What is the recommended management for a patient with gastritis, including those with Helicobacter pylori (H. pylori) infection and a history of bleeding or perforation?

Gastritis Management

For gastritis management, initiate high-potency PPI therapy (esomeprazole 20-40mg or rabeprazole 20mg twice daily) taken 30 minutes before meals, test all patients for H. pylori using urea breath test or stool antigen, and if positive, immediately start 14-day bismuth quadruple therapy or triple therapy based on local clarithromycin resistance patterns. 1

Immediate Pharmacologic Treatment

• Start high-potency PPIs (esomeprazole 20-40mg or rabeprazole 20mg twice daily) as first-line therapy, taken 30 minutes before meals for optimal acid suppression. 1
• Continue PPI therapy for at least 8 weeks to allow complete healing of erosive gastritis. 1
• Lansoprazole 30mg twice daily serves as an alternative high-potency option for patients intolerant to esomeprazole or rabeprazole. 1

Essential H. pylori Testing

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

H. pylori Eradication Protocol

If H. pylori is detected, eradication is mandatory regardless of symptom severity to prevent gastric cancer progression. 2, 1

First-Line Treatment Selection

• In areas with low clarithromycin resistance (<15-20%): Use 14-day triple therapy with PPI twice daily + clarithromycin 500mg twice daily + amoxicillin 1000mg twice daily. 2, 3, 4
• In areas with high clarithromycin resistance (>20%) or when resistance is unknown: Use 14-day bismuth quadruple therapy (PPI + bismuth subsalicylate + metronidazole + tetracycline). 2, 1

The choice between regimens is critical—clarithromycin resistance has increased globally, making bismuth quadruple therapy increasingly preferred as first-line treatment. 1

Treatment Timing Considerations

• Start H. pylori eradication immediately upon diagnosis; delaying treatment allows continued mucosal damage and progression toward atrophic gastritis. 1
• For bleeding gastritis/ulcers, initiate eradication therapy as soon as oral feeding resumes (typically after 72-96 hours of IV PPI). 2

PPI Duration Based on Gastritis Type

The duration of PPI therapy differs significantly based on complications:

• Uncomplicated gastritis: Continue PPI for 4 weeks total after completing H. pylori eradication. 3
• Gastritis with erosions or complicated cases: Extend PPI to 6-8 weeks to ensure complete mucosal healing. 2, 3
• Gastric ulcers (not just gastritis): Continue PPI until complete healing is confirmed endoscopically, as gastric ulcers require longer acid suppression than duodenal ulcers. 2

Confirmation of Eradication

• Test for successful H. pylori eradication 4-6 weeks after completing antibiotic therapy using urea breath test or stool antigen test. 2, 1
• Ensure patient has been off PPI therapy for at least 2 weeks before testing to avoid false-negative results. 1
• Endoscopic follow-up with biopsy-based testing is reserved for gastric ulcers or MALT lymphoma cases. 2

Special Populations Requiring Aggressive Treatment

• First-degree relatives of gastric cancer patients: Mandatory H. pylori eradication due to 2-3 times increased cancer risk. 1
• Patients with atrophic gastritis or corpus-predominant gastritis: Urgent H. pylori eradication and assessment for iron/B12 deficiencies. 1
• NSAID or aspirin users: H. pylori eradication is mandatory before continuing these medications, as co-infection dramatically increases ulcer risk. 1

Critical Management Pitfalls to Avoid

• Never prescribe long-term PPI therapy without first testing for and eradicating H. pylori—this accelerates progression to corpus-predominant atrophic gastritis, a precancerous condition. 1, 5
• Do not use antibiotic courses shorter than 14 days, as this results in treatment failure and promotes antibiotic resistance. 1
• Avoid relying on symptom resolution alone without confirming H. pylori eradication, as persistent infection continues despite symptom improvement. 1
• Do not use inadequate PPI dosing or incorrect timing (must be 30 minutes before meals), as this reduces effectiveness. 1
• Never discontinue PPI treatment prematurely before 8 weeks in erosive gastritis, as this prevents adequate mucosal healing. 1

NSAID Management

• Immediately discontinue all NSAIDs if gastritis is present, as this alone heals 95% of ulcers and reduces recurrence from 40% to 9%. 3
• If NSAIDs cannot be discontinued, switch to selective COX-2 inhibitor (celecoxib) with mandatory long-term PPI co-therapy. 3
• H2-receptor antagonists are inadequate for NSAID-associated gastric pathology. 3

Why H. pylori Eradication is Non-Negotiable

• H. pylori is the most consistent risk factor for gastric cancer, and its elimination is the most promising strategy to reduce gastric cancer incidence. 2
• Eradication prevents long-term recurrence, with ulcer relapse rates >60% per year in H. pylori-positive patients versus 2.6% in eradicated patients. 3
• The infection causes chronic gastritis that can progress to atrophic gastritis, intestinal metaplasia, and ultimately gastric adenocarcinoma. 6, 7