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 Management Approach
First-Line PPI Therapy
Start with high-potency PPIs rather than lower-potency options for optimal symptom control and healing 1
- 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, 2
- Avoid pantoprazole when possible due to significantly lower potency (40 mg pantoprazole = only 9 mg omeprazole) 1
Take PPIs 30 minutes before meals for maximum effectiveness—inadequate timing is a common pitfall that reduces treatment efficacy 1, 3
Duration: Treat for 4-8 weeks initially for symptom relief and healing 3, 2
Critical Step: Test for H. pylori
All patients with gastritis must be assessed for H. pylori infection before finalizing the treatment plan, as this fundamentally changes management 4, 1
- Use non-invasive testing: urea breath test or monoclonal stool antigen test 1
- Do not rely on serology alone as it cannot distinguish active from past infection 4
H. pylori-Positive Gastritis
If H. pylori is detected, eradication therapy is mandatory and takes priority over symptom management alone 4, 1
Preferred Eradication Regimen
Bismuth quadruple therapy for 14 days is the first-line treatment due to increasing antibiotic resistance 1
- High-potency PPI (esomeprazole or rabeprazole) twice daily
- Bismuth subsalicylate
- Metronidazole
- Tetracycline
Alternative: Concomitant 4-drug therapy when bismuth is unavailable 1
Confirm eradication with non-serological testing 4+ weeks after completing therapy—failure to confirm eradication leads to persistent infection and complications 1
Special Consideration for NSAID Users
- H. pylori eradication is beneficial and should be performed before starting NSAID treatment, particularly in patients with ulcer history 4, 1
- Eradication is mandatory in patients with peptic ulcer history who require NSAIDs 4
H. pylori-Negative Gastritis
NSAID-Induced Gastritis
If gastritis is related to NSAID use:
- Discontinue NSAIDs if possible 1
- If NSAIDs must be continued:
Non-NSAID, H. pylori-Negative Gastritis
- Continue full-dose PPI therapy (esomeprazole 20-40 mg twice daily or equivalent) 1
- Antacids can be used on-demand for breakthrough symptoms, providing rapid temporary relief 1
Autoimmune Gastritis
When autoimmune gastritis is suspected or confirmed:
- Check antiparietal cell antibodies and anti-intrinsic factor antibodies to confirm diagnosis 4
- Evaluate for vitamin B-12 and iron deficiencies—these are common and require supplementation 4, 1
- Screen for autoimmune thyroid disease, as concomitant autoimmune disorders are common 4, 1
- Surveillance endoscopy every 3 years for advanced atrophic gastritis 4
- Screen for type 1 gastric neuroendocrine tumors with upper endoscopy 4
Long-Term PPI Use Considerations
Important caveat: Long-term PPI treatment in H. pylori-positive patients accelerates progression to corpus-predominant atrophic gastritis 4
- Eradicate H. pylori before initiating long-term PPI therapy to prevent progression to atrophic gastritis 4, 1
- Use the lowest effective dose for the shortest time needed 3
- Monitor for potential complications: kidney problems, severe diarrhea (C. difficile), bone fractures with prolonged use, and certain types of lupus 3
Common Pitfalls to Avoid
- Inadequate PPI dosing or wrong timing (must take 30 minutes before meals) 1
- Premature discontinuation of treatment before adequate healing 1
- Failure to test for and eradicate H. pylori 1
- Relying on symptom resolution alone without confirming H. pylori eradication 1
- Not evaluating for vitamin B-12 and iron deficiencies in atrophic gastritis 4, 1