What is the treatment for pain in gastritis?

Treatment for Pain in Gastritis

Acetaminophen (500-1000 mg per dose, maximum 3-4 g daily) is the safest and most appropriate first-line analgesic for gastritis-related pain due to its favorable gastrointestinal safety profile. 1

First-Line Pain Management

• Acetaminophen should be the primary analgesic choice because it does not damage gastric mucosa like NSAIDs, which are contraindicated in gastritis. 1
• Dosing should be 500-1000 mg per dose, with careful attention to the maximum daily limit of 3-4 grams to prevent hepatotoxicity. 1
• Patients must be educated about avoiding combination products containing both acetaminophen and NSAIDs, as the NSAID component will worsen gastric inflammation. 1
• If acetaminophen is used chronically, periodic liver function monitoring is recommended. 1

Acid Suppression as Primary Treatment

While acetaminophen addresses pain, the underlying gastritis requires concurrent acid suppression:

• High-potency proton pump inhibitors (PPIs) such as esomeprazole 20-40 mg or rabeprazole 20 mg twice daily are first-line for treating the gastritis itself, taken 30 minutes before meals. 2
• PPIs reduce gastric acid production, which directly decreases pain by reducing acid-induced mucosal irritation. 2
• Treatment duration should be at least 8 weeks for adequate mucosal healing. 2
• H2-receptor antagonists like ranitidine can be used as alternatives, though they are less potent than PPIs. 3

Second-Line Pain Management

If acetaminophen provides inadequate relief:

• Antispasmodics may be considered as second-line agents for abdominal pain relief, particularly when pain is exacerbated by meals. 1, 4
• Low-dose tricyclic antidepressants (TCAs) such as amitriptyline 10 mg once daily, titrated to 30-50 mg can be effective for persistent visceral pain through noradrenaline reuptake inhibition. 4
• TCAs work by modulating pain perception centrally rather than through gastric mechanisms, making them appropriate for refractory pain. 4
• The mechanism involves blocking reuptake of serotonin and norepinephrine, which are key neurotransmitters in visceral pain perception. 4

Critical H. pylori Evaluation

• All patients with gastritis must be tested for H. pylori infection using non-invasive methods such as urea breath test or monoclonal stool antigen test. 2
• If H. pylori is positive, eradication therapy is mandatory regardless of symptom severity, as persistent infection perpetuates inflammation and pain. 2
• Bismuth quadruple therapy for 14 days (PPI + bismuth subsalicylate + metronidazole + tetracycline) is first-line for H. pylori eradication. 2
• Eradication should be confirmed 4-6 weeks after completing antibiotics using non-serological testing, with the patient off PPIs for at least 2 weeks before testing. 2

Medications to Absolutely Avoid

• Opioids should not be used for gastritis pain as they cause nausea, constipation, delay gastric emptying, and risk addiction without addressing the underlying pathology. 4, 1
• NSAIDs (including aspirin, ibuprofen, naproxen) are contraindicated as they directly damage gastric mucosa through topical effects and impaired healing mechanisms. 5
• Conventional analgesics like NSAIDs will worsen gastritis and increase risk of ulceration and bleeding. 5

Common Pitfalls to Avoid

• Inadequate PPI dosing or incorrect timing (not 30 minutes before meals) reduces effectiveness and prolongs pain. 2
• Premature discontinuation of PPIs before 8 weeks prevents adequate mucosal healing, leading to persistent pain. 2
• Failure to test for and eradicate H. pylori when present allows continued inflammation and pain despite acid suppression. 2
• Prescribing long-term PPIs without first eradicating H. pylori accelerates progression to atrophic gastritis and increases cancer risk. 2
• Relying on symptom resolution alone without confirming mucosal healing or H. pylori eradication allows persistent disease. 2

Monitoring Recommendations

• Patients should be monitored for signs of gastrointestinal bleeding, especially if they have risk factors such as older age or history of peptic ulcer disease. 1
• If pain persists despite appropriate acetaminophen dosing and adequate PPI therapy for 8 weeks, endoscopic evaluation should be considered to assess for complications or alternative diagnoses. 2
• First-degree relatives of patients with gastric cancer should receive H. pylori eradication as they are at 2-3 times increased risk. 2