What is the recommended management for a patient with gastritis, considering potential Helicobacter pylori (H. pylori) infection and erosive gastritis?

Management of Gastritis

All patients with gastritis should be tested for H. pylori infection using non-invasive methods (urea breath test or stool antigen test), and if positive, receive 14-day bismuth quadruple therapy combined with high-potency proton pump inhibitors for both eradication and symptom control. 1, 2

Initial Assessment and Testing

Test every gastritis patient for H. pylori using urea breath test or monoclonal stool antigen test—never rely on serology as it remains positive after eradication and cannot confirm treatment success 1, 2. Ensure patients are off PPIs for at least 2 weeks before testing to avoid false-negative results 2.

For patients with erosive gastritis or atrophic changes, check antiparietal cell antibodies and anti-intrinsic factor antibodies to evaluate for autoimmune gastritis, and screen for vitamin B-12 and iron deficiencies 1. First-degree relatives of gastric cancer patients warrant H. pylori testing given their 2-3 times increased risk 2.

Treatment Based on H. pylori Status

H. pylori-Positive Gastritis

Bismuth quadruple therapy for 14 days is the mandatory first-line treatment due to increasing antibiotic resistance 1, 2, 3. The regimen includes:

• High-potency PPI (esomeprazole 20-40 mg or rabeprazole 20 mg twice daily) 1, 2
• Bismuth subsalicylate
• Metronidazole
• Tetracycline 2

Alternatively, use concomitant 4-drug therapy when bismuth is unavailable 1, 3. Prioritize "Access group" antibiotics (amoxicillin, tetracycline, metronidazole) over "Watch group" antibiotics (clarithromycin, levofloxacin) to minimize resistance 2, 3. Triple therapy with amoxicillin 1 gram, clarithromycin 500 mg, and lansoprazole 30 mg, all twice daily for 14 days, remains an option when guided by local resistance patterns 4, 1.

Critical timing: PPIs must be taken 30 minutes before meals for optimal effectiveness 1, 2, 3. Higher-potency PPIs (esomeprazole, rabeprazole) significantly improve H. pylori eradication rates compared to standard options 1, 3.

Confirm eradication 4-6 weeks after completing antibiotics using non-serological testing (urea breath test or stool antigen), ensuring the patient has been off PPIs for at least 2 weeks 2. This step is non-negotiable—relying on symptom resolution without confirmation allows persistent infection and progression to atrophic gastritis 1, 2.

H. pylori-Negative Gastritis

For H. pylori-negative patients, high-potency PPIs remain first-line therapy 1, 3:

• 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

Avoid pantoprazole when possible due to lower potency (40 mg pantoprazole equals only 9 mg omeprazole) 1. Treatment duration should be at least 8 weeks for healing of erosive changes 2.

H. pylori-negative chronic gastritis is more common than previously recognized, with 67.5% of erosive esophagitis patients showing moderate to severe body gastritis despite negative H. pylori status 5.

Special Clinical Scenarios

NSAID-Induced Gastritis

Discontinue NSAIDs immediately if possible 1, 3. If NSAIDs must be continued:

• Add high-potency PPI therapy for gastroprotection 1, 3
• Eradicate H. pylori before starting long-term NSAID therapy—H. pylori infection increases NSAID-associated ulcer risk 1, 2, 3
• Use the lowest effective NSAID dose for the shortest duration 1, 3

Misoprostol reduces NSAID-associated gastric ulcers by 74% but causes diarrhea and abdominal pain, limiting its use 1.

High-Risk Patients Requiring Cancer Prevention

H. pylori eradication is mandatory for gastric cancer prevention in these populations 6:

• First-degree relatives of gastric cancer patients (2-3 times increased risk) 6, 2
• Patients with severe pan-gastritis, corpus-predominant gastritis, or severe atrophy 6
• Previous gastric neoplasia treated by endoscopic or subtotal resection 6
• Chronic gastric acid inhibition planned for more than 1 year 6
• Heavy smoking or high occupational exposure to dust, coal, quartz, or cement 6

Eradication is most effective before development of preneoplastic conditions like atrophic gastritis 6. The risk of gastric cancer can be reduced more effectively by employing eradication treatment before atrophy develops 6.

Patients on Long-Term PPI Therapy

Long-term PPI treatment in H. pylori-positive patients accelerates progression to corpus-predominant atrophic gastritis 1, 2, 7. Omeprazole therapy causes H. pylori to migrate from antrum to corpus, leading to increased corpus gastritis despite stable bacterial counts 7. Therefore, eradicate H. pylori before initiating chronic PPI therapy 1, 2.

For patients already on long-term PPIs, H. pylori testing should be performed on combined corpus and antral specimens, as antral cultures may be falsely negative in 61% of cases during acid suppression 7.

Surveillance and Follow-Up

Surveillance endoscopy every 3 years is recommended for patients with advanced atrophic gastritis 1. Use OLGA-staging or OLGIM histological staging to stratify cancer risk and guide management decisions 6.

For autoimmune gastritis, perform interval endoscopic surveillance based on individualized risk assessment, and screen for concomitant autoimmune thyroid disease 1.

Critical Pitfalls to Avoid

• Inadequate PPI dosing or incorrect timing (must be 30 minutes before meals) reduces effectiveness 1, 2, 3
• Premature discontinuation before 8 weeks prevents adequate mucosal healing 1, 2
• Antibiotic courses shorter than 14 days result in treatment failure 1, 2
• Failure to confirm H. pylori eradication allows persistent infection and cancer progression 1, 2
• Prescribing long-term PPIs without first eradicating H. pylori accelerates atrophic gastritis 1, 2, 7
• Failure to evaluate vitamin B-12 and iron deficiencies in atrophic gastritis leads to inadequate management 1

Adjunctive Therapy

Antacids provide rapid, temporary relief and can be used on-demand for breakthrough symptoms 1, 3. For patients with residual symptoms after successful H. pylori eradication (confirmed by negative tests), continue full-dose PPI therapy 1, 3. Gradual improvement with fluctuations is expected 1, 3.