What is the management for severe gastritis?

Management of Severe Gastritis

High-potency proton pump inhibitors (PPIs) such as esomeprazole 20-40 mg or rabeprazole 20 mg twice daily are the first-line treatment for severe gastritis, taken 30 minutes before meals for optimal effectiveness. 1, 2

Immediate Treatment Approach

First-Line Acid Suppression

• Esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily are the preferred high-potency PPIs for severe gastritis 1, 2
• Lansoprazole 30 mg twice daily is an alternative high-potency option 1
• Avoid pantoprazole when possible due to significantly lower potency (40 mg pantoprazole equals only 9 mg omeprazole equivalent) 1
• PPIs must be taken 30 minutes before meals to maximize effectiveness 2
• Treatment duration should be at least 8 weeks for healing of erosive changes 1, 3

Adjunctive Symptom Relief

• Antacids can be used on-demand for breakthrough symptoms while awaiting PPI effect 1, 2
• H2-receptor antagonists provide faster initial symptom relief than PPIs but are less effective for mucosal healing 1

Essential Diagnostic Evaluation

H. pylori Testing (Critical Step)

• All patients with severe gastritis must be tested for H. pylori infection using non-invasive methods 2, 4
• Use urea breath test or monoclonal stool antigen test—never use serological testing as it remains positive after eradication and cannot confirm treatment success 4
• If H. pylori is positive, eradication therapy is mandatory regardless of symptom severity 1, 2

Additional Workup for Severe Cases

• Check antiparietal cell antibodies and anti-intrinsic factor antibodies if atrophic gastritis is suspected to identify autoimmune etiology 1
• Evaluate for vitamin B-12 and iron deficiency anemia, particularly in patients with atrophic changes 1
• Screen for concomitant autoimmune thyroid disease in autoimmune gastritis 1

H. pylori Eradication Protocol (If Positive)

Preferred Regimen

• Bismuth quadruple therapy for 14 days is the first-line treatment due to increasing antibiotic resistance 1, 2, 4
  • High-potency PPI (esomeprazole or rabeprazole) twice daily
  • Bismuth subsalicylate
  • Metronidazole
  • Tetracycline
• Concomitant 4-drug therapy is an alternative when bismuth is unavailable 1

Antibiotic Selection Strategy

• Prioritize "Access group" antibiotics (amoxicillin, tetracycline, metronidazole) over "Watch group" antibiotics (clarithromycin, levofloxacin) to minimize resistance 2, 4
• Treatment duration must be 14 days—shorter courses have inadequate eradication rates 2
• Higher-potency PPIs improve H. pylori eradication rates compared to standard-potency options 1

Confirmation of Eradication

• Confirm eradication 4-6 weeks after completing therapy using urea breath test or stool antigen test 2, 4
• Never rely on symptom resolution alone—persistent infection despite symptom improvement leads to complications including progression to atrophic gastritis and gastric cancer 1, 4

NSAID-Induced Gastritis Management

If NSAIDs Are the Cause

• Discontinue NSAIDs immediately if possible 2
• If NSAIDs must be continued, add high-dose PPI therapy for gastroprotection 1, 2
• Use the lowest effective NSAID dose for the shortest duration 1, 2
• Eradicate H. pylori before starting long-term NSAID therapy to prevent ulcer development 1
• Misoprostol reduces NSAID-associated gastric ulcers by 74% but causes diarrhea and abdominal pain in many patients 1

Special Considerations for Severe Cases

Patients Requiring Long-Term Acid Suppression

• For patients at high risk of gastritis complications (those taking NSAIDs or anticoagulants), add PPI or H2-blocker prophylaxis during corticosteroid therapy 5
• Long-term PPI treatment in H. pylori-positive patients accelerates progression to corpus-predominant atrophic gastritis—eradicate H. pylori before initiating chronic PPI therapy 1, 4

Monitoring and Surveillance

• Surveillance endoscopy every 3 years should be considered in patients with advanced atrophic gastritis due to increased gastric cancer risk 1
• Monitor for vitamin B-12 deficiency in patients on PPIs longer than 3 years 3
• Check magnesium levels before initiating PPI treatment in patients on digoxin or diuretics, then monitor periodically 3

Critical Pitfalls to Avoid

• Inadequate PPI dosing or incorrect timing (must be taken 30 minutes before meals) reduces effectiveness 1, 2
• Premature discontinuation of treatment before 8 weeks prevents adequate mucosal healing 1
• Failure to test for and eradicate H. pylori when present leads to persistent inflammation and cancer risk 1, 2
• Using antibiotic courses shorter than 14 days results in treatment failure 2
• Relying on symptom resolution without confirming H. pylori eradication allows persistent infection 1, 4
• Prescribing long-term PPIs without first eradicating H. pylori accelerates progression to atrophic gastritis 1, 4

Expected Clinical Course

• Gradual symptom improvement with fluctuations is expected over the first 2-4 weeks of appropriate therapy 1, 2
• Complete mucosal healing typically requires 8 weeks of high-dose PPI therapy 1, 3
• If symptoms persist despite appropriate therapy and confirmed H. pylori eradication, consider endoscopic evaluation to rule out other causes including malignancy 3