What are the guidelines for treating chronic gastritis?

Treatment Guidelines for Chronic Gastritis

First-Line Treatment Approach

Bismuth quadruple therapy for 14 days is the preferred first-line treatment for H. pylori-associated chronic gastritis, consisting of a proton pump inhibitor (PPI), bismuth, metronidazole, and tetracycline. 1, 2 This regimen has replaced clarithromycin-based triple therapy due to increasing antibiotic resistance worldwide. 1

Initial Diagnostic Testing

• Test all patients with chronic gastritis for H. pylori infection using non-invasive methods: urea breath test or monoclonal stool antigen test. 2, 3 These tests have superior accuracy compared to serology.
• Avoid serological testing for confirming eradication as antibodies remain positive after successful treatment. 2
• If atrophic gastritis is present on histology, check antiparietal cell antibodies and anti-intrinsic factor antibodies to identify autoimmune etiology. 2, 4

H. pylori-Positive Chronic Gastritis

Recommended First-Line Regimens

Bismuth quadruple therapy (14 days): 1, 2, 3

• PPI (high-potency preferred)
• Bismuth subsalicylate or bismuth subcitrate
• Metronidazole 500 mg three times daily
• Tetracycline 500 mg four times daily

Alternative when bismuth is unavailable: Concomitant 4-drug therapy for 14 days consisting of PPI, amoxicillin, clarithromycin, and metronidazole. 1, 3, 4

Antibiotic Selection Strategy

• Prioritize "Access group" antibiotics (amoxicillin, tetracycline, metronidazole) over "Watch group" antibiotics (clarithromycin, levofloxacin) to minimize resistance development. 2, 3
• Avoid clarithromycin-based triple therapy as it is no longer effective in most regions due to resistance rates exceeding 15%. 1, 5
• Duration must be 14 days—shorter courses significantly reduce eradication rates. 1, 2, 3

Second-Line Treatment After First-Line Failure

• If bismuth quadruple therapy failed: Use levofloxacin triple therapy (PPI, amoxicillin, levofloxacin) for 14 days. 1
• If levofloxacin was used previously: Use bismuth quadruple therapy. 1
• Avoid previously used antibiotics as resistance is likely the cause of failure. 1

Third-Line and Rescue Therapy

• Obtain culture and antimicrobial sensitivity testing before selecting third-line treatment. 1
• Consider rifabutin-based triple therapy or high-dose dual therapy (PPI plus amoxicillin) for subsequent attempts. 1

Confirmation of Eradication

• Confirm eradication 4-6 weeks after completing therapy using urea breath test or stool antigen test (not serology). 2, 3, 4
• Do not rely on symptom resolution alone as persistent infection can occur despite symptom improvement. 3, 4

Acid Suppression for All Types of Chronic Gastritis

PPI Selection and Dosing

High-potency PPIs taken 30 minutes before meals are first-line for symptom relief and mucosal healing: 2, 3, 4

• Esomeprazole 20-40 mg twice daily (equivalent to 32 mg omeprazole) 3, 4
• Rabeprazole 20 mg twice daily (equivalent to 36 mg omeprazole) 3, 4
• Lansoprazole 30 mg twice daily (equivalent to 27 mg omeprazole) 3, 4
• Avoid pantoprazole when possible due to lower potency (40 mg pantoprazole = 9 mg omeprazole). 4

Timing and Duration

• Take PPIs 30 minutes before meals for optimal acid suppression. 2, 3, 4
• Higher-potency PPIs improve H. pylori eradication rates when used as part of combination therapy. 3, 4

NSAID-Induced Chronic Gastritis

Management Strategy

• Discontinue NSAIDs immediately if possible. 2, 3, 4
• If NSAIDs must be continued: Add PPI therapy for gastroprotection using high-potency agents at doses listed above. 3, 4
• Test and treat H. pylori before initiating long-term NSAID therapy in all patients, especially those with prior peptic ulcer history. 2, 3, 4
• Use the lowest effective NSAID dose for the shortest duration to minimize gastric injury risk. 3, 4

Alternative Gastroprotection

• Misoprostol 200 mcg four times daily reduces NSAID-associated gastric ulcers by 74%, but side effects (diarrhea, abdominal pain) limit its use. 3, 4

Autoimmune Chronic Gastritis

Screening and Monitoring

• Screen for vitamin B-12 and iron deficiencies in all patients with autoimmune gastritis, particularly those with corpus-predominant disease. 2, 4
• Screen for autoimmune thyroid disease as concomitant autoimmune disorders are common. 2, 4
• Check antiparietal cell antibodies and anti-intrinsic factor antibodies to confirm autoimmune etiology. 2, 4

Surveillance

• Perform endoscopy every 3 years for advanced atrophic gastritis (extensive anatomic distribution and high histologic grade) due to increased gastric cancer risk. 2, 4
• Use OLGA staging to determine surveillance intervals and cancer prevention strategies. 2

Chronic Atrophic Gastritis

Cancer Prevention Strategy

• H. pylori eradication reduces gastric cancer risk and is most effective when performed before the development of atrophic changes. 1
• Eradication can reverse atrophic changes in the corpus but not in the antrum, and intestinal metaplasia is generally irreversible. 1
• Surveillance endoscopy every 3 years is recommended for patients with advanced atrophic gastritis. 2, 4

Long-Term PPI Considerations

• Eradicate H. pylori in patients requiring long-term PPIs as this heals gastritis and prevents progression to atrophic gastritis. 4
• Long-term PPI use in H. pylori-positive patients accelerates progression to corpus-predominant atrophic gastritis. 4

Adjunctive Therapy

• Antacids provide rapid, temporary symptom relief and can be used on-demand for breakthrough symptoms. 2, 3, 4
• For residual symptoms after successful H. pylori eradication: Continue full-dose PPI therapy for epigastric pain or reflux symptoms. 3, 4

Critical Pitfalls to Avoid

• Never use antibiotic therapy for less than 14 days as this significantly reduces eradication rates. 2, 3
• Never rely on symptom resolution alone without confirming H. pylori eradication with non-serological testing. 2, 3, 4
• Never use previously failed antibiotics in subsequent eradication attempts as resistance is likely. 1
• Never take PPIs at incorrect times—they must be taken 30 minutes before meals for optimal effectiveness. 2, 3, 4
• Never fail to evaluate for vitamin B-12 and iron deficiencies in patients with atrophic gastritis. 4
• Never use clarithromycin-based triple therapy in regions with clarithromycin resistance >15% (most of the world). 1, 5