Treatment of 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 for symptom relief and mucosal healing. 1, 2
Initial Assessment and Testing
Before initiating treatment, all patients with gastritis must be tested for H. pylori infection using non-invasive methods such as urea breath test or monoclonal stool antigen tests. 1, 2 This is critical because H. pylori-positive gastritis requires eradication therapy in addition to acid suppression to prevent progression to atrophic gastritis and reduce gastric cancer risk. 3, 1
Treatment Based on Etiology
H. pylori-Positive Gastritis
Bismuth quadruple therapy for 14 days is the preferred first-line regimen due to increasing clarithromycin resistance rates. 1, 2 This consists of:
- High-potency PPI (twice daily)
- Bismuth subsalicylate
- Metronidazole
- Tetracycline
When bismuth is unavailable, concomitant 4-drug therapy serves as an alternative first-line option. 1, 2 Triple therapy (PPI + clarithromycin + amoxicillin) should only be used in areas with documented low clarithromycin resistance (<15%). 3, 4
Higher-potency PPIs significantly improve H. pylori eradication rates. 1, 2 The dose-response relationship is well-established, with cure rates increasing from 45% with omeprazole 20 mg once daily to 82.5% with omeprazole 60 mg twice daily when combined with amoxicillin. 5
After completing eradication therapy, confirmation of successful eradication is mandatory using non-serological testing 4+ weeks after treatment completion. 1, 2 Relying solely on symptom resolution without confirming eradication leads to persistent infection and complications. 1
H. pylori-Negative Gastritis
For non-H. pylori gastritis, PPI monotherapy remains the cornerstone of treatment:
- Esomeprazole: 20-40 mg twice daily (equivalent to 32 mg omeprazole) 1
- Rabeprazole: 20 mg twice daily (equivalent to 36 mg omeprazole) 1
- Lansoprazole: 30 mg twice daily (equivalent to 27 mg omeprazole) 1
Avoid pantoprazole when possible due to significantly lower potency (40 mg pantoprazole = only 9 mg omeprazole). 1
Critical timing: PPIs must be taken 30 minutes before meals for optimal effectiveness. 2, 4 Inadequate timing is a common pitfall that reduces treatment efficacy. 1
NSAID-Induced Gastritis
The management algorithm for NSAID-induced gastritis is:
Test for H. pylori and eradicate if positive before initiating or continuing NSAID therapy. 3, 1, 2 H. pylori eradication is mandatory in patients with a history of peptic ulcers who require NSAIDs or aspirin. 3
Discontinue NSAIDs if clinically feasible. 2 If NSAIDs must be continued, add high-dose PPI therapy for gastroprotection. 1, 2
Use the lowest effective NSAID dose for the shortest duration. 1, 2
For aspirin users with ulcer history, the residual risk of peptic ulcer bleeding after successful H. pylori eradication is very low, even without additional gastroprotection. 3
Misoprostol (synthetic PGE1) reduces NSAID-associated gastric ulcers by 74%, but its use is limited by side effects including diarrhea and abdominal pain. 1, 2
Treatment Duration and Follow-up
Standard treatment duration is 4-8 weeks for acute gastritis. 4 If symptoms persist after 8 weeks, an additional 4-week course may be considered. 4
For patients on long-term PPIs who are H. pylori-positive, eradication heals gastritis and prevents progression to atrophic gastritis. 3, 1 Long-term PPI use in H. pylori-positive patients accelerates corpus-predominant gastritis and atrophic changes. 3, 1
Special Populations and Considerations
Autoimmune Gastritis
- Check antiparietal cell antibodies and anti-intrinsic factor antibodies 1
- Evaluate for vitamin B-12 and iron deficiencies 1
- Screen for concomitant autoimmune thyroid disease 1
- Consider surveillance endoscopy every 3 years for advanced atrophic gastritis 1
Gastric MALT Lymphoma
H. pylori eradication is first-line treatment for low-grade gastric MALT lymphoma (Lugano stage I/II), achieving cure in 60-80% of cases. 3 However, when t(11,18) translocation is present, eradication is usually ineffective and patients require chemotherapy or radiotherapy. 3
Common Pitfalls to Avoid
- Inadequate PPI dosing or incorrect timing (must be 30 minutes before meals) 1, 2
- Premature discontinuation of treatment before completing full course 1
- Failure to test for and eradicate H. pylori when present 1, 2
- Insufficient antibiotic duration (must be 14 days, not 7-10 days) 2
- Not confirming H. pylori eradication after treatment 1, 2
- Failure to evaluate for vitamin B-12 and iron deficiencies in atrophic gastritis 1
Adjunctive Therapy
Antacids provide rapid, temporary symptom relief and can be used on-demand for breakthrough symptoms during PPI therapy. 1, 2 However, they do not heal gastritis and should not be used as monotherapy. 1
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