What is the recommended treatment for a patient with gastritis, potentially complicated by H. pylori infection?

Management of Gastritis

All patients with gastritis must be tested for H. pylori infection using urea breath test or stool antigen test, and if positive, treated with bismuth quadruple therapy for 14 days, followed by mandatory eradication confirmation. 1, 2

Initial Assessment and H. pylori Testing

• Test every gastritis patient for H. pylori using non-invasive methods (urea breath test or monoclonal stool antigen test) as the first diagnostic step. 3, 2
• Ensure patients are off PPIs for at least 2 weeks before testing to avoid false-negative results. 2
• For patients with erosive gastritis or atrophic changes on endoscopy, check antiparietal cell antibodies and anti-intrinsic factor antibodies to evaluate for autoimmune gastritis. 1, 2
• Screen for vitamin B-12 and iron deficiencies in patients with atrophic gastritis, as failure to do so leads to inadequate management. 1

Treatment for H. pylori-Positive Gastritis

Bismuth quadruple therapy for 14 days is the mandatory first-line treatment due to increasing antibiotic resistance rates, particularly to clarithromycin. 1, 4, 5

Bismuth Quadruple Therapy Regimen:

• High-potency PPI twice daily: Esomeprazole 20-40 mg or rabeprazole 20 mg (taken 30 minutes before meals) 1, 4
• Bismuth subsalicylate 4
• Metronidazole 4
• Tetracycline 4
• Duration: 14 days (significantly superior to shorter courses) 4

The British Society of Gastroenterology confirms that H. pylori eradication is an efficacious treatment for H. pylori-positive patients with functional dyspepsia, though adverse events are more common than with control therapy. 3

Why High-Potency PPIs Matter:

• Rabeprazole 20 mg twice daily is equivalent to 36 mg omeprazole and improves eradication rates. 1
• Esomeprazole 20-40 mg twice daily is equivalent to 32 mg omeprazole. 1
• Avoid pantoprazole when possible—40 mg pantoprazole equals only 9 mg omeprazole, making it significantly less effective. 1

Mandatory Eradication Confirmation:

• Confirm eradication 4-6 weeks after completing antibiotics using urea breath test or stool antigen test. 2, 4
• Patients must be off PPIs for at least 2 weeks before confirmation testing. 2, 4
• The Maastricht consensus acknowledges that serology should not be used to assess early success or failure, as antibody titers take up to 6 months to fall by 50%. 3
• Relying solely on symptom resolution without confirming eradication leads to persistent infection and complications. 1

Treatment for H. pylori-Negative Gastritis

For patients without H. pylori infection, empirical acid suppression with PPIs is the recommended treatment. 3

PPI Monotherapy:

• Standard-dose PPI once daily (esomeprazole 20-40 mg, rabeprazole 20 mg, or lansoprazole 30 mg) for 8 weeks. 1, 6
• There does not appear to be a dose response for symptom control, so use the lowest dose that controls symptoms. 3
• Take PPIs 30 minutes before meals to maximize effectiveness—inadequate timing reduces acid suppression. 1
• Premature discontinuation before 8 weeks prevents adequate mucosal healing. 2

Alternative Options:

• H2-receptor antagonists (H2RAs) may be efficacious but are less effective than PPIs for healing gastric lesions, though they provide faster symptom relief. 3, 1
• H2RAs decrease duodenal ulcer risk but are significantly less effective for gastric ulcer protection. 1

Special Considerations for NSAID-Induced Gastritis

Discontinue all NSAIDs immediately if clinically feasible. 1, 2

If NSAIDs Cannot Be Stopped:

• Add high-dose PPI therapy indefinitely for gastroprotection (esomeprazole 40 mg or rabeprazole 20 mg twice daily). 1, 2
• Use the lowest effective NSAID dose for the shortest duration. 1
• Never combine multiple NSAIDs—this dramatically increases GI risk, especially with aspirin. 1
• PPIs reduce endoscopic NSAID-related ulcers by 90%. 1

High-Risk Patients Requiring Intensive Gastroprotection:

• Previous peptic ulcer or ulcer complication 1
• Age >65 years 1
• Concurrent corticosteroid use 1
• Concurrent anticoagulation or antiplatelet therapy 1
• High-dose or multiple NSAID use 1

For high-risk patients, combine a COX-2 selective inhibitor with a PPI for maximum protection. 1

H. pylori and NSAIDs:

• Eradicate H. pylori before starting long-term NSAID therapy, especially in patients with previous ulcer history. 1, 2
• In patients already on NSAIDs with H. pylori infection, both PPI therapy and H. pylori eradication are necessary—eradication alone is insufficient. 1

Misoprostol as Alternative:

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

Surveillance and Follow-Up

Surveillance endoscopy every 3 years is recommended for patients with advanced atrophic gastritis. 1, 2

Risk Stratification:

• Use OLGA-staging or OLGIM histological staging to stratify gastric cancer risk and guide management decisions. 2
• H. pylori eradication is mandatory for gastric cancer prevention in high-risk populations, including first-degree relatives of gastric cancer patients (who have 2-3 times increased risk), patients with severe pan-gastritis, corpus-predominant gastritis, or severe atrophy. 2
• Long-term PPI users with H. pylori infection are at increased risk of progressing to corpus-predominant and atrophic gastritis, making eradication particularly important. 1, 4

If First-Line H. pylori Therapy Fails

Approximately 15-20% of patients fail first-line therapy and require retreatment. 4

Second-Line Options:

• Levofloxacin-based triple therapy (PPI + amoxicillin + levofloxacin) 5
• Alternative bismuth quadruple therapy if not used initially 5
• Antibiotic susceptibility testing should guide retreatment when available. 4, 5

Third-Line Therapy:

• European guidelines recommend culture before selection of third-line treatment based on microbial antibiotic sensitivity. 5
• Alternative candidates include quinolones, tetracycline, rifabutin, and furazolidone; high-dose PPI/amoxicillin therapy might also be promising. 5

Critical Pitfalls to Avoid

• Inadequate PPI dosing or incorrect timing (not taking 30 minutes before meals) reduces effectiveness. 1, 2
• Premature discontinuation before 8 weeks prevents adequate mucosal healing. 2
• Failure to confirm H. pylori eradication allows persistent infection and cancer progression. 2
• Prescribing long-term PPIs without first eradicating H. pylori accelerates atrophic gastritis and increases gastric cancer risk. 1, 2
• Using clarithromycin triple therapy without resistance data is unreliable due to high clarithromycin resistance rates exceeding 15% in most regions. 4
• Stopping H. pylori treatment early leads to treatment failure in over 20% of patients. 4, 5

Adjunctive Measures

• Regular aerobic exercise is strongly recommended for all patients with functional dyspepsia. 3
• Antacids provide rapid, temporary relief of symptoms and can be used on-demand for breakthrough symptoms. 1
• Screen for concomitant autoimmune disorders, particularly autoimmune thyroid disease, in patients with autoimmune gastritis. 1