What is the treatment for acute gastritis?

Treatment of Acute Gastritis

Initial Pharmacologic Management

Start omeprazole 20 mg once daily taken 30 minutes before meals for most patients with acute gastritis, which can be increased to 40 mg once daily for more severe cases or inadequate response. 1, 2

• PPIs are the cornerstone of acute gastritis treatment and should be initiated promptly 1, 2
• The medication must be taken 30 minutes before eating to maximize acid suppression effectiveness 1
• For patients requiring more aggressive acid suppression, consider higher-potency PPIs such as esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily 1
• Alternative H2-receptor antagonists like ranitidine can be used, though PPIs are generally preferred for their superior acid suppression 3
• Treatment duration is typically 4-8 weeks depending on severity and underlying cause 2

Mandatory H. pylori Testing and Eradication

All patients with gastritis must be tested for H. pylori, and if positive, receive eradication therapy regardless of symptom severity. 4, 1

• Bismuth quadruple therapy for 14 days is the preferred first-line treatment: PPI (omeprazole 20 mg twice daily) + bismuth + metronidazole + tetracycline 1
• H. pylori eradication is mandatory before starting NSAID treatment in patients with a peptic ulcer history 4
• Testing for H. pylori should be performed in aspirin users with a history of gastroduodenal ulcer, as the long-term incidence of peptic ulcer bleeding is low after successful eradication even without gastroprotective treatment 4
• Failure to eradicate H. pylori leads to persistent infection, progression to atrophic gastritis, and increased risk of gastric cancer 4

Cause-Specific Considerations

NSAID-Associated Gastritis

• H. pylori eradication is beneficial before starting NSAID treatment and is mandatory in patients with a peptic ulcer history 4
• NSAID-associated gastric ulcers can develop without H. pylori infection, representing a distinct pathophysiologic mechanism 5
• Continue PPI therapy throughout NSAID use in high-risk patients 4

Infectious Gastroenteritis with Gastritis Features

• Fluid and electrolyte replacement is the cornerstone of treatment for infectious gastroenteritis with vomiting 1
• Ondansetron may be given to children >4 years of age and adolescents to facilitate oral rehydration tolerance 1
• Antiemetics are not routinely recommended for children <4 years of age or adults with acute gastroenteritis 1

Severe or Hemorrhagic Gastritis

• Supportive measures including fluid resuscitation and blood product transfusion as needed 6
• Higher-dose PPI therapy (omeprazole 40 mg twice daily or equivalent) for aggressive acid suppression 1, 2
• Endoscopic evaluation to assess severity and rule out malignancy, as severe H. pylori acute gastritis can mimic gastric carcinoma or lymphoma 7

Gastroprotection for High-Risk Patients

• For patients at higher risk of developing gastritis (those taking NSAIDs or anticoagulants), histamine-2 blockers or proton pump inhibitors should be given during steroid therapy 4
• Consider prophylactic PPI therapy in patients requiring long-term corticosteroids, particularly those on ≥20 mg/day prednisone equivalent 4

Critical Pitfalls to Avoid

• Never use loperamide in children under 18 years - deaths have been reported in 0.54% of children given loperamide, all occurring in children <3 years old 1
• Loperamide should be avoided in any patient with suspected inflammatory diarrhea or fever regardless of age due to risk of toxic megacolon 1
• Failure to test for and eradicate H. pylori leads to persistent infection and complications including progression to atrophic gastritis and gastric cancer 4, 1
• Long-term PPI treatment in H. pylori-positive patients accelerates the development of corpus-predominant gastritis and atrophic gastritis; eradication prevents this progression 4

Monitoring and Follow-Up

• Surveillance endoscopy every 3 years should be considered in patients who develop advanced atrophic gastritis 1
• Reassess symptoms after 4 weeks of PPI therapy; if inadequate response, increase dose or extend treatment to 8 weeks 2
• Confirm H. pylori eradication 4 weeks after completing antibiotic therapy 7
• Most patients with acute gastritis heal within 4-8 weeks with appropriate acid suppression therapy 2, 3