How should gastritis be treated?

Treatment of Gastritis

Gastritis treatment depends critically on identifying and addressing the underlying cause, with H. pylori eradication being the cornerstone for infectious gastritis and high-potency proton pump inhibitors (PPIs) serving as the foundation for symptom management and mucosal healing. 1

Initial Diagnostic Approach

Before initiating treatment, determine the etiology of gastritis:

• Test all patients for H. pylori infection using non-invasive methods such as urea breath test or monoclonal stool antigen test, which have superior accuracy compared to serology 1, 2
• Assess for NSAID use, autoimmune gastritis (check antiparietal cell and anti-intrinsic factor antibodies), and other causes 3, 1
• Consider endoscopy with topographical biopsies in patients with alarm features, persistent symptoms, or risk factors for gastric cancer 3

Treatment Based on Etiology

H. pylori-Positive Gastritis

Bismuth quadruple therapy for 14 days is the preferred first-line treatment due to increasing antibiotic resistance to clarithromycin 3, 1, 2:

• PPI (esomeprazole 20-40 mg or rabeprazole 20 mg twice daily) 3, 1
• Bismuth subsalicylate or bismuth subcitrate 3, 2
• Metronidazole 3, 2
• Tetracycline 3, 2

This regimen is favored because it avoids clarithromycin (which has high resistance rates) and uses "Access group" antibiotics with lower resistance potential 3, 2. The 14-day duration maximizes eradication rates 1, 2.

Alternative first-line option when bismuth is unavailable: Concomitant 4-drug therapy for 14 days consisting of PPI, amoxicillin, clarithromycin, and metronidazole 3, 1, 2

Critical point: Avoid clarithromycin-based triple therapy in areas with >15% clarithromycin resistance, which now includes most regions 3

Second-line treatment after first-line failure: Levofloxacin triple therapy (PPI, amoxicillin, levofloxacin) for 14 days, but only if levofloxacin was not used previously 3, 2

Confirm eradication: Perform non-serological testing (urea breath test or stool antigen) at least 4 weeks after completing therapy and at least 2 weeks after stopping PPI therapy 3, 1

H. pylori-Negative Gastritis

For NSAID-induced gastritis:

• Discontinue or reduce NSAID dose to the lowest effective dose for the shortest duration 1
• Initiate high-potency PPI therapy: esomeprazole 20-40 mg twice daily or rabeprazole 20 mg twice daily, taken 30 minutes before meals 3, 1
• Consider H. pylori testing and eradication before starting long-term NSAID therapy, as eradication can prevent NSAID-associated ulcers in patients with prior ulcer history 3, 1
• Add misoprostol (reduces NSAID-associated gastric ulcers by 74%) if PPI therapy is insufficient, though side effects including diarrhea limit tolerability 1

For autoimmune gastritis:

• Screen for vitamin B12 and iron deficiency and replace as needed 3
• Screen for autoimmune thyroid disease (commonly coexists) 3
• Perform endoscopic surveillance for type 1 gastric neuroendocrine tumors every 1-2 years 3
• Consider endoscopy every 3 years for advanced atrophic gastritis due to increased gastric cancer risk 3, 2

PPI Selection and Dosing

Use high-potency PPIs for optimal outcomes 3, 1:

• Preferred agents: Esomeprazole 20-40 mg twice daily or rabeprazole 20-40 mg twice daily 3, 1
• Alternative: Lansoprazole 30 mg twice daily 1
• Avoid pantoprazole as it has significantly lower potency (40 mg pantoprazole = 9 mg omeprazole equivalent) 3
• Timing: Take 30 minutes before meals for optimal acid suppression 1

The higher potency PPIs (esomeprazole, rabeprazole) improve H. pylori eradication rates, particularly with amoxicillin-containing regimens 3.

Adjunctive Therapy

• Antacids provide rapid, temporary symptom relief and can be used on-demand for breakthrough symptoms 1, 2
• Continue full-dose PPI therapy for residual dyspeptic symptoms after successful H. pylori eradication 1, 2

Common Pitfalls to Avoid

• Inadequate PPI dosing (use high-potency agents at appropriate doses) 1
• Premature discontinuation of treatment (complete full 14-day antibiotic course) 1
• Failure to confirm H. pylori eradication after treatment 1
• Using clarithromycin-based triple therapy in areas with high resistance 3
• Insufficient antibiotic duration (must be 14 days, not 7-10 days) 3, 1
• Relying on serology for H. pylori diagnosis or test of cure (use breath test or stool antigen) 1, 2

Long-Term Management

For patients with atrophic gastritis:

• Endoscopic surveillance every 3 years for advanced atrophic gastritis (extensive anatomic distribution or high-grade histology) due to increased gastric cancer risk 3, 2
• Screen for nutritional deficiencies (vitamin B12, iron, calcium, magnesium, zinc) particularly in corpus-predominant atrophy 3, 4

H. pylori eradication is most effective for gastric cancer prevention when performed before development of atrophic changes 3, 2. In high-risk populations, eradication reduces gastric cancer incidence and is cost-effective 3.