What is the treatment for a patient with erosive gastritis and H. pylori (Helicobacter pylori) positive?

Treatment of H. pylori-Positive Erosive Gastritis

Start H. pylori eradication therapy immediately upon diagnosis—do not delay treatment, as H. pylori gastritis can progress to atrophic gastritis and gastric cancer, and eradication heals gastritis and prevents these complications. 1

Immediate Management Strategy

Step 1: Initiate Dual Therapy (PPI + H. pylori Eradication)

Begin high-potency PPI therapy concurrently with H. pylori eradication treatment right away. 2

• Start esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily, taken 30 minutes before meals 2
• The PPI addresses the erosive gastritis symptoms and creates optimal conditions for antibiotic efficacy 2
• Continue PPI therapy for at least 8 weeks total to ensure complete healing of erosive changes 2

Step 2: H. pylori Eradication Regimen (First-Line)

Bismuth quadruple therapy for 14 days is the preferred first-line treatment due to increasing antibiotic resistance. 2

The regimen includes:

• High-potency PPI (as above) twice daily 2
• Bismuth subsalicylate 525 mg four times daily 2
• Metronidazole 500 mg three times daily 2
• Tetracycline 500 mg four times daily 2

Alternative if bismuth is unavailable: Concomitant 4-drug therapy with PPI, amoxicillin, clarithromycin, and metronidazole for 14 days 2, 3

Step 3: Confirm Eradication

Test for successful H. pylori eradication 4-6 weeks after completing antibiotic therapy using non-serological methods. 4

• Use urea breath test or monoclonal stool antigen test 2
• Do NOT use serological testing, as antibodies remain positive after eradication and cannot confirm treatment success 2
• Ensure patient has been off PPI therapy for at least 2 weeks before testing to avoid false-negative results 4

Critical Timing Considerations

There is no reason to delay H. pylori eradication therapy—start immediately upon diagnosis. 4, 1

• H. pylori eradication heals gastritis and prevents progression to atrophic gastritis 1
• Long-term PPI treatment in H. pylori-positive patients accelerates progression to corpus-predominant atrophic gastritis 4, 1, 2
• Eradicating H. pylori before initiating chronic PPI therapy is mandatory to prevent this progression 2
• The presence of erosive gastritis indicates active inflammation that requires both symptomatic treatment (PPI) and definitive treatment (H. pylori eradication) 5

Why Immediate Treatment Matters

Erosive gastritis in H. pylori-positive patients represents a sequela of H. pylori-induced gastritis with more severe inflammation. 5

• Studies show 99% of chronic antral erosions are associated with H. pylori gastritis 5
• The density of H. pylori colonization and severity of gastritis are significantly more pronounced in patients with erosions compared to those without 5
• H. pylori eradication is recommended for gastric cancer prevention, especially before development of preneoplastic conditions like atrophic gastritis 1
• Delaying treatment allows continued mucosal damage and progression toward atrophy 4, 1

Common Pitfalls to Avoid

Do not make these critical errors:

• Never prescribe long-term PPIs without first eradicating H. pylori—this accelerates progression to atrophic gastritis 2
• Never use antibiotic courses shorter than 14 days—this results in treatment failure and promotes resistance 2
• Never rely on symptom resolution alone—always confirm H. pylori eradication with objective testing 2
• Never use inadequate PPI dosing or incorrect timing (must be 30 minutes before meals)—this reduces effectiveness 2
• Never stop PPI therapy before 8 weeks—premature discontinuation prevents adequate mucosal healing 2

Special Considerations for This Patient

All patients with atrophic gastritis or erosive gastritis should be assessed for H. pylori and treated if positive. 4

• If this patient is taking NSAIDs or aspirin, H. pylori eradication is mandatory before continuing these medications, as H. pylori increases risk of NSAID-associated ulcers 4
• First-degree relatives of patients with gastric cancer should receive H. pylori eradication as they are at 2-3 times increased risk 4
• Patients with corpus-predominant gastritis should be evaluated for iron and vitamin B-12 deficiencies 4