What is the best management approach for a patient with alcohol-induced gastritis, likely with a history of chronic alcohol use and potential underlying liver disease and malnutrition?

Management of Alcohol-Induced Gastritis

The cornerstone of managing alcohol-induced gastritis is immediate and complete alcohol abstinence combined with proton pump inhibitor therapy, aggressive nutritional support with 35-40 kcal/kg/day and protein 1.2-1.5 g/kg/day, and comprehensive vitamin/mineral supplementation, particularly thiamine, B-complex vitamins, and zinc. 1

Immediate Interventions

Alcohol Cessation (Most Critical)

• Complete and permanent alcohol abstinence is non-negotiable, as continued alcohol consumption perpetuates mucosal damage through acetaldehyde production and free radical generation 1, 2, 3
• Implement brief alcohol intervention immediately during the clinical encounter, which reduces alcohol consumption by approximately 41 grams per week 1
• Arrange extended alcohol counseling after the initial visit to maintain long-term abstinence 1

Acid Suppression Therapy

• Prescribe proton pump inhibitors (PPIs) as first-line therapy to reduce gastric acid secretion and promote mucosal healing 1
• Omeprazole 20 mg once daily taken before meals is the standard dosing for gastric mucosal injury 4
• Continue PPI therapy until mucosal healing is confirmed and symptoms completely resolve 1
• PPIs are superior to H2-receptor antagonists, which are superior to placebo for symptomatic relief 1
• Antacids may be used concomitantly with PPIs if needed 4

Nutritional Therapy (Essential Component)

• Provide 35-40 kcal/kg/day with protein intake of 1.2-1.5 g/kg/day 1
• For severely ill patients, increase protein to 1.5 g/kg/day 1
• Thiamine supplementation is mandatory: 100-300 mg/day IV for 3-4 days for acute deficiency, or 100-300 mg/day orally for 4-12 weeks for prevention 1, 5
• Administer thiamine BEFORE any glucose-containing IV fluids to prevent Wernicke encephalopathy 5
• Supplement with comprehensive vitamins and minerals: vitamin A, vitamin B12, folic acid, pyridoxine, vitamin D, and zinc 1
• B-complex vitamins are particularly important in alcohol users 1

Pharmacotherapy for Alcohol Use Disorder

Medication Selection Based on Liver Status

• For patients WITHOUT advanced liver disease or cirrhosis: Naltrexone 50 mg daily combined with counseling is first-line 1
• For patients WITH cirrhosis or advanced fibrosis: Baclofen 30-60 mg daily (titrated up to 80 mg/day over 12 weeks) is the preferred medication, as it is safe in cirrhotic patients 1, 5
• Acamprosate 666 mg three times daily is an alternative safe option in liver disease 1
• AVOID naltrexone and disulfiram in advanced liver disease due to hepatotoxicity risk 1, 5

Alcohol Withdrawal Management

• Benzodiazepines are the gold standard for treating alcohol withdrawal syndrome, but use short-acting agents (oxazepam or lorazepam) in patients with suspected liver disease 6, 5
• Symptom-adapted dosing is preferred over fixed-schedule dosing, especially in cirrhotic patients where >70% may not require pharmacological treatment 6
• Monitor regularly for 24 hours after last symptoms to ensure no seizure development 6

Management of Complications

Gastrointestinal Bleeding

• For active bleeding related to alcoholic gastritis, endoscopic therapy is necessary 1
• Consider angiographic embolization when endoscopy is ineffective 1

Nausea and Vomiting

• Use dopamine receptor antagonists (prochlorperazine, haloperidol, metoclopramide) for initial management 1
• Do NOT use metoclopramide as monotherapy for GERD-like symptoms, as it has fair evidence of being ineffective 1
• Add 5-HT3 receptor antagonists or anticholinergic agents for persistent symptoms 1

Psychosocial Support (Mandatory)

• Pharmacotherapy alone is insufficient—combine with cognitive behavioral therapy, as medication without behavioral intervention significantly reduces treatment effectiveness 1
• Refer to addiction specialist or structured alcohol treatment program for individual psychotherapy, group therapy, and family therapy 1
• Use motivational interviewing techniques with empathic, non-judgmental approach 7

Monitoring and Follow-Up

• Schedule follow-up in 4-6 weeks to reassess liver enzymes, alcohol abstinence status, medication adherence, and treatment side effects 7
• Perform baseline liver function tests, complete blood count, and assess for advanced liver disease using FIB-4 score or transient elastography 7
• If cirrhosis is confirmed, initiate upper endoscopy for variceal screening and hepatocellular carcinoma surveillance with ultrasound ± AFP every 6 months 7

Critical Pitfalls to Avoid

• Never use acetaminophen or combination opioid-acetaminophen products in patients with alcoholic liver disease due to significant hepatotoxicity risk 5
• Never use NSAIDs in alcoholic patients due to multiple high-risk factors including gastric mucosal injury and potential liver disease 5
• Never give glucose-containing IV fluids before thiamine administration 5
• Never rely on pharmacotherapy alone without psychosocial interventions for alcohol cessation 5
• Recognize that alcoholic gastritis commonly coexists with alcoholic liver disease, requiring comprehensive assessment 1

Additional Considerations

• Screen for Helicobacter pylori infection, which is common in alcoholics and produces ammonia through urea breakdown, contributing to mucosal toxicity 2
• In H. pylori-positive patients, antibiotic eradication therapy results in histological and symptomatic improvement in the majority of cases 2
• Monitor for nutritional deficiencies, which are extremely common and worsen outcomes 1
• Assess for other alcohol-related organ damage including pancreatitis, as the pathogenic mechanisms involve similar metabolite-mediated injury 3