What is the recommended treatment for gastritis, especially when caused by Helicobacter pylori (H. pylori)?

Gastritis Treatment

For gastritis, start with high-potency proton pump inhibitors (PPIs) such as esomeprazole or rabeprazole 20-40 mg twice daily taken 30 minutes before meals, and if H. pylori is present, use bismuth quadruple therapy for 14 days as first-line treatment. 1

First-Line PPI Therapy for Symptom Relief

• Esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily are the preferred PPIs due to their superior potency and effectiveness for gastritis healing 1, 2
• Lansoprazole 30 mg twice daily is an acceptable alternative 1
• Avoid pantoprazole when possible as 40 mg pantoprazole equals only 9 mg of omeprazole, making it significantly less potent 1
• PPIs must be taken 30 minutes before eating on an empty stomach without concomitant antacids to maximize effectiveness 1, 2

H. pylori Testing and Eradication

All patients with gastritis must be tested for H. pylori infection using non-invasive tests such as urea breath test or monoclonal stool antigen tests 1, 2

First-Line H. pylori Treatment: Bismuth Quadruple Therapy

Bismuth quadruple therapy for 14 days is the preferred first-line treatment due to increasing clarithromycin resistance exceeding 15-20% in most regions 1, 2, 3

The regimen consists of: 1, 3

• PPI (standard dose) twice daily
• Bismuth subsalicylate ~300 mg four times daily
• Metronidazole 500 mg three to four times daily (total 1.5-2 g daily)
• Tetracycline 500 mg four times daily

This achieves 80-90% eradication rates even against metronidazole-resistant strains due to bismuth's synergistic effect, and no bacterial resistance to bismuth has been described 1, 3

Alternative When Bismuth is Unavailable

Concomitant non-bismuth quadruple therapy for 14 days consists of: 2, 3

• PPI twice daily
• Amoxicillin 1000 mg twice daily 4
• Clarithromycin 500 mg twice daily
• Metronidazole 500 mg twice daily

This regimen avoids the pitfall of sequential therapy by administering all antibiotics simultaneously, preventing resistance development during treatment 3

Critical Optimization Factors

• 14-day duration is mandatory - this improves eradication by approximately 5% compared to 7-10 day regimens 1, 2, 3
• High-dose PPI twice daily increases cure rates by 6-12% compared to standard once-daily dosing 3, 5
• Higher-potency PPIs (esomeprazole or rabeprazole 40 mg twice daily) may increase cure rates by an additional 8-12% 1, 3

Confirmation of Eradication

Test for eradication at least 4 weeks after completing therapy using urea breath test or monoclonal stool antigen test 1, 2, 3

• Discontinue PPI at least 2 weeks before testing 3
• Never use serology to confirm eradication - antibodies persist long after successful treatment 3
• Relying solely on symptom resolution without confirming eradication leads to persistent infection and complications 1

Second-Line Treatment After First-Line Failure

If bismuth quadruple therapy was used first and failed: 3

• Levofloxacin triple therapy for 14 days: PPI twice daily + amoxicillin 1000 mg twice daily + levofloxacin 500 mg once daily (or 250 mg twice daily)
• However, levofloxacin resistance rates are 11-30% (primary) and 19-30% (secondary), so avoid if prior fluoroquinolone exposure 3

If clarithromycin-based therapy was used first and failed: 3

• Switch to bismuth quadruple therapy for 14 days

After two failed eradication attempts with confirmed patient adherence, antibiotic susceptibility testing should guide further treatment 3, 6

Third-Line and Rescue Therapies

• Rifabutin-based triple therapy for 14 days: rifabutin 150 mg twice daily + amoxicillin 1000 mg twice daily + PPI twice daily 3, 6
• High-dose dual amoxicillin-PPI therapy for 14 days: amoxicillin 2-3 grams daily in 3-4 split doses + high-dose PPI twice daily 3

NSAID-Induced Gastritis

• Use the lowest effective NSAID dose for the shortest duration 1, 2
• Add PPI therapy for gastroprotection in high-risk patients taking NSAIDs 1, 2
• Test for and eradicate H. pylori before starting long-term NSAID therapy, especially in patients with history of peptic ulcers 1, 2
• Misoprostol reduces NSAID-associated gastric ulcers by 74% but causes diarrhea and abdominal pain in many patients 1, 2

Adjunctive Treatments

• Antacids provide rapid, temporary relief for breakthrough symptoms and can be used on-demand 1, 2
• Probiotics may reduce antibiotic-associated diarrhea (which occurs in 21-41% of patients during H. pylori treatment) but do not increase eradication rates 3

Special Considerations for 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 in advanced atrophic gastritis 1

Critical Pitfalls to Avoid

• Inadequate PPI dosing - must use twice-daily dosing, not once daily 1, 2
• Premature discontinuation of treatment - complete the full 14-day course 1, 2
• Failure to test for H. pylori when gastritis is present 1, 2
• Using clarithromycin-based triple therapy without knowing local resistance patterns - most regions now have >15% resistance 3
• Repeating antibiotics that previously failed, especially clarithromycin and levofloxacin where resistance develops rapidly 3
• Insufficient antibiotic duration - 7-10 days is inadequate, use 14 days 1, 2, 3
• Not confirming H. pylori eradication after treatment 1, 2

Patient Factors Affecting Treatment Success

• Smoking increases eradication failure risk (odds ratio 1.95) 3
• High BMI reduces drug concentrations at the gastric mucosal level 3
• Poor compliance occurs in >10% of patients and dramatically reduces eradication rates 3

Post-Eradication Management

• H. pylori eradication heals gastritis and prevents progression to atrophic gastritis in patients on long-term PPIs 1
• For residual symptoms after confirmed eradication, continue full-dose PPI therapy for epigastric pain or reflux symptoms 1
• Gradual improvement with fluctuations is expected 1
• Long-term PPI treatment in H. pylori-positive patients accelerates progression to atrophic gastritis, making eradication essential 1