What is the recommended 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 are the first-line treatment for gastritis, taken 30 minutes before meals for optimal effectiveness. 1, 2

Initial Assessment

• Test all gastritis patients for H. pylori infection using non-invasive methods such as urea breath test or monoclonal stool antigen test—never use serological testing for confirming eradication as it remains 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

• Screen for vitamin B-12 and iron deficiencies, particularly in patients with corpus-predominant disease or autoimmune gastritis. 3

Treatment Based on Etiology

H. pylori-Positive Gastritis

Bismuth quadruple therapy for 14 days is the preferred first-line treatment (PPI + bismuth + metronidazole + tetracycline) due to increasing antibiotic resistance to clarithromycin and metronidazole. 1, 2, 3

• When bismuth is unavailable, use concomitant 4-drug therapy as an alternative first-line option. 1

• Use antibiotics from the "Access group" (amoxicillin, tetracycline, metronidazole) rather than "Watch group" antibiotics (clarithromycin, levofloxacin) when possible to minimize resistance development. 3

• Higher-potency PPIs such as rabeprazole or esomeprazole improve H. pylori eradication rates compared to standard-dose omeprazole. 1, 4

• Confirm eradication 4-6 weeks after completing therapy using non-serological testing—relying solely on symptom resolution without confirming eradication leads to persistent infection and complications. 1, 3

NSAID-Induced Gastritis

• Discontinue NSAIDs immediately if possible. 3

• If NSAIDs must be continued, add PPI therapy for gastroprotection using high-potency options. 1, 2

• Test and treat H. pylori before initiating long-term NSAID therapy in all patients, especially those with prior peptic ulcer history. 1, 3

• Use the lowest effective NSAID dose for the shortest duration to minimize risk. 2

• Misoprostol reduces NSAID-associated gastric ulcers by 74% and duodenal ulcers by 53%, but its use is limited by side effects including diarrhea, abdominal pain, and nausea. 1

Non-H. pylori, Non-NSAID Gastritis

• Use high-potency PPIs as first-line therapy: esomeprazole 20-40 mg twice daily (equivalent to 32 mg omeprazole) or rabeprazole 20 mg twice daily (equivalent to 36 mg omeprazole). 1

• Lansoprazole 30 mg twice daily (equivalent to 27 mg omeprazole) is an acceptable alternative. 1

• Avoid pantoprazole when possible due to lower potency—40 mg pantoprazole is equivalent to only 9 mg omeprazole. 1

Autoimmune Gastritis

• Screen for concomitant autoimmune thyroid disease as autoimmune disorders commonly coexist. 3

• Evaluate and treat vitamin B-12 and iron deficiencies. 3

• Consider interval endoscopic surveillance based on individualized risk assessment. 1

Adjunctive Therapy

• Antacids provide rapid, temporary relief of symptoms and can be used on-demand for breakthrough symptoms. 1, 2, 3

• For patients with residual symptoms after successful H. pylori eradication (confirmed by negative tests), full-dose PPI therapy remains the recommended treatment. 1, 2

Follow-up and Surveillance

• For advanced atrophic gastritis (extensive anatomic distribution and high histologic grade), perform surveillance endoscopy every 3 years. 1, 3

• Use OLGA staging to determine surveillance intervals and cancer prevention strategies in atrophic gastritis. 3

• Gradual improvement of symptoms with fluctuations is expected with appropriate treatment. 1, 2

Critical Pitfalls to Avoid

• Never use antibiotic therapy for less than 14 days duration—this significantly reduces H. pylori eradication rates. 1, 2, 3

• Always take PPIs 30 minutes before meals—inadequate timing relative to meals reduces effectiveness. 1, 2

• Never rely on symptom resolution alone to confirm H. pylori eradication—always use non-serological testing. 1, 3

• Do not prematurely discontinue PPI treatment before adequate healing occurs. 1

• Failure to evaluate for vitamin B-12 and iron deficiencies in patients with atrophic gastritis leads to inadequate management. 1

• Long-term PPI treatment in H. pylori-positive patients accelerates progression to corpus-predominant and atrophic gastritis—eradicate H. pylori first. 1