What is the recommended treatment for a patient with gastritis?

Gastritis Treatment

Start with high-potency proton pump inhibitors (PPIs) as first-line therapy: esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily, taken 30 minutes before meals. 1, 2

First-Line PPI Therapy

The American College of Gastroenterology and American Gastroenterological Association establish PPIs as the cornerstone of gastritis treatment, with clear superiority over H2-receptor antagonists for both symptom relief and mucosal healing. 1, 2

Recommended high-potency PPI regimens:

• 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

Critical timing: Take PPIs 30 minutes before meals to maximize acid suppression effectiveness. 1, 2, 3

Avoid pantoprazole when possible due to significantly lower potency (40 mg pantoprazole = only 9 mg omeprazole equivalent). 1

Treatment duration: Continue for at least 8 weeks to ensure adequate mucosal healing, particularly for erosive changes. 3

Mandatory H. pylori Testing and Eradication

All patients with gastritis must be tested for H. pylori infection using non-invasive methods. 1, 2, 3

Preferred diagnostic tests:

• Urea breath test 1, 2, 3
• Monoclonal stool antigen test 1, 2, 3

Do not use serological testing as it remains positive after eradication and cannot confirm treatment success. 3

If H. pylori Positive: Bismuth Quadruple Therapy

First-line eradication regimen (14 days): 1, 2, 3

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

This bismuth quadruple therapy is preferred due to increasing antibiotic resistance patterns. 1, 2

Alternative when bismuth unavailable: Concomitant 4-drug therapy for 14 days. 1, 2

Antibiotic selection priority: Use "Access group" antibiotics (amoxicillin, tetracycline, metronidazole) over "Watch group" antibiotics (clarithromycin, levofloxacin) to minimize resistance development. 3

Confirm eradication: Test 4-6 weeks after completing antibiotics using urea breath test or stool antigen test, ensuring patient has been off PPI therapy for at least 2 weeks before testing to avoid false-negative results. 3

NSAID-Induced Gastritis Management

Immediate action: Discontinue all NSAIDs if clinically feasible. 1, 2

If NSAIDs cannot be stopped:

• Continue high-dose PPI therapy indefinitely for gastroprotection 1
• Use the lowest effective NSAID dose for the shortest duration 1, 2
• Never combine multiple NSAIDs as this dramatically increases GI risk 1

High-risk patients requiring intensive gastroprotection include: 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 high-risk patients: Combine a COX-2 selective inhibitor with a PPI for maximum protection. 1

H. pylori eradication is mandatory before starting long-term NSAID therapy, especially in patients with previous ulcer history. 1, 2, 3 Both PPI therapy and H. pylori eradication are necessary in infected patients requiring continued NSAIDs—eradication alone is insufficient. 1

Alternative Gastroprotective Agent

Misoprostol 600-800 mg daily reduces NSAID-associated gastric ulcers by 74% and GI complications by 40%, but causes diarrhea and abdominal pain in ~20% of patients, significantly limiting tolerability. 1, 2

H2-receptor antagonists are inadequate for gastroprotection as they decrease duodenal ulcer risk but not gastric ulcer risk. 1

Adjunctive Therapy

Antacids provide rapid, temporary symptom relief and can be used on-demand for breakthrough symptoms while awaiting PPI effectiveness. 1, 2

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, 3

Failure to test for and eradicate H. pylori leads to persistent inflammation and increased gastric cancer risk. 1, 2, 3

Using antibiotic courses shorter than 14 days results in treatment failure and resistance development. 2, 3

Relying on symptom resolution without confirming H. pylori eradication allows persistent infection and complications. 1, 2, 3

Prescribing long-term PPIs without first eradicating H. pylori accelerates progression to corpus-predominant atrophic gastritis, a preneoplastic condition. 1, 3, 4

Special Populations and Monitoring

For autoimmune gastritis: Check antiparietal cell antibodies and anti-intrinsic factor antibodies, evaluate for vitamin B-12 and iron deficiencies, and screen for concomitant autoimmune thyroid disease. 1

Surveillance endoscopy every 3 years should be considered in individuals with advanced atrophic gastritis. 1

First-degree relatives of gastric cancer patients should receive H. pylori eradication as they have 2-3 times increased risk. 3