Initial Treatment for Gastritis in a 48-Year-Old Female
Start with a high-potency proton pump inhibitor (PPI) such as esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily, taken 30 minutes before meals, while simultaneously testing for H. pylori infection using a non-invasive test. 1, 2
First-Line PPI Therapy
The American College of Gastroenterology recommends high-potency PPIs as the cornerstone of initial gastritis treatment 1, 2. Your specific options include:
- Esomeprazole: 20-40 mg twice daily (equivalent to 32 mg omeprazole) 2
- Rabeprazole: 20 mg twice daily (equivalent to 36 mg omeprazole) 2
- Lansoprazole: 30 mg twice daily (equivalent to 27 mg omeprazole) 2
Critical timing: Take PPIs 30 minutes before meals for optimal effectiveness 1. This is a common pitfall—inadequate timing significantly reduces therapeutic benefit 2.
Avoid pantoprazole when possible due to lower potency (40 mg pantoprazole equals only 9 mg omeprazole) 2.
Mandatory H. pylori Testing
You must test for H. pylori infection immediately using:
Do not use serological testing—it remains positive after successful treatment and cannot confirm eradication 1.
Treatment Algorithm Based on H. pylori Status
If H. pylori POSITIVE:
Switch to bismuth quadruple therapy for 14 days: 1, 2
- High-potency PPI (esomeprazole 20-40 mg or rabeprazole 20 mg) twice daily 2
- Bismuth subsalicylate 1
- Metronidazole 1
- Tetracycline 1
Alternative if bismuth unavailable: Concomitant 4-drug therapy 1, 2
Confirm eradication 4-6 weeks after completing therapy using urea breath test or stool antigen—never rely on symptom resolution alone 1, 2. This is critical because failure to confirm eradication leads to persistent infection and complications 2.
If H. pylori NEGATIVE:
Continue PPI monotherapy for 4-8 weeks 1. Higher-potency PPIs (esomeprazole, rabeprazole) provide superior symptom relief and mucosal healing compared to lower-potency options 2, 3.
Adjunctive Therapy
- Antacids can be used on-demand for breakthrough symptoms—they provide rapid but temporary relief 1, 2
Special Considerations for NSAID Use
If this patient takes NSAIDs regularly:
- Use the lowest effective NSAID dose for the shortest duration 1, 2
- Continue PPI therapy for gastroprotection 2
- If H. pylori positive, eradicate before continuing long-term NSAIDs 1, 2
Common Pitfalls to Avoid
- Inadequate PPI dosing or wrong timing (must be 30 minutes before meals) 1, 2
- Premature discontinuation of treatment before 4-8 weeks 2
- Failure to test for H. pylori when present 1, 2
- Insufficient antibiotic duration if H. pylori positive (must be 14 days, not shorter) 1
- Relying on symptom resolution without confirming H. pylori eradication 2
Expected Course
Gradual improvement with symptom fluctuations is normal with appropriate treatment 1. If symptoms persist despite 4-8 weeks of appropriate PPI therapy and confirmed H. pylori eradication (if applicable), consider endoscopic evaluation to rule out other causes 1.