Gastritis Treatment
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. 1, 2
First-Line PPI Therapy
The American Gastroenterological Association and American College of Gastroenterology recommend high-potency PPIs as the cornerstone of gastritis treatment, with specific dosing as follows: 1, 2
- Esomeprazole: 20-40 mg twice daily (equivalent to 32 mg omeprazole) 1
- Rabeprazole: 20 mg twice daily (equivalent to 36 mg omeprazole) 1
- Lansoprazole: 30 mg twice daily (equivalent to 27 mg omeprazole) 1
Critical timing: PPIs must be taken 30 minutes before meals for optimal effectiveness, and treatment should continue for at least 8 weeks to ensure adequate mucosal healing. 1, 3
Avoid pantoprazole when possible due to significantly lower potency—40 mg pantoprazole equals only 9 mg omeprazole. 1
Mandatory H. pylori Testing and Eradication
All patients with gastritis must be tested for H. pylori infection using non-invasive methods (urea breath test or monoclonal stool antigen test—not serology). 1, 3
If H. pylori Positive:
Bismuth quadruple therapy for 14 days is the preferred first-line treatment due to increasing antibiotic resistance: 1, 2, 3
- High-potency PPI (esomeprazole or rabeprazole at doses above) twice daily
- Bismuth subsalicylate
- Metronidazole
- Tetracycline
Alternative regimen: Concomitant 4-drug therapy (PPI + amoxicillin + clarithromycin + metronidazole) for 5-14 days when bismuth is unavailable, with eradication rates around 90%. 1, 4
Prioritize "Access group" antibiotics (amoxicillin, tetracycline, metronidazole) over "Watch group" antibiotics (clarithromycin, levofloxacin) to minimize resistance development. 3
Confirmation of Eradication:
Test for successful H. pylori eradication 4-6 weeks after completing antibiotic therapy using urea breath test or stool antigen test, ensuring the patient has been off PPI therapy for at least 2 weeks before testing to avoid false-negative results. 3
NSAID-Induced Gastritis
For patients taking NSAIDs: 1, 2
- Use the lowest effective NSAID dose for the shortest duration 1
- Add PPI therapy for gastroprotection in all high-risk patients 1
- Eradicate H. pylori before starting long-term NSAID therapy, as H. pylori increases the risk of NSAID-associated ulcers 1, 3
- Misoprostol reduces NSAID-associated gastric ulcers by 74% but causes diarrhea and abdominal pain, limiting its use 1
Adjunctive Therapy
- Antacids provide rapid, temporary relief and can be used on-demand for breakthrough symptoms 1, 2
- H2-receptor antagonists (ranitidine 150 mg twice daily) provide faster symptom relief than PPIs but are less effective for healing gastric lesions 1, 5
Special Populations
Autoimmune Gastritis:
- Check antiparietal cell antibodies and anti-intrinsic factor antibodies 1
- Evaluate for vitamin B-12 and iron deficiencies 1
- Screen for concomitant autoimmune thyroid disease 1
Advanced Atrophic Gastritis:
- Surveillance endoscopy every 3 years is recommended 1
Critical Pitfalls to Avoid
- Inadequate PPI dosing or incorrect timing (must be 30 minutes before meals) reduces effectiveness 1, 3
- Premature discontinuation before 8 weeks prevents adequate mucosal healing 3
- Failure to test for and eradicate H. pylori leads to persistent inflammation and cancer risk 1, 3
- Antibiotic courses shorter than 14 days result in treatment failure 1, 3
- Relying on symptom resolution without confirming H. pylori eradication allows persistent infection and complications 1, 3
- Prescribing long-term PPIs without first eradicating H. pylori accelerates progression to corpus-predominant atrophic gastritis 1, 3
Persistent Symptoms After H. pylori Eradication
For patients with residual symptoms despite confirmed H. pylori eradication: 1