What is the treatment for gastritis?

Treatment for Gastritis

High-potency proton pump inhibitors (PPIs) such as esomeprazole 20-40 mg or rabeprazole 20 mg twice daily, taken 30 minutes before meals, are the first-line treatment for gastritis, with mandatory H. pylori testing and eradication if positive. 1, 2

Immediate Pharmacologic Management

First-Line PPI Therapy

• Esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily are the preferred high-potency options for gastritis treatment 1, 2
• Lansoprazole 30 mg twice daily serves as an alternative high-potency option for patients who cannot tolerate esomeprazole or rabeprazole 1
• Avoid pantoprazole when possible due to significantly lower potency (40 mg pantoprazole equals only 9 mg omeprazole equivalent) 2
• Critical timing: Take PPIs 30 minutes before meals to maximize effectiveness 1, 3
• Treatment duration must be at least 8 weeks for adequate healing of erosive changes 1, 3

Alternative Acid-Suppression Options

• H2-receptor antagonists (ranitidine, famotidine) provide faster symptom relief but are less effective than PPIs for healing gastric lesions 2, 4
• Antacids offer rapid, temporary symptom relief and can be used on-demand for breakthrough symptoms 2

Mandatory H. pylori Assessment and Eradication

Testing Requirements

• All patients with gastritis must be tested for H. pylori using non-invasive methods: urea breath test or monoclonal stool antigen test 1, 2
• Do not use serological testing as it remains positive after eradication and cannot confirm treatment success 1
• Patients must be off PPI therapy for at least 2 weeks before testing to avoid false-negative results 2

H. pylori Eradication Protocol

• Bismuth quadruple therapy for 14 days is first-line treatment due to increasing antibiotic resistance: high-potency PPI + bismuth subsalicylate + metronidazole + tetracycline 5, 1, 2
• Concomitant 4-drug therapy (PPI + clarithromycin + amoxicillin + metronidazole) is an alternative when bismuth is unavailable 1, 2
• Prioritize "Access group" antibiotics (amoxicillin, tetracycline, metronidazole) over "Watch group" antibiotics (clarithromycin, levofloxacin) to minimize resistance 1
• Confirm eradication 4-6 weeks after completing therapy using non-serological testing (urea breath test or stool antigen) 2

Why H. pylori Eradication is Mandatory

• H. pylori eradication heals gastritis and prevents progression to atrophic gastritis, particularly in patients requiring long-term PPI therapy 5, 2
• Long-term PPI treatment in H. pylori-positive patients accelerates progression to corpus-predominant atrophic gastritis, which is a precancerous condition 5, 1
• Eradication is mandatory before starting NSAID or aspirin therapy in patients with a history of peptic ulcers, as H. pylori increases risk of NSAID-associated ulcers 5, 2

Special Clinical Scenarios

NSAID-Associated Gastritis

• Discontinue NSAIDs if possible; if continuation is necessary, add PPI therapy for gastroprotection 2, 6
• Use the lowest effective NSAID dose for the shortest duration 2
• H. pylori eradication is beneficial and mandatory before starting long-term NSAID treatment, especially in patients with peptic ulcer history 5, 2
• Misoprostol reduces NSAID-associated gastric ulcers by 74% but is limited by side effects (diarrhea, abdominal pain) 2, 7

Atrophic Gastritis

• All patients with atrophic gastritis must be assessed for H. pylori and treated if positive 5, 2
• Obtain biopsies from body and antrum/incisura in separately labeled jars when endoscopic features of atrophic gastritis are present 5
• Evaluate for iron and vitamin B-12 deficiencies, especially in corpus-predominant gastritis 5, 2
• Consider surveillance endoscopy every 3 years in individuals with advanced atrophic gastritis 5, 2

Autoimmune Gastritis

• Check antiparietal cell antibodies and anti-intrinsic factor antibodies to assist with diagnosis 5, 2
• Screen for concomitant autoimmune thyroid disease, which is common in these patients 5, 2
• Screen for type 1 gastric neuroendocrine tumors with upper endoscopy 5

Critical Pitfalls to Avoid

Treatment Errors

• Inadequate PPI dosing or incorrect timing (not taking 30 minutes before meals) drastically reduces effectiveness 1, 2
• Premature discontinuation before 8 weeks prevents adequate mucosal healing 1, 2
• Failure to test for and eradicate H. pylori leads to persistent inflammation and increased cancer risk 1, 2

H. pylori Management Errors

• Using antibiotic courses shorter than 14 days results in treatment failure 1
• Relying on symptom resolution without confirming eradication allows persistent infection and complications 2
• Prescribing long-term PPIs without first eradicating H. pylori accelerates progression to atrophic gastritis 1, 2

Monitoring Failures

• Failure to evaluate for vitamin B-12 and iron deficiencies in patients with atrophic gastritis leads to inadequate management 5, 2
• Not recognizing that residual symptoms after successful H. pylori eradication may require continued PPI therapy based on predominant symptoms 2