What is the treatment for acute gastritis?

Treatment of Acute Gastritis

Start omeprazole 20 mg once daily taken 30 minutes before meals for most patients with acute gastritis, and test all patients for H. pylori infection with eradication therapy if positive. 1, 2

Initial Pharmacologic Management

Proton Pump Inhibitor Therapy

• Initiate omeprazole 20 mg once daily before meals as first-line treatment 1, 2
• Take the medication 30 minutes before eating to maximize acid suppression effectiveness 1
• Increase to omeprazole 40 mg once daily if symptoms persist or for more severe presentations 1, 2
• For patients requiring more aggressive acid suppression, consider higher-potency PPIs: esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily 1
• Continue treatment for 4-8 weeks depending on symptom resolution and underlying cause 2

Antacids as Adjunctive Therapy

• Antacids may be used concomitantly with omeprazole for additional symptom relief 2

H. Pylori Testing and Eradication

Universal Testing Requirement

• Test every patient with gastritis for H. pylori infection regardless of presentation 3, 1
• This is critical because failure to identify and eradicate H. pylori leads to persistent infection, chronic gastritis, and complications including peptic ulcers and gastric cancer 3, 1

First-Line Eradication Regimen

• Bismuth quadruple therapy for 14 days is the preferred first-line treatment: 1
  • Omeprazole 20 mg twice daily
  • Bismuth subsalicylate
  • Metronidazole 500 mg
  • Tetracycline 500 mg
• All components taken together twice daily for the full 14-day course 1

Post-Eradication Management

• If ulcer was present at treatment initiation, continue omeprazole 20 mg once daily for an additional 18 days after completing eradication therapy 2
• Confirm successful eradication using non-serological testing (urea breath test or stool antigen test, NOT serology) 3
• Histological resolution of gastritis typically occurs 4-5 weeks after successful H. pylori eradication 4

Infectious Gastroenteritis Management

Rehydration as Cornerstone

• Fluid and electrolyte replacement is the primary treatment for infectious gastroenteritis with vomiting 1, 5
• Oral rehydration solution (ORS) is first-line for mild to moderate dehydration 5
• Reserve intravenous rehydration for severe dehydration, shock, altered mental status, or failure of oral rehydration 5

Antiemetic Therapy

• Ondansetron may be given to children >4 years of age and adolescents to facilitate oral rehydration tolerance 1, 5
• Antiemetics are NOT routinely recommended for children <4 years of age or adults with acute gastroenteritis 1
• Note that ondansetron may increase stool volume despite reducing vomiting 1

Critical Pitfalls to Avoid

Antimotility Agents

• 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, 5
• Avoid loperamide in any patient with suspected inflammatory diarrhea, fever, or bloody stools regardless of age due to risk of toxic megacolon 1, 5

Testing and Treatment Errors

• Do not rely on serology alone to confirm H. pylori eradication - use urea breath test or stool antigen test 3
• Failure to test for H. pylori in gastritis patients leads to missed opportunities for curative treatment 1
• Do not use inappropriate fluids like apple juice or sports drinks as primary rehydration solutions 5

Monitoring and Follow-Up

Endoscopic Surveillance

• Surveillance endoscopy every 3 years should be considered in patients who develop advanced atrophic gastritis (defined by anatomic extent and histologic grade) 3, 1
• For autoimmune gastritis, surveillance intervals should be individualized based on risk assessment 3
• Screen for type 1 gastric neuroendocrine tumors in autoimmune gastritis patients 3

Nutritional Assessment

• Evaluate for iron and vitamin B-12 deficiencies in all patients with atrophic gastritis, especially if corpus-predominant 3
• In autoimmune gastritis, screen for concomitant autoimmune thyroid disease 3

Special Considerations

Hemorrhagic Gastritis

• Acute hemorrhagic gastritis accounts for approximately 25% of upper GI bleeding cases 6
• Treatment parallels classic peptic ulcer disease management with aggressive acid suppression 6
• Address underlying predisposing conditions: alcohol abuse, NSAID use, portal hypertension, physiologic stress 6

Severe or Complicated Cases

• For acute phlegmonous gastritis (rare bacterial infection of gastric wall), early antibiotic therapy can be curative without surgery if diagnosed promptly 7
• Endoscopic ultrasonography may identify fluid collections requiring drainage 7