What is the recommended management approach for a patient with acute gastritis, potentially caused by NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) or H. pylori infection?

Management of Acute Gastritis

For acute gastritis, initiate high-dose proton pump inhibitor (PPI) therapy immediately—specifically esomeprazole 40 mg twice daily or rabeprazole 20 mg twice daily—while simultaneously testing for H. pylori infection and discontinuing NSAIDs if they are the suspected cause. 1

Immediate First-Line Treatment

Start PPI therapy without delay as the cornerstone of acute gastritis management:

• Esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily are the preferred high-potency PPIs for optimal symptom relief and mucosal healing 1
• Lansoprazole 30 mg twice daily is an acceptable alternative 1
• Avoid pantoprazole when possible due to significantly lower potency (40 mg pantoprazole equals only 9 mg omeprazole equivalent) 1
• PPIs should be taken 30 minutes before meals to maximize effectiveness 1

Identify and Address the Underlying Cause

If NSAID-Induced Gastritis is Suspected:

Discontinue all NSAIDs immediately if clinically feasible 2, 1

• If NSAIDs cannot be stopped, continue high-dose PPI therapy indefinitely for gastroprotection 2, 1
• Use the lowest effective NSAID dose for the shortest duration when continuation is necessary 2, 1
• Avoid combining multiple NSAIDs (including low-dose aspirin with other NSAIDs), as this dramatically increases GI risk 2, 1
• Consider switching to a COX-2 selective inhibitor plus PPI in high-risk patients requiring continued anti-inflammatory therapy 2

Test for H. pylori Infection:

All patients with acute gastritis must be tested for H. pylori using non-invasive methods 1

• Preferred tests: urea breath test or monoclonal stool antigen test 1
• If H. pylori-positive, initiate eradication therapy immediately 3, 1

H. pylori Eradication Protocol (When Positive)

Bismuth quadruple therapy for 14 days is the preferred first-line regimen due to increasing antibiotic resistance 1:

• PPI (high-dose) + bismuth + metronidazole + tetracycline for 14 days 1, 4

Alternative first-line option when bismuth is unavailable:

• Concomitant 4-drug therapy 1

Standard triple therapy (less preferred due to resistance):

• PPI + amoxicillin 1000 mg twice daily + clarithromycin 500 mg twice daily for 14 days 3, 5
• Amoxicillin should be taken at the start of meals to minimize GI intolerance 5

Confirm successful eradication with non-serological testing 4-6 weeks after completing therapy 1

Special Considerations for Combined NSAID Use and H. pylori Infection

The interaction between NSAIDs and H. pylori creates additive risk:

• H. pylori eradication should be performed before starting long-term NSAID therapy, especially in patients with previous ulcer history 2, 1
• In patients already on NSAIDs with H. pylori infection, eradication reduces ulcer recurrence but does not eliminate NSAID-related risk 2, 6
• Both PPI therapy AND H. pylori eradication are necessary in infected patients requiring continued NSAIDs—eradication alone is insufficient 2, 3

Adjunctive Therapy

Antacids can be used for rapid, temporary symptom relief while awaiting PPI effect 1

Misoprostol (synthetic prostaglandin):

• Reduces NSAID-associated gastric ulcers by 74% at doses of 600-800 mg daily 2, 1
• Limited by significant side effects: diarrhea, abdominal pain, and nausea occur in ~20% of patients 2, 1
• Reserved for patients who cannot tolerate PPIs or have contraindications 2

H2-receptor antagonists are NOT recommended as they are significantly less effective than PPIs for gastric protection and only reduce duodenal (not gastric) ulcer risk 2, 1

Treatment Duration and Follow-Up

• Continue PPI therapy for 8 weeks minimum to ensure complete mucosal healing 3
• After H. pylori eradication, maintenance PPI therapy is generally unnecessary unless NSAIDs must be continued 3
• For patients requiring ongoing NSAIDs, continue PPI indefinitely 2, 3

Critical Pitfalls to Avoid

Inadequate PPI dosing is a common error—ensure twice-daily dosing for acute gastritis, not once-daily 1

Premature discontinuation of treatment before 8 weeks prevents complete healing 1

Failure to test for H. pylori leaves a treatable cause unaddressed and increases risk of progression to atrophic gastritis 1

Using H2-receptor antagonists instead of PPIs provides inadequate gastroprotection, particularly for gastric (versus duodenal) lesions 2, 1

Continuing NSAIDs without gastroprotection in high-risk patients (previous ulcer, age >65, concurrent corticosteroids or anticoagulants) significantly increases complication risk 2

Relying on symptom resolution alone without confirming H. pylori eradication can lead to persistent infection and complications 1

Risk Stratification for NSAID Users

High-risk patients requiring intensive gastroprotection include those with 2, 1:

• Previous peptic ulcer or ulcer complication
• Age >65 years
• Concurrent corticosteroid use
• Concurrent anticoagulation or antiplatelet therapy
• High-dose or multiple NSAID use

For these patients, combine a COX-2 inhibitor with a PPI for maximum protection 2, 1