What is the treatment for gastritis symptoms?

Treatment of Gastritis Symptoms

Proton pump inhibitors (PPIs) are the first-line treatment for gastritis symptoms, 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

Initial Pharmacologic Management

PPI Selection and Dosing

• Esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily are the preferred high-potency PPIs for gastritis treatment 1
• Lansoprazole 30 mg twice daily is an alternative high-potency option 1
• Avoid pantoprazole when possible due to significantly lower potency (40 mg pantoprazole equals only 9 mg omeprazole equivalent) 1
• PPIs should be taken 30 minutes before meals to maximize effectiveness 1
• Omeprazole delayed-release capsules are typically dosed once daily before a meal, with timing based on individual clinical presentation 2

H2-Receptor Antagonists as Alternative

• H2-receptor antagonists (H2RAs) like ranitidine provide faster symptom relief than PPIs but are less effective for mucosal healing 1
• H2RAs are more effective for duodenal ulcers than gastric ulcers 1
• Ranitidine 150 mg twice daily provides symptomatic relief within 24 hours for GERD-related symptoms 3

Adjunctive Symptomatic Treatment

• Antacids provide rapid, temporary relief and can be used on-demand for breakthrough symptoms 1
• Concomitant antacids should be given as needed for pain relief 3

H. pylori Assessment and Eradication

All patients with gastritis must be assessed for H. pylori infection, as this fundamentally changes management. 4, 1

Testing Strategy

• Use non-invasive tests: urea breath test or monoclonal stool antigen tests 1
• Avoid serological testing for confirmation of eradication 4

Eradication Regimens

• Bismuth quadruple therapy for 14 days is the preferred first-line treatment (PPI + bismuth + metronidazole + tetracycline) due to increasing antibiotic resistance 4, 1
• Concomitant 4-drug therapy is an alternative when bismuth is unavailable 1
• Higher-potency PPIs (rabeprazole or esomeprazole) improve H. pylori eradication rates 1
• Successful eradication must be confirmed using non-serological testing 4, 1

Benefits of H. pylori Eradication

• Eradication heals gastritis and prevents progression to atrophic gastritis, particularly in patients on long-term PPIs 4, 1
• Long-term PPI treatment in H. pylori-positive patients accelerates progression to corpus-predominant atrophic gastritis 4, 1

NSAID-Associated Gastritis

Prevention and Management

• Discontinue NSAIDs if possible 1
• If NSAIDs must be continued, add PPI therapy for gastroprotection 1
• Use the lowest effective NSAID dose for the shortest duration 1
• H. pylori eradication is mandatory before starting long-term NSAID therapy in patients with peptic ulcer history 4, 1

Alternative Gastroprotection

• Misoprostol reduces NSAID-associated gastric ulcers by 74% and duodenal ulcers by 53%, though side effects (diarrhea, abdominal pain, nausea) limit its use 1

Special Considerations for Atrophic Gastritis

Diagnostic Workup

• When endoscopic features of atrophic gastritis are present, obtain biopsies from body and antrum/incisura in separately labeled jars 4
• In suspected autoimmune gastritis, check antiparietal cell antibodies and anti-intrinsic factor antibodies 4, 1
• Evaluate for vitamin B-12 and iron deficiencies in all patients with atrophic gastritis, especially if corpus-predominant 4, 1
• Screen for autoimmune thyroid disease in patients with autoimmune gastritis 4, 1

Surveillance Strategy

• Surveillance endoscopy every 3 years for advanced atrophic gastritis (defined by anatomic extent and histologic grade) 4, 1
• For autoimmune gastritis, individualized surveillance intervals based on risk assessment 4, 1
• Screen for type 1 gastric neuroendocrine tumors with upper endoscopy in autoimmune gastritis patients 4

Common Pitfalls to Avoid

• Inadequate PPI dosing or premature discontinuation reduces treatment effectiveness 1
• Failure to confirm H. pylori eradication leads to persistent infection and complications 1
• Not evaluating for vitamin B-12 and iron deficiencies in atrophic gastritis results in inadequate management 4, 1
• Using pantoprazole as first-line PPI due to its significantly lower potency 1
• Relying on symptom resolution alone without confirming H. pylori eradication 1

Duration of Treatment

• Most duodenal ulcers heal within 4 weeks; treatment beyond 8 weeks has not been adequately studied 3
• Gastric ulcers typically heal within 6 weeks; further treatment usefulness is not demonstrated 3
• GERD symptoms commonly improve within 24 hours of starting therapy 3
• Erosive esophagitis may require up to 8 weeks for healing 2
• Long-term PPI use beyond 12 months for maintenance therapy requires careful consideration of risks versus benefits 2