What is the treatment for gastritis?

Treatment of Gastritis

High-potency proton pump inhibitors (PPIs) such as esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily, taken 30 minutes before meals, are the first-line treatment for gastritis, with H. pylori testing mandatory in all patients to guide additional antimicrobial therapy. 1, 2, 3

Initial Assessment and H. pylori Testing

All patients with gastritis must be tested for H. pylori infection using non-invasive methods:

• Urea breath test or monoclonal stool antigen test are the recommended diagnostic approaches 1, 3
• Avoid serological testing for confirming eradication as antibodies remain positive after successful treatment 3
• If atrophic gastritis is present on histology, check antiparietal cell antibodies and anti-intrinsic factor antibodies to identify autoimmune etiology 3

H. pylori-Positive Gastritis

Bismuth quadruple therapy for 14 days is the preferred first-line treatment due to increasing clarithromycin resistance:

• PPI (high-potency) + bismuth + metronidazole + tetracycline for 14 days 1, 2, 3
• Use antibiotics from the "Access group" (amoxicillin, tetracycline, metronidazole) rather than "Watch group" antibiotics (clarithromycin, levofloxacin) to minimize resistance development 3
• Concomitant 4-drug therapy (PPI + amoxicillin + clarithromycin + metronidazole) is an alternative when bismuth is unavailable 1, 2

Higher-potency PPIs improve H. pylori eradication rates:

• Esomeprazole 20-40 mg twice daily 1, 2
• Rabeprazole 20 mg twice daily (equivalent to 36 mg omeprazole) 1
• Lansoprazole 30 mg twice daily (equivalent to 27 mg omeprazole) 1
• Avoid pantoprazole when possible due to lower potency (40 mg pantoprazole = 9 mg omeprazole) 1

Confirm eradication 4-6 weeks after completing therapy using non-serological testing (urea breath test or stool antigen) 3

H. pylori-Negative Gastritis

For patients without H. pylori infection, acid suppression alone is appropriate:

• High-potency PPI taken 30 minutes before meals 1, 2, 3
• Esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily 1, 2
• Antacids provide rapid, temporary relief for breakthrough symptoms and can be used on-demand 1, 2

NSAID-Induced Gastritis

Discontinue NSAIDs immediately if possible 3

If NSAIDs must be continued:

• Add high-potency PPI therapy for gastroprotection 1, 2
• Use the lowest effective NSAID dose for the shortest duration 1, 2
• Test and treat H. pylori before initiating long-term NSAID therapy, especially in patients with prior peptic ulcer history 3
• Misoprostol reduces NSAID-associated gastric ulcers by 74% but causes diarrhea and abdominal pain, limiting its use 1, 2

Autoimmune Gastritis

Screen for nutritional deficiencies and associated autoimmune conditions:

• Check vitamin B-12 and iron levels in all patients, particularly with corpus-predominant disease 3
• Screen for autoimmune thyroid disease as concomitant autoimmune disorders are common 3
• Provide vitamin B-12 supplementation as needed 1

Atrophic Gastritis Surveillance

Perform endoscopic surveillance every 3 years for advanced atrophic gastritis (extensive anatomic distribution and high histologic grade) 1, 3

• Use OLGA staging to determine surveillance intervals and cancer prevention strategies 3
• H. pylori eradication heals gastritis and prevents progression to atrophic gastritis in patients receiving long-term PPIs 1, 3

Critical Pitfalls to Avoid

Inadequate antibiotic duration:

• Never use antibiotic therapy <14 days duration as this significantly reduces eradication rates 3
• Insufficient duration is a common cause of treatment failure 1, 2

Failure to confirm H. pylori eradication:

• Do not rely on symptom resolution alone 1, 2, 3
• Confirm eradication with non-serological testing 4-6 weeks after treatment completion 3

Inadequate PPI dosing:

• PPIs must be taken 30 minutes before meals for optimal effectiveness 1, 2
• Premature discontinuation of treatment reduces healing rates 1, 2

Failure to evaluate nutritional deficiencies:

• Not checking vitamin B-12 and iron levels in atrophic gastritis leads to inadequate management 1