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

Gastritis Management

Immediate First-Line Treatment

Start high-potency PPI therapy immediately with esomeprazole 20-40mg or rabeprazole 20mg twice daily, taken 30 minutes before meals, and test all patients for H. pylori infection using non-invasive methods to guide definitive treatment. 1

• Continue PPI therapy for at least 8 weeks to allow complete healing of erosive gastritis 1
• PPIs are the most potent gastric acid-suppressing agents available and superior to H2-receptor antagonists for healing gastric and duodenal ulcers 2, 3

Mandatory H. pylori Testing

All patients with gastritis must be tested for H. pylori infection, as eradication is non-negotiable regardless of symptom severity to prevent gastric cancer progression. 1

• Use urea breath test or monoclonal stool antigen test as first-line non-invasive testing methods 1, 4
• Critical pitfall to avoid: Testing must be performed at least 2 weeks after stopping PPI therapy to avoid false-negative results 1
• H. pylori infection affects half the global population and causes chronic gastritis that can progress to peptic ulcer, gastric cancer, and MALT lymphoma 5

H. pylori Eradication Protocol (If Positive)

If H. pylori is detected, eradication is mandatory and should be initiated immediately upon diagnosis, as delaying treatment allows continued mucosal damage and progression toward atrophic gastritis. 1

Treatment Selection Based on Local Resistance Patterns:

Low clarithromycin resistance areas (<15-20%):

• Use 14-day triple therapy: PPI twice daily + clarithromycin 500mg twice daily + amoxicillin 1000mg twice daily 1, 6
• Amoxicillin dosing per FDA label: 1 gram twice daily (every 12 hours) for 14 days 7

High clarithromycin resistance areas (>20%) or unknown resistance:

• Use 14-day bismuth quadruple therapy: PPI + bismuth subsalicylate + metronidazole + tetracycline 1
• This regimen should be preferred when resistance patterns are uncertain 1

Special Timing Considerations:

• For patients with bleeding gastritis/ulcers, initiate eradication therapy as soon as oral feeding resumes, typically after 72-96 hours of IV PPI (80mg bolus followed by 8mg/hour continuous infusion) 1, 6

PPI Duration After H. pylori Eradication

The duration of PPI therapy after completing antibiotics depends on gastritis severity:

• Uncomplicated gastritis: Continue PPI for 4 weeks total after completing H. pylori eradication 1, 6
• Gastritis with erosions or complicated cases (bleeding/perforation history): Extend PPI to 6-8 weeks to ensure complete mucosal healing 1, 6

Confirmation of Eradication (Mandatory)

Test for successful H. pylori eradication 4-6 weeks after completing antibiotic therapy using urea breath test or stool antigen test. 1, 4

• Ensure patient has been off PPI therapy for at least 2 weeks before testing to avoid false-negative results 1
• Never rely on symptom resolution alone without confirming eradication, as persistent infection continues despite symptom improvement 1
• H. pylori eradication reduces ulcer recurrence from 50-60% to 0-2% and prevents long-term recurrence with relapse rates dropping from >60% per year to 2.6% 6, 4

NSAID Management (Critical Component)

Immediately discontinue all NSAIDs if gastritis is present, as this alone heals 95% of ulcers and reduces recurrence from 40% to 9%. 1

• If NSAIDs cannot be discontinued, switch to selective COX-2 inhibitor (celecoxib) with mandatory long-term PPI co-therapy 1, 6
• H2-receptor antagonists are inadequate for NSAID-associated gastritis as they only protect against duodenal ulcers, not gastric ulcers 6

Critical Management Pitfalls to Avoid

Never prescribe long-term PPI therapy without first testing for and eradicating H. pylori, as this accelerates progression to corpus-predominant atrophic gastritis, a precancerous condition. 1, 8

• PPI therapy in H. pylori-positive patients causes corpus-predominant gastritis, which is frequently found in the background mucosa of patients with gastric cancer 8
• Empirical PPI therapy alone without H. pylori testing results in inadequate treatment and high recurrence rates 6

High-Risk Populations Requiring Aggressive Treatment

Mandatory H. pylori eradication is required in:

• First-degree relatives of gastric cancer patients due to 2-3 times increased cancer risk 1
• Patients with atrophic gastritis or corpus-predominant gastritis, who require urgent eradication and assessment for iron/B12 deficiencies 1
• H. pylori eradication is the most promising strategy to reduce gastric cancer incidence 1

Long-Term Management After Successful Eradication

• After documented H. pylori eradication, maintenance PPI therapy is generally not necessary as rebleeding becomes extremely rare 6, 4
• Discontinue PPI after confirmed eradication in uncomplicated cases 4