What is the treatment for acute gastritis?

Treatment of Acute Gastritis

Proton pump inhibitors (PPIs) are the first-line treatment for acute gastritis, with omeprazole 20-40 mg once daily taken before meals being the standard approach for symptom relief and mucosal healing. 1, 2

Initial Management Approach

Primary Pharmacologic Treatment

• Start omeprazole 20 mg once daily before meals for most patients with acute gastritis, which can be increased to 40 mg once daily for more severe cases or inadequate response 1, 2

• PPIs should be taken 30 minutes before eating to maximize effectiveness 1

• Treatment duration is typically 4-8 weeks for healing of gastric mucosal damage 2, 3

• Higher-potency PPIs (esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily) may be considered for patients requiring more aggressive acid suppression 1

Alternative Options When PPIs Are Insufficient

• H2-receptor antagonists (H2RAs) provide faster symptom relief than PPIs but are less effective for healing gastric lesions 1

• H2RAs are particularly less effective for gastric ulcers compared to duodenal ulcers 1

• Antacids may be used concomitantly with PPIs for breakthrough symptoms and provide rapid temporary relief 1, 2

Cause-Specific Management

If H. pylori Infection is Present

• All patients with gastritis should be tested for H. pylori, and if positive, receive eradication therapy 1

• Bismuth quadruple therapy for 14 days is the preferred first-line treatment: PPI (omeprazole 20 mg twice daily) + bismuth + metronidazole + tetracycline 1

• Concomitant 4-drug therapy is an alternative when bismuth is unavailable 1

• Higher-potency PPIs (rabeprazole or esomeprazole) improve H. pylori eradication rates 1

• Successful eradication must be confirmed using non-serological testing 1

If NSAID-Induced Gastritis

• Discontinue NSAIDs immediately if possible 1

• If NSAIDs must be continued, add PPI therapy for gastroprotection at standard doses (omeprazole 20-40 mg daily) 1

• Use the lowest effective NSAID dose for the shortest duration to minimize ongoing gastric injury 1

• Misoprostol reduces NSAID-associated gastric ulcers by 74% but is limited by side effects including diarrhea, abdominal pain, and nausea 1

If Infectious Gastroenteritis with Vomiting

• Fluid and electrolyte replacement is the cornerstone of treatment and takes priority over all other interventions 4

• Ondansetron may be given to children >4 years of age and adolescents to facilitate oral rehydration tolerance, though it may increase stool volume 4

• Antiemetics are not routinely recommended for children <4 years of age or adults with acute gastroenteritis 4

• Antimotility drugs (loperamide) should NOT be given to children <18 years of age and should be avoided in any patient with fever or inflammatory diarrhea due to risk of toxic megacolon 4

• Early refeeding decreases intestinal permeability, reduces illness duration, and improves nutritional outcomes in adults 4

Critical Pitfalls to Avoid

• Never use loperamide in children under 18 years - deaths have been reported in 0.54% of children given loperamide, all occurring in children <3 years old 4

• Avoid loperamide in any patient with suspected inflammatory diarrhea or fever regardless of age due to risk of toxic megacolon 4

• Do not use pantoprazole when other PPIs are available, as 40 mg pantoprazole is equivalent to only 9 mg omeprazole 1

• Inadequate PPI dosing (wrong timing relative to meals) significantly reduces effectiveness 1

• Failure to test for and eradicate H. pylori leads to persistent infection and complications 1

• Do not instruct patients to refrain from eating solid food for 24 hours - this approach is not useful 4

• The BRAT diet and dairy avoidance have limited supporting data despite being commonly recommended 4

Monitoring and Follow-Up

• Most patients heal within 4 weeks; some may require an additional 4 weeks of PPI therapy 2

• If no response after 8 weeks of treatment, consider additional 4 weeks or investigate for other causes 2

• For patients on long-term PPI therapy (>3 years), monitor for vitamin B-12 deficiency and hypomagnesemia 2

• Surveillance endoscopy every 3 years should be considered in patients who develop advanced atrophic gastritis 1