What is the recommended treatment for a patient with gastritis, possibly caused by H. pylori infection or NSAID (Non-Steroidal Anti-Inflammatory Drug) use?

Gastritis Treatment

For gastritis, initiate high-potency proton pump inhibitor (PPI) therapy with esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily, test all patients for H. pylori infection, and if positive, administer bismuth quadruple therapy for 14 days to achieve >90% eradication success. 1, 2

Initial Assessment and Testing

• Test all patients with gastritis for H. pylori infection using non-invasive methods such as urea breath test or monoclonal stool antigen tests (avoid serology) 1, 3
• Evaluate for NSAID use as a contributing factor, as NSAIDs are a major cause of gastritis alongside H. pylori infection 4
• Check antiparietal cell antibodies and anti-intrinsic factor antibodies if autoimmune gastritis is suspected, and screen for vitamin B-12 and iron deficiencies 1

First-Line Pharmacological Treatment

PPI Selection and Dosing

High-potency PPIs are superior for gastritis treatment and H. pylori eradication:

• 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 significantly lower potency (40 mg pantoprazole = only 9 mg omeprazole) 1

Standard PPI therapy duration is 6-8 weeks for complete mucosal healing 3. PPIs are more effective than H2-receptor antagonists for healing gastric ulcers and providing symptom relief 5, 6.

H. pylori-Positive Gastritis Treatment

Bismuth Quadruple Therapy (Preferred First-Line)

The American College of Gastroenterology recommends bismuth quadruple therapy for 14 days as the preferred first-line treatment due to increasing antibiotic resistance: 1, 2

• PPI (high-potency preferred) twice daily
• Bismuth subsalicylate
• Metronidazole 500 mg twice daily
• Tetracycline 500 mg four times daily

This regimen achieves >90% eradication success, particularly in areas with high clarithromycin resistance 2.

Alternative Triple Therapy Regimens

If bismuth is unavailable, use concomitant 4-drug therapy or triple therapy based on local resistance patterns: 1

• Standard triple therapy (14 days): PPI standard dose twice daily + clarithromycin 500 mg twice daily + amoxicillin 1000 mg twice daily 3, 7
• For high clarithromycin resistance: Sequential therapy for 10 days (days 1-5: PPI + amoxicillin; days 6-10: PPI + clarithromycin + metronidazole) 3
• If first-line fails: Levofloxacin 500 mg once daily + amoxicillin 1000 mg twice daily + PPI twice daily for 10 days 3

Confirmation of Eradication

Document H. pylori eradication after treatment completion using non-invasive testing (urea breath test or stool antigen test), as eradication reduces ulcer recurrence from 50-60% to 0-2%. 3 Relying solely on symptom resolution without confirming eradication leads to persistent infection and complications 1.

NSAID-Associated Gastritis

Immediate Management

• Discontinue all NSAIDs immediately when gastritis is diagnosed, as this heals 95% of ulcers and reduces recurrence from 40% to 9% 3
• Test for and eradicate H. pylori if present, as eradication in NSAID users reduces peptic ulcer likelihood by 50% 3
• Initiate PPI therapy at standard doses for 6-8 weeks 3

If NSAIDs Must Be Continued

For patients requiring continued NSAID therapy: 4, 3

• Switch to selective COX-2 inhibitor (celecoxib) or lower-risk nsNSAID (ibuprofen, etodolac, diclofenac) 4
• Add PPI therapy for gastroprotection - PPIs reduce endoscopic NSAID-related ulcers by 90% 4
• Consider misoprostol 200 µg four times daily (600 mg/day minimum) if PPIs are insufficient, though side effects (diarrhea, abdominal pain, nausea in ~20%) limit widespread use 4
• Maintain long-term PPI therapy as secondary prophylaxis 3

Risk Assessment

Carefully assess both GI and cardiovascular risk factors before selecting NSAID therapy: 4

• For patients where GI bleeding risk outweighs CV risk: use lower-risk NSAIDs or COX-2 inhibitors 4
• For patients where CV risk is greater: avoid COX-2 inhibitors entirely 4
• In patients with known CV disease, prescribe low-dose aspirin, though this negates GI-sparing effects of COX-2 inhibitors 4

Alternative and Adjunctive Therapies

H2-Receptor Antagonists

H2-receptor antagonists are less effective than PPIs and should not be used as first-line therapy: 4, 1, 3

• Standard-dose H2RAs reduce duodenal ulcers but NOT gastric ulcers 4
• Double-dose H2RAs show benefit primarily in H. pylori-positive patients 4
• H2RAs are inadequate for gastroprotection in high-risk NSAID users 4

Misoprostol

Misoprostol is the only gastroprotective agent proven in large outcome trials to reduce NSAID-associated GI complications by 40% 4. It decreases gastric ulcers by 74% and duodenal ulcers by 53% compared to placebo 4. However, effective doses (≥600 mg/day) cause abdominal pain, diarrhea, and nausea in ~20% of patients, resulting in frequent discontinuation 4.

Antacids

Antacids provide rapid, temporary symptom relief and can be used on-demand for breakthrough symptoms 1.

Long-Term Management and Follow-Up

For H. pylori-Positive Patients

Eradication of H. pylori heals gastritis and prevents progression to atrophic gastritis, particularly in patients receiving long-term PPIs. 1 One-week triple therapy leads to subsidence of acute inflammatory changes in all cases, with residual inflammation persisting in only 17% 8.

Surveillance Recommendations

• Surveillance endoscopy every 3 years should be considered in individuals with advanced atrophic gastritis 1
• For autoimmune gastritis, individualized risk assessment determines surveillance intervals 1
• Screen for concomitant autoimmune disorders, particularly autoimmune thyroid disease 1

Residual Symptoms After H. pylori Eradication

For patients with persistent symptoms after confirmed H. pylori eradication (negative follow-up tests): 1

• Continue full-dose PPI therapy (e.g., esomeprazole 40 mg once daily) for epigastric pain or reflux symptoms
• Gradual improvement with fluctuations is expected
• Ensure PPIs are taken 30 minutes before eating to maximize effectiveness

Critical Pitfalls to Avoid

• Inadequate PPI dosing or premature discontinuation - use high-potency PPIs at appropriate doses for full 6-8 weeks 1
• Failure to test for and eradicate H. pylori - this is essential for long-term resolution 1, 3
• Using pantoprazole as first-line therapy - significantly lower potency compared to other PPIs 1
• Relying on H2-receptor antagonists alone - inadequate for gastric ulcer prevention and gastroprotection 4
• Not confirming H. pylori eradication - leads to persistent infection and complications 1, 3
• Continuing NSAIDs without gastroprotection - dramatically increases ulcer and bleeding risk 4
• Failure to evaluate for vitamin B-12 and iron deficiencies in atrophic gastritis 1
• Combining multiple NSAIDs including aspirin without specific indication - increases GI toxicity 4