What is the best treatment for a gastritis flare-up?

Treatment of Gastritis Flare-Up

Start high-potency proton pump inhibitors (PPIs) immediately at twice-daily dosing—specifically esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily, taken 30 minutes before meals—as first-line treatment for rapid symptom relief and mucosal healing. 1, 2, 3

Immediate Management

PPI Selection and Dosing

• Esomeprazole 20-40 mg twice daily (equivalent to 32 mg omeprazole) is the preferred high-potency option 1, 2
• Rabeprazole 20 mg twice daily (equivalent to 36 mg omeprazole) is equally effective 1, 2
• Lansoprazole 30 mg twice daily (equivalent to 27 mg omeprazole) is an alternative 1
• Avoid pantoprazole when possible due to significantly lower potency (40 mg pantoprazole = only 9 mg omeprazole) 1
• Critical timing: Take PPIs 30 minutes before meals for optimal effectiveness 2, 3

Adjunctive Symptom Relief

• Add antacids for rapid, temporary relief of breakthrough symptoms on-demand 1, 2, 3
• These provide immediate symptomatic relief while PPIs work to heal the mucosa 1

Essential H. pylori Assessment

Test all gastritis patients for H. pylori infection using non-invasive methods (urea breath test or monoclonal stool antigen test) rather than serology 1, 3

If H. pylori Positive

• Bismuth quadruple therapy for 14 days is the preferred first-line treatment due to increasing clarithromycin resistance: PPI + bismuth + metronidazole + tetracycline 1, 2, 3
• Concomitant 4-drug therapy is an alternative when bismuth is unavailable 1, 2
• Use antibiotics from the "Access group" (amoxicillin, tetracycline, metronidazole) rather than "Watch group" antibiotics when possible to minimize resistance 3
• Higher-potency PPIs (esomeprazole or rabeprazole) improve H. pylori eradication rates 1
• Confirm eradication 4-6 weeks after completing therapy using non-serological testing 3
• For bleeding ulcers, start H. pylori eradication treatment when oral feeding is reintroduced 4

If H. pylori Negative

• Continue full-dose PPI therapy for 4-8 weeks 1, 2
• Gradual improvement with fluctuations is expected 2

NSAID-Related Gastritis

• Discontinue NSAIDs immediately if possible 3
• If NSAIDs must be continued, use the lowest effective dose for the shortest duration 1, 2
• Add PPI therapy for gastroprotection in all high-risk patients taking NSAIDs 1, 2
• Test and eradicate H. pylori before starting long-term NSAID therapy, especially in patients with prior peptic ulcer history 1, 3
• Misoprostol reduces NSAID-associated gastric ulcers by 74% but causes diarrhea and abdominal pain in many patients 1, 2

Duration and Follow-Up

• Continue PPI therapy for 4-8 weeks for initial healing 2, 5
• For gastric ulcers, continue PPI treatment until complete healing is confirmed by endoscopy 4
• For complicated ulcers, continue PPI until H. pylori eradication is confirmed 4
• If symptoms persist despite 8 weeks of treatment, consider an additional 4 weeks 5

Critical Pitfalls to Avoid

• Never use antibiotic therapy <14 days duration as this significantly reduces H. pylori eradication rates 3
• Do not rely on symptom resolution alone—confirm H. pylori eradication with non-serological testing 1, 3
• Inadequate PPI dosing (wrong timing relative to meals) reduces effectiveness dramatically 1, 2
• Premature discontinuation of treatment before mucosal healing is complete 1
• Failure to address underlying H. pylori infection when present 1
• Using serology to confirm eradication (remains positive after successful treatment) 3

Special Considerations for Atrophic Gastritis

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 3
• Screen for autoimmune thyroid disease 3
• Consider surveillance endoscopy every 3 years for advanced atrophic gastritis 3