What is the initial treatment approach for a patient presenting to the emergency room (ER) with gastritis?

Initial Treatment of Gastritis in the Emergency Department

For patients presenting to the ER with gastritis, initiate treatment with a proton pump inhibitor (PPI) such as omeprazole 20-40 mg once daily, provide supportive care with IV fluids if needed, and consider antiemetics for nausea/vomiting. 1, 2

Immediate Assessment and Risk Stratification

Upon presentation, rapidly assess for:

• Signs of hemodynamic instability (hypotension, tachycardia) requiring immediate fluid resuscitation 3, 4
• Alarm symptoms including hematemesis, melena, or severe abdominal pain suggesting complications like bleeding or perforation 3
• NSAID use history, as these patients are at higher risk for potentially life-threatening ulcer complications and should not have NSAIDs accepted as the sole cause until lower GI pathology is excluded 3
• Alcohol abuse, portal hypertension, or ICU-level physiologic stress, which are predisposing conditions for acute hemorrhagic gastritis 5

Pharmacologic Management

Acid Suppression Therapy

Proton pump inhibitors are superior to H2 receptor antagonists and should be first-line therapy 3:

• Omeprazole 20 mg once daily for symptomatic GERD/gastritis (can increase to 40 mg for active gastric ulcer) 1, 2
• Omeprazole 40 mg once daily for active benign gastric ulcer for 4-8 weeks 1, 2
• Take before meals; antacids may be used concomitantly 1, 2

Antiemetic Therapy

For nausea and vomiting, consider 3:

• Prochlorperazine, trimethobenzamide, or promethazine (antidopaminergic agents acting centrally) 3
• 5-HT3 receptor antagonists (ondansetron) on an as-needed basis, though evidence for non-chemotherapy-induced nausea is limited 3

Supportive Care

• IV fluid resuscitation for hemodynamically unstable patients 3, 4
• Nothing by mouth (NPO) if severe symptoms, signs of complications, or emphysematous gastritis 4
• Broad-spectrum antibiotics if emphysematous gastritis or signs of systemic toxicity are present 4

H. pylori Considerations

While not typically tested in the acute ER setting, H. pylori is the main etiologic factor for chronic gastritis and should be addressed in follow-up 6, 7:

• Eradication is the cornerstone of treatment for H. pylori-positive gastritis 6
• Standard triple therapy: omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg, all twice daily for 10 days 1, 2
• In regions with high clarithromycin resistance, sequential or quadruple therapy should be used instead 7

When to Pursue Endoscopy

Endoscopy is NOT typically performed emergently for uncomplicated gastritis, but consider urgent evaluation for 3:

• Elderly patients (age >60 years increases risk of complications) 3
• Alarm symptoms: hematemesis, melena, dysphagia, unintentional weight loss 3
• Regular NSAID users due to risk of life-threatening ulcer complications 3
• Hemodynamically stable patients with GI bleeding: sigmoidoscopy and esophagogastroduodenoscopy after stabilization 3

Hemorrhagic Gastritis Management

For acute hemorrhagic gastritis with bleeding 3, 5:

• Packed red blood cells to maintain hemoglobin >7 g/dL (consider >9 g/dL threshold for massive bleeding or cardiovascular comorbidities) 3
• Nasogastric tube insertion to protect airway and decompress stomach in patients with hematemesis or massive melena 3
• Endoscopic evaluation after hemodynamic stabilization, though diffuse mucosal bleeding makes endoscopic therapy more difficult 5
• Surgery is reserved as last resort for patients who continue to bleed despite aggressive medical and endoscopic therapy 5

Special Considerations and Pitfalls

Emphysematous Gastritis

• Initial non-operative management should be attempted even with portal venous gas or pneumoperitoneum: NPO, PPI, IV fluids, and antibiotics 4
• Surgical exploration reserved only for clinical deterioration, peritonitis, or failure of conservative management 4
• Repeat CT scan in 3-4 days to document resolution of pneumatosis 4

NSAID-Related Gastropathy

• Ideally stop NSAID therapy if gastritis or ulcer is identified 3
• If NSAIDs must be continued, prophylactic PPI therapy is superior to misoprostol and ranitidine for both healing and prophylaxis 3
• Risk factors requiring prophylaxis: previous peptic ulcer disease, age >60 years, glucocorticosteroid use, anticoagulant use 3

Gastric Protection

• Esomeprazole 40 mg/day for gastric protection in high-risk patients (e.g., those on dual antiplatelet therapy or anticoagulation) 3

Disposition and Follow-Up

• Discharge home if symptoms improve with initial therapy, patient is hemodynamically stable, and can tolerate oral intake 8, 4
• Admit for observation if persistent symptoms, hemodynamic instability, or concern for complications 4
• Arrange outpatient endoscopy for patients >60 years, those with alarm symptoms, or regular NSAID users 3
• Test for H. pylori in follow-up using non-serological methods (stool antigen or urea breath test) and treat if positive 6
• Screen for iron and vitamin B12 deficiencies in patients with corpus-predominant atrophic gastritis (occurs in up to 50% of cases) 6

Emerging Therapies

Erector spinae plane block (ESPB) may provide considerable symptom relief for refractory gastritis when conventional therapies fail, allowing discharge rather than admission 8.