Gastritis Management
Start with high-potency proton pump inhibitors (PPIs) as first-line treatment—specifically esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily—taken 30 minutes before meals, while simultaneously testing all patients for H. pylori infection using non-invasive methods (urea breath test or stool antigen test). 1, 2
Initial Treatment Approach
First-Line Acid Suppression
Preferred PPIs and dosing:
Avoid pantoprazole when possible due to significantly lower potency (40 mg pantoprazole = only 9 mg omeprazole equivalent) 1
Critical timing: Take PPIs 30 minutes before meals for optimal effectiveness 1, 2
Treatment duration: Continue for 4-8 weeks initially, then reassess response 1, 2
Mandatory H. pylori Testing
Test every patient with gastritis using urea breath test or monoclonal stool antigen test 1, 2
Avoid serological testing as it remains positive after successful treatment and cannot confirm eradication 1
H. pylori-Positive Gastritis Management
First-Line Eradication Therapy
Bismuth quadruple therapy for 14 days is the preferred regimen due to increasing clarithromycin resistance: 1, 2
- High-dose PPI (esomeprazole 40 mg or rabeprazole 20 mg) twice daily
- Bismuth subsalicylate
- Metronidazole
- Tetracycline
Alternative First-Line Option
Concomitant 4-drug therapy when bismuth is unavailable: 1, 2
- PPI (high-dose) twice daily
- Amoxicillin 1 g twice daily
- Clarithromycin 500 mg twice daily
- Metronidazole 500 mg twice daily
- Duration: 5-14 days (longer duration improves eradication by 5-10%) 3
Confirming Eradication
Retest 4-6 weeks after completing therapy using non-serological methods (urea breath test or stool antigen) 2, 4
Never rely on symptom resolution alone—objective confirmation is mandatory to prevent persistent infection and complications 1, 2
NSAID-Induced Gastritis
Management Strategy
Discontinue NSAIDs if possible 2
If NSAIDs must continue:
Misoprostol alternative: Reduces NSAID-associated gastric ulcers by 74%, but limited by side effects (diarrhea, abdominal pain) 1
Residual Symptoms After H. pylori Eradication
For patients with persistent symptoms despite confirmed H. pylori eradication, continue full-dose PPI therapy (esomeprazole 40 mg or rabeprazole 20 mg once daily) targeting the predominant symptom pattern. 1, 2
- Gradual improvement with fluctuations is expected 1
- Absence of alarm symptoms (bleeding, vomiting, weight loss) is reassuring 1
Special Populations: Pediatric Patients
Start with omeprazole 1 mg/kg/day (up to 40 mg/day) taken 30 minutes before meals 4
Avoid H2-receptor antagonists as first-line due to inferior efficacy and tachyphylaxis within 6 weeks 4
If H. pylori positive: Use bismuth quadruple therapy for 14 days with age-appropriate dosing 4
Autoimmune Gastritis Considerations
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 patients with advanced atrophic gastritis 1
Critical Pitfalls to Avoid
Inadequate PPI dosing or wrong timing relative to meals reduces effectiveness dramatically 1, 2
Premature discontinuation of treatment before completing full course 1
Failure to test for H. pylori in all gastritis patients leads to persistent disease 1, 2, 4
Using symptom resolution as endpoint without objective confirmation of H. pylori eradication 1, 2
Insufficient antibiotic duration (must be 14 days for optimal eradication) 1, 2
Missing vitamin B-12 and iron deficiency evaluation in atrophic gastritis 1