What is the initial treatment for a patient diagnosed with gastritis?

Initial Treatment for Gastritis

For patients diagnosed with gastritis, initiate high-potency proton pump inhibitor (PPI) therapy with esomeprazole 20-40 mg or rabeprazole 20 mg twice daily, taken 30 minutes before meals, while simultaneously testing for H. pylori infection using non-invasive methods (urea breath test or stool antigen test). 1, 2, 3

Immediate First Steps

Start Acid Suppression Therapy

• Prescribe high-potency PPIs as first-line treatment: esomeprazole 20-40 mg twice daily OR rabeprazole 20 mg twice daily 1, 2, 3
• Lansoprazole 30 mg twice daily is an acceptable alternative 2, 3
• Avoid pantoprazole when possible due to significantly lower potency (40 mg pantoprazole equals only 9 mg omeprazole equivalent) 3
• Critical timing: PPIs must be taken 30 minutes before meals for optimal effectiveness 2

Test for H. pylori Immediately

• Order urea breath test OR monoclonal stool antigen test (not serology, as it remains positive after treatment) 1, 3
• Do not wait for test results to start PPI therapy—begin symptom management immediately 2

Treatment Algorithm Based on H. pylori Status

If H. pylori POSITIVE:

Switch to bismuth quadruple therapy for 14 days (the preferred first-line regimen due to increasing antibiotic resistance): 1, 2, 3

• High-potency PPI (esomeprazole 20-40 mg or rabeprazole 20 mg) twice daily
• Bismuth subsalicylate
• Metronidazole
• Tetracycline
• Duration must be 14 days—shorter courses have inadequate eradication rates 2

Alternative if bismuth unavailable: Concomitant 4-drug therapy 2, 3

Confirm eradication 4-6 weeks after completing therapy using non-serological testing (urea breath test or stool antigen)—do not rely on symptom resolution alone 1, 2

If H. pylori NEGATIVE:

• Continue high-potency PPI therapy (esomeprazole 20-40 mg or rabeprazole 20 mg twice daily) 2, 3
• Investigate other causes: NSAID use, autoimmune gastritis, bile reflux 3
• If NSAID-induced: discontinue NSAIDs if possible; if continuation necessary, maintain PPI gastroprotection 2, 3
• If atrophic gastritis on histology: check antiparietal cell antibodies and anti-intrinsic factor antibodies to identify autoimmune etiology 1, 3

Adjunctive Symptomatic Relief

• Antacids provide rapid, temporary relief and can be used on-demand for breakthrough symptoms while PPIs take effect 2, 3

Critical Pitfalls to Avoid

Common errors that lead to treatment failure:

• Inadequate PPI dosing: Using low-potency PPIs or incorrect timing (must be 30 minutes before meals) 2, 3
• Premature discontinuation: Stopping treatment before completing the full course 2
• Failure to test for H. pylori: Missing the underlying infection leads to persistent inflammation 2, 3
• Relying on symptom resolution alone: Symptoms may improve while H. pylori persists, requiring confirmation testing 2, 3
• Insufficient antibiotic duration: H. pylori therapy must be 14 days, not shorter 2
• Using serological testing for diagnosis or confirmation: Serology remains positive after successful eradication and cannot confirm cure 1

Special Considerations

Long-term PPI Use Warning

• In H. pylori-positive patients, long-term PPI therapy accelerates progression to corpus-predominant atrophic gastritis 3, 4
• Always eradicate H. pylori before initiating long-term PPI therapy to prevent this progression 1, 3

NSAID Users

• Use the lowest effective NSAID dose for the shortest duration 2, 3
• Eradicate H. pylori before starting long-term NSAID therapy, especially in patients with prior peptic ulcer history 3
• Add PPI gastroprotection for high-risk patients requiring continued NSAID use 2, 3

Patient Education

• Emphasize completing the full antibiotic course for H. pylori eradication 1
• Explain that gradual symptom improvement with fluctuations is expected 2
• Clarify that successful treatment requires confirmation testing, not just symptom resolution 2