What is the recommended management of gastritis in an adult patient?

Management of Gastritis in Adults

Start with high-potency proton pump inhibitors (esomeprazole 20-40 mg or rabeprazole 20 mg twice daily) taken 30 minutes before meals, test all patients for H. pylori using non-serological methods, and eradicate the infection with 14-day bismuth quadruple therapy if positive. 1

Immediate Pharmacologic Treatment

• Initiate high-potency PPIs as first-line therapy: esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily, taken 30 minutes before meals. 1
• Lansoprazole 30 mg twice daily serves as an alternative high-potency option for patients intolerant to esomeprazole or rabeprazole. 1
• Continue PPI therapy for at least 8 weeks to allow adequate healing of erosive mucosal changes. 1
• The 30-minute pre-meal timing is critical for optimal PPI effectiveness and should not be compromised. 1

Mandatory H. pylori Assessment

• Test every gastritis patient for H. pylori infection using urea breath test or monoclonal stool antigen test—never rely on serology alone as it remains positive after eradication. 1, 2
• If H. pylori is detected, eradication therapy is mandatory regardless of symptom severity or gastritis type. 1, 2
• Confirm successful eradication 4-6 weeks after completing antibiotics using non-serological testing, ensuring the patient has been off PPIs for at least 2 weeks to avoid false-negative results. 1

H. pylori Eradication Protocol

• Prescribe bismuth quadruple therapy for 14 days as first-line treatment: high-potency PPI + bismuth subsalicylate + metronidazole + tetracycline. 1
• This regimen is preferred due to increasing clarithromycin resistance rates that have rendered standard triple therapy inadequate in many regions. 1, 3
• When bismuth is unavailable, use concomitant 4-drug therapy as an alternative. 1
• Prioritize "Access group" antibiotics (amoxicillin, tetracycline, metronidazole) over "Watch group" antibiotics (clarithromycin, levofloxacin) to minimize resistance development. 1
• Antibiotic courses shorter than 14 days result in treatment failure and should be avoided. 1

Special Considerations for Atrophic Gastritis

When histopathology confirms atrophic gastritis (loss of gastric glands with or without metaplasia):

• Recognize that intestinal metaplasia on biopsy almost invariably indicates underlying atrophic gastritis, even if not explicitly stated in the pathology report. 4
• Obtain separate biopsies from gastric body and antrum/incisura in individually labeled jars for accurate risk stratification. 4, 2
• All atrophic gastritis patients require H. pylori testing and eradication if positive, as this may modify the natural history of atrophy. 2
• For corpus-predominant (autoimmune) gastritis, check antiparietal cell antibodies and anti-intrinsic factor antibodies to confirm the diagnosis. 4, 2
• Screen all autoimmune gastritis patients for autoimmune thyroid disease due to high comorbidity rates. 2

Management of Micronutrient Deficiencies

• Evaluate all atrophic gastritis patients for iron and vitamin B-12 deficiencies, particularly those with corpus-predominant disease. 1, 2
• Iron deficiency occurs in up to 50% of patients with corpus-predominant atrophic gastritis and often presents before B-12 deficiency. 2
• Recognize pernicious anemia as a late-stage manifestation characterized by vitamin B-12 deficiency and macrocytic anemia. 4, 2
• Patients newly diagnosed with pernicious anemia who lack recent endoscopy should undergo upper endoscopy with topographic biopsies to confirm atrophy and exclude gastric neoplasia. 4, 2

Surveillance Strategy for Advanced Disease

• Consider surveillance endoscopy every 3 years for patients with advanced atrophic gastritis (extensive anatomic distribution and high histologic grade). 4, 2
• For autoimmune gastritis patients who develop gastric neuroendocrine tumors, schedule surveillance every 1-2 years depending on NET burden. 2
• Small NETs (<1 cm) should be removed endoscopically. 2
• NETs >2 cm, those invading past the submucosa, or those with lymph node metastasis require surgical resection. 2

High-Risk Patient Modifications

• For patients taking NSAIDs or anticoagulants, H. pylori eradication is mandatory before continuing these medications, as H. pylori increases the risk of NSAID-associated ulcers 2-3 fold. 1
• Add PPI or H2-blocker prophylaxis during corticosteroid therapy in patients at high risk for gastritis complications. 1
• First-degree relatives of gastric cancer patients should receive H. pylori eradication due to their 2-3 times increased cancer risk. 1

Critical Pitfalls to Avoid

• Never prescribe long-term PPIs in H. pylori-positive patients without first eradicating the infection—this accelerates progression to corpus-predominant atrophic gastritis. 1
• Inadequate PPI dosing, incorrect timing (not 30 minutes before meals), or premature discontinuation before 8 weeks prevents adequate mucosal healing. 1
• Failure to confirm H. pylori eradication allows persistent infection, continued mucosal damage, and progression toward atrophy and malignancy. 1
• Relying on symptom resolution alone without objective confirmation of eradication is insufficient. 1
• Standard triple therapy should be abandoned in regions with high clarithromycin resistance (>15%), where it achieves suboptimal eradication rates. 3