What is the recommended treatment for a patient with gastritis?

Gastritis Treatment

Start with high-potency proton pump inhibitors (PPIs) as first-line therapy—specifically esomeprazole 20-40 mg or rabeprazole 20 mg twice daily, taken 30 minutes before meals—while simultaneously testing all patients for H. pylori infection using non-invasive methods (urea breath test or stool antigen test). 1, 2

First-Line PPI Therapy

High-potency PPIs are the cornerstone of gastritis treatment, with clear superiority over standard options. 1, 2

• Esomeprazole 20-40 mg twice daily (equivalent to 32 mg omeprazole) is the preferred first-line agent 1
• Rabeprazole 20 mg twice daily (equivalent to 36 mg omeprazole) is equally effective 1
• Lansoprazole 30 mg twice daily (equivalent to 27 mg omeprazole) serves as an alternative for patients intolerant to the above 1, 3
• Avoid pantoprazole when possible—40 mg pantoprazole equals only 9 mg omeprazole, making it significantly less potent 1

Critical timing: PPIs must be taken 30 minutes before meals to maximize effectiveness, and treatment should continue for at least 8 weeks to ensure adequate mucosal healing 2, 3

Mandatory H. pylori Testing and Eradication

Every patient with gastritis requires H. pylori testing—this is non-negotiable regardless of symptom severity. 1, 3

• Use urea breath test or monoclonal stool antigen test for diagnosis 1, 3
• Never use serological testing as it remains positive after eradication and cannot confirm treatment success 3

If H. pylori Positive: Bismuth Quadruple Therapy

Bismuth quadruple therapy for 14 days is the mandatory first-line treatment due to rising antibiotic resistance. 1, 2, 3

The regimen includes:

• High-potency PPI (esomeprazole or rabeprazole at doses above)
• Bismuth subsalicylate
• Metronidazole
• Tetracycline
• Duration: 14 days minimum—shorter courses result in treatment failure 2, 3

Alternative when bismuth unavailable: Concomitant 4-drug therapy 1, 2

Prioritize "Access group" antibiotics (amoxicillin, tetracycline, metronidazole) over "Watch group" antibiotics (clarithromycin, levofloxacin) to minimize resistance development 2, 3

Confirming H. pylori Eradication

Test for eradication 4-6 weeks after completing antibiotics using urea breath test or stool antigen—never rely on symptom resolution alone. 3

• Patient must be off PPI therapy for at least 2 weeks before testing to avoid false-negative results 3
• Failure to confirm eradication allows persistent infection, continued mucosal damage, and progression to atrophic gastritis 1, 3

NSAID-Induced Gastritis

If NSAIDs are the culprit, discontinue them immediately when possible. 2

• If NSAIDs must continue, add high-potency PPI therapy for gastroprotection 1, 2
• Eradicate H. pylori before starting long-term NSAID therapy—H. pylori significantly increases NSAID-associated ulcer risk 1, 3
• Use the lowest effective NSAID dose for the shortest duration 1, 2
• Misoprostol reduces NSAID-associated gastric ulcers by 74% but causes diarrhea and abdominal pain, limiting its use 1, 2

Adjunctive Therapy

• Antacids provide rapid, temporary symptom relief and can be used on-demand for breakthrough symptoms 1, 2
• H2-receptor antagonists (ranitidine 150 mg twice daily) provide faster symptom relief than PPIs but are less effective for healing gastric lesions 1, 4

Special Populations and Considerations

Autoimmune Gastritis

• Check antiparietal cell antibodies and anti-intrinsic factor antibodies 1
• Evaluate for vitamin B-12 and iron deficiencies 1, 3
• Screen for concomitant autoimmune thyroid disease 1

Advanced Atrophic Gastritis

• Surveillance endoscopy every 3 years is recommended 1
• First-degree relatives of gastric cancer patients should receive H. pylori eradication as they face 2-3 times increased risk 3

Critical Pitfalls to Avoid

These errors lead to treatment failure and disease progression:

• Inadequate PPI dosing or wrong timing (not 30 minutes before meals) reduces effectiveness 1, 2, 3
• Premature discontinuation before 8 weeks prevents adequate mucosal healing 1, 3
• Failure to test for H. pylori when present leads to persistent inflammation and cancer risk 1, 3
• Antibiotic courses shorter than 14 days result in treatment failure 2, 3
• Relying on symptom resolution without confirming eradication allows persistent infection and complications 1, 3
• Prescribing long-term PPIs without first eradicating H. pylori accelerates progression to corpus-predominant atrophic gastritis 1, 3, 5

Residual Symptoms After H. pylori Eradication

If symptoms persist despite confirmed H. pylori eradication (negative post-treatment testing), continue full-dose PPI therapy. 1, 2

• Residual symptoms are common and do not indicate treatment failure 1
• Gradual improvement with fluctuations is expected 1, 2
• Absence of alarm symptoms (bleeding, vomiting, weight loss) is reassuring 1
• If symptoms persist despite appropriate therapy, consider endoscopic evaluation to rule out other causes 2