when bismuth is unavailable: Concomitant 4-drug therapy 2, 3

Critical treatment principles:

• Use antibiotics from the "Access group" (amoxicillin, tetracycline, metronidazole) rather than "Watch group" (clarithromycin, levofloxacin) when possible 1
• Never use antibiotic therapy for less than 14 days—this significantly reduces eradication rates 1, 2
• Confirm eradication 4-6 weeks after completing therapy using non-serological testing (urea breath test or stool antigen) 1, 2

NSAID-Induced Gastritis

• Discontinue NSAIDs immediately if possible 1, 2
• If NSAIDs must be continued, add PPI therapy for gastroprotection 2, 3
• Test and treat H. pylori before initiating long-term NSAID therapy in all patients, especially those with prior peptic ulcer history 1, 2
• Use the lowest effective NSAID dose for the shortest duration 2, 3

Autoimmune Gastritis

• Screen for vitamin B-12 and iron deficiencies in all patients 1, 3
• Screen for autoimmune thyroid disease 1, 3
• Provide vitamin B-12 supplementation as needed 3
• Consider interval endoscopic surveillance based on individualized risk assessment 3

Acid Suppression Therapy (All Gastritis Types)

PPI Selection and Dosing

High-potency PPIs are superior to lower-potency options 1, 2, 3:

• Esomeprazole: 20-40 mg twice daily (equivalent to 32 mg omeprazole) 2, 3
• Rabeprazole: 20 mg twice daily (equivalent to 36 mg omeprazole) 2, 3
• Lansoprazole: 30 mg twice daily (equivalent to 27 mg omeprazole) 2, 3
• Avoid pantoprazole when possible due to lower potency (40 mg pantoprazole = 9 mg omeprazole) 3

Critical administration details:

• Take PPIs 30 minutes before meals for optimal effectiveness 1, 2, 3, 5
• Duration: 4-8 weeks for symptom relief and mucosal healing 5, 6

Alternative Acid Suppression

• H2-receptor antagonists (ranitidine, famotidine) provide faster symptom relief but are less effective than PPIs for healing gastric lesions 3, 6
• Antacids provide rapid, temporary relief and can be used on-demand for breakthrough symptoms 1, 2, 3

Follow-Up and Monitoring

Post-Treatment Assessment

• Confirm H. pylori eradication 4-6 weeks after completing therapy using non-serological testing 1, 2
• Do not rely on symptom resolution alone—persistent infection can occur despite symptom improvement 2, 3
• For patients with residual symptoms after successful H. pylori eradication, continue full-dose PPI therapy 2, 3

Surveillance for Atrophic Gastritis

• Use OLGA staging to determine surveillance intervals and cancer prevention strategies 1
• Perform endoscopy every 3 years for advanced atrophic gastritis (extensive anatomic distribution and high histologic grade) 1, 3

Patient Education and Supportive Care

Essential Patient Counseling

• Explain that gastroesophageal reflux is a physiologic process 4
• Provide standardized educational material on GERD mechanisms, weight management, lifestyle and dietary behaviors 4
• Emphasize the importance of completing the full antibiotic course 1, 2

Supportive Measures for Patients on Immunosuppressants

For patients requiring corticosteroids (rare in uncomplicated gastritis):

• Monitor blood glucose 4
• Provide histamine-2 blockers or PPIs for gastritis prophylaxis in high-risk patients (those taking NSAIDs or anticoagulants) 4
• Consider vitamin D and calcium supplementation to reduce osteoporosis risk 4

Critical Pitfalls to Avoid

Common errors that compromise treatment success:

• Inadequate PPI dosing or incorrect timing relative to meals 2, 3
• Premature discontinuation of treatment 2, 3
• Failure to address H. pylori infection when present 2, 3
• Using antibiotic therapy for less than 14 days 1, 2
• Relying solely on symptom resolution without confirming H. pylori eradication 2, 3
• Failure to evaluate for vitamin B-12 and iron deficiencies in patients with atrophic gastritis 3

Special Considerations

Long-Term PPI Use Concerns

• Long-term PPI treatment in H. pylori-positive patients is associated with corpus-predominant gastritis and accelerated progression to atrophic gastritis 3, 7, 8
• Eradicate H. pylori before initiating long-term PPI therapy to prevent progression to atrophic gastritis 3
• Chronic PPI use may mask H. pylori infection and increase the risk of intestinal metaplasia 8

Expected Treatment Course

• Gradual improvement of symptoms with fluctuations is expected with appropriate treatment 2, 3
• For persistent symptoms despite appropriate therapy, consider endoscopic evaluation to rule out other causes 2