What is the treatment for alcohol-induced gastritis on a background of chronic gastritis?

Treatment of Alcohol-Induced Gastritis on Chronic Gastritis

Immediate alcohol cessation combined with proton pump inhibitor therapy (lansoprazole 30 mg daily or equivalent) and H. pylori eradication if present forms the cornerstone of treatment, with thiamine supplementation (100-300 mg/day IV for 3-4 days) mandatory to prevent Wernicke's encephalopathy. 1, 2, 3

Immediate Management

Alcohol Cessation - The Critical First Step

• Implement brief alcohol intervention immediately during hospitalization using the FRAMES model (Feedback about dangers, Responsibility, Advice to abstain, Menu of alternatives, Empathy, Self-efficacy encouragement), which reduces alcohol consumption by approximately 41 g/week 4, 5
• Administer benzodiazepines for alcohol withdrawal syndrome as the treatment of choice 4
• Thiamine must be given without hesitation: 100-300 mg/day IV for 3-4 days upon admission, as alcohol-related gastritis impairs thiamine absorption and deficiency risk is extremely high 1

Acid Suppression Therapy

• Start proton pump inhibitor therapy immediately: lansoprazole 30 mg daily for 4-8 weeks for healing of gastric inflammation 2
• Alternative: ranitidine 150 mg twice daily if PPI is contraindicated, though PPIs are superior 6
• Critical caveat: PPIs raise gastrin and chromogranin A levels, which can confound diagnostic testing if autoimmune gastritis is suspected 1

H. pylori Testing and Eradication

Why This Matters

• H. pylori infection occurs in 29-33% of alcoholics and is the primary driver of chronic active gastritis, not alcohol itself 3, 7
• Chronic alcohol abuse favors H. pylori colonization, which produces ammonia that compounds mucosal injury 8, 9
• Studies demonstrate that histologic gastritis does not improve with alcohol abstinence alone but normalizes almost completely after H. pylori eradication 3

Testing and Treatment Protocol

• Test all patients for H. pylori via endoscopic biopsy with culture, direct microscopy, and histology (culture is more sensitive than histology in alcoholics) 7
• If H. pylori positive: Triple therapy with lansoprazole 30 mg twice daily + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily for 10-14 days 2, 3
• Alternative regimen if clarithromycin-allergic: bismuth subsalicylate + amoxicillin + metronidazole 3
• Dyspeptic symptoms improve significantly only after H. pylori elimination, not with antacids alone 3

Nutritional Support and Micronutrient Replacement

Essential Vitamin Supplementation

• Thiamine 100-300 mg/day IV initially, then oral maintenance - absorption is impaired by alcohol-related gastritis 1
• Vitamin B12 assessment and replacement if corpus-predominant atrophy is present (common in chronic gastritis progressing to atrophic gastritis) 1
• Screen for and replace iron deficiency, particularly if corpus involvement exists 1
• Supplement fat-soluble vitamins (A, D, E, K) and minerals (calcium, magnesium, zinc, folate) if malabsorption is present 1

Dietary Modifications

• Provide 35-40 kcal/kg/day with protein intake of 1.2-1.5 g/kg/day 4, 5
• Diet rich in carbohydrates and protein, moderate fat content (30% of calories) 1
• Frequent small meals to maximize tolerance 1

Long-Term Management

Surveillance and Monitoring

• Endoscopy with topographical biopsies to assess extent of atrophic changes - advanced atrophic gastritis requires surveillance endoscopy every 3 years 1
• Monitor for progression to intestinal metaplasia, dysplasia, or gastric adenocarcinoma 1
• Screen for autoimmune thyroid disease if autoimmune gastritis is suspected (occurs in up to one-third of autoimmune gastritis patients) 1

Alcohol Relapse Prevention

• Arrange extended alcohol counseling after discharge 4
• For alcohol-dependent patients without advanced liver disease: disulfiram, naltrexone, or acamprosate combined with counseling 4
• Individual psychotherapy including psychiatric evaluation, psychoeducation, group therapy, and cognitive behavioral therapy 4
• Involvement in Alcoholics Anonymous for continued support 4

Common Pitfalls to Avoid

• Do not assume alcohol alone causes the gastritis - H. pylori is present in nearly one-third of cases and drives the chronic inflammation 3, 7
• Do not delay thiamine supplementation - use IV route initially as oral absorption is impaired by gastritis 1
• Do not stop PPIs abruptly before H. pylori testing - withdraw cautiously 10-14 days before gastrin measurement if needed for diagnostic purposes 1
• Do not use antacids alone - they provide no improvement in histologic gastritis or symptoms compared to H. pylori eradication 3
• Do not neglect vitamin B12 and iron screening - deficiencies develop insidiously as chronic gastritis progresses to atrophic gastritis 1