What is the recommended treatment for pain management in gastritis?

Pain Management in Gastritis

Proton pump inhibitors (PPIs) are the first-line treatment for gastritis pain, with high-potency options like esomeprazole 20-40 mg or rabeprazole 20 mg twice daily taken 30 minutes before meals being most effective for symptom relief and mucosal healing. 1, 2

Initial Pharmacological Management

• Start with high-potency PPIs as first-line therapy to reduce acid production and allow healing of inflamed gastric mucosa 1, 2
• Recommended PPI regimens include:
  • Esomeprazole 20-40 mg twice daily 1, 2
  • Rabeprazole 20 mg twice daily 1, 2
  • Lansoprazole 30 mg twice daily 2
• Timing is critical: administer PPIs 30 minutes before meals for optimal acid suppression 2
• Antispasmodics can be added for meal-related pain exacerbations 1
• Antacids provide rapid, temporary relief and can be used on-demand for breakthrough symptoms 3, 2

H. pylori Testing and Treatment

• Test all gastritis patients for H. pylori using urea breath test or monoclonal stool antigen test 3
• If H. pylori-positive, bismuth quadruple therapy for 14 days is the preferred first-line treatment due to increasing antibiotic resistance 4, 3, 2
• Successful H. pylori eradication significantly improves symptom resolution 2
• Confirm eradication 4-6 weeks after completing therapy using non-serological testing 3

Non-Pharmacological Approaches

Introduce non-pharmacological therapies early as part of comprehensive pain management rather than waiting for medication failure 1

• Cognitive behavioral therapy has the strongest evidence, supported by more than 30 randomized controlled trials for gastrointestinal pain 1
• Gut-directed hypnotherapy focuses on somatic awareness and down-regulation of pain sensations through guided imagery 1
• Mindfulness-based stress reduction can decrease visceral hypersensitivity and improve cognitive appraisal of symptoms 1

Advanced Pharmacological Options for Persistent Pain

When pain persists despite PPI therapy and non-pharmacological approaches:

• Tricyclic antidepressants (TCAs) rank first for relief of abdominal pain in gastrointestinal disorders 1
• Start at low doses and titrate every few weeks until therapeutic benefit is achieved 4
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) are effective alternatives for patients who cannot tolerate TCAs 4, 1
• Mirtazapine may benefit certain patients with persistent gastritis pain 1
• These neuromodulators work by modulating the pain modulatory system in the brain and spinal cord, not by treating mood symptoms 4

Critical Pitfalls to Avoid

• Never prescribe opioids (including tramadol) for chronic gastritis pain as they are ineffective, potentially harmful, and carry risk of developing narcotic bowel syndrome 4, 1
• Avoid inadequate PPI dosing or premature discontinuation of treatment 2
• Do not use pantoprazole as it has lower potency (40 mg pantoprazole = 9 mg omeprazole) 4
• Avoid pain catastrophizing language suggesting the patient "shouldn't be in so much pain" or continuing to order tests to find the "cause" of pain 1
• Do not rely solely on symptom resolution without confirming H. pylori eradication if initially positive 3, 2

Establishing an Effective Treatment Approach

• Develop a collaborative, empathic patient-provider relationship to address management of persistent pain 1
• Educate patients on the pathogenesis of pain, including the role of the gut-brain axis and psychosocial contexts contributing to pain 1
• Set shared goals and expectations for pain management with the patient 1
• Differentiate when pain is triggered by visceral factors (acid-related) versus centrally mediated factors to guide appropriate treatment selection 1
• Recognize that factors initiating problems are not always the same as those perpetuating the problem 1