How should gastritis be treated?

Treatment of Gastritis

The cornerstone of gastritis treatment is high-potency proton pump inhibitors (PPIs) combined with H. pylori testing and eradication when present, as this approach addresses both symptom relief and prevents progression to serious complications including peptic ulcers and gastric cancer. 1, 2

Initial Assessment and H. pylori Testing

• All patients with gastritis must be tested for H. pylori infection using non-invasive methods such as urea breath test or monoclonal stool antigen test 2, 3
• Serological testing should be avoided for confirming eradication as antibodies remain positive after successful treatment 2
• If atrophic gastritis is identified on histology, check antiparietal cell antibodies and anti-intrinsic factor antibodies to identify autoimmune etiology 4, 2

First-Line Acid Suppression Therapy

• Start high-potency PPIs taken 30 minutes before meals for optimal effectiveness 1, 2
• Preferred PPI options with dosing:
  • Esomeprazole 20-40 mg twice daily (most potent option) 1, 3
  • Rabeprazole 20 mg twice daily 1, 3
  • Lansoprazole 30 mg twice daily 1, 3
• Avoid pantoprazole when possible due to significantly lower potency (40 mg pantoprazole equals only 9 mg omeprazole) 3

H. pylori-Positive Gastritis Treatment

When H. pylori is detected, eradication is mandatory to prevent progression to atrophic gastritis and gastric cancer. 4, 2

• Bismuth quadruple therapy for 14 days is the preferred first-line treatment due to increasing clarithromycin resistance 1, 2, 3, 5
  • Components: PPI + bismuth + metronidazole + tetracycline 3
• Concomitant 4-drug therapy is an alternative when bismuth is unavailable 1, 3
• Treatment duration must be 14 days—shorter courses significantly reduce eradication rates 1, 2
• Use antibiotics from the "Access group" (amoxicillin, tetracycline, metronidazole) rather than "Watch group" antibiotics when possible to minimize resistance 2, 3

Confirmation of Eradication

• Confirm eradication 4-6 weeks after completing therapy using non-serological testing (urea breath test or stool antigen) 2, 3
• Never rely solely on symptom resolution—persistent infection occurs despite symptom improvement 2, 3

NSAID-Induced Gastritis

• Discontinue all NSAIDs immediately if clinically feasible 2, 3
• If NSAIDs cannot be stopped:
  • Continue high-dose PPI therapy indefinitely for gastroprotection 2, 3
  • Use the lowest effective NSAID dose for the shortest duration 1, 3
  • Consider switching to COX-2 selective inhibitor plus PPI in high-risk patients 3
• Test and eradicate H. pylori before initiating long-term NSAID therapy, especially in patients with prior peptic ulcer history 1, 2, 3
• Misoprostol 600-800 mg daily reduces NSAID-associated gastric ulcers by 74% but causes diarrhea and abdominal pain in ~20% of patients, limiting tolerability 1, 3

High-Risk Patients Requiring Intensive Gastroprotection

• Age >65 years 3
• Previous peptic ulcer or ulcer complication 3
• Concurrent corticosteroid use 3
• Concurrent anticoagulation or antiplatelet therapy 3
• High-dose or multiple NSAID use 3

Autoimmune Gastritis Management

• Screen for vitamin B-12 and iron deficiencies in all patients, particularly with corpus-predominant disease 4, 2, 3
• Screen for autoimmune thyroid disease as concomitant autoimmune disorders are common 4, 2
• Patients with pernicious anemia who have not had recent endoscopy should undergo endoscopy with topographical biopsies to confirm corpus-predominant atrophic gastritis and rule out gastric neoplasia including neuroendocrine tumors 4

Atrophic Gastritis Surveillance

• Surveillance endoscopy every 3 years should be performed in individuals with advanced atrophic gastritis (extensive anatomic distribution and high histologic grade) 4, 2, 3
• Screen for type 1 gastric neuroendocrine tumors with upper endoscopy; small tumors should be removed endoscopically followed by surveillance every 1-2 years 4

Adjunctive Therapy

• Antacids provide rapid, temporary symptom relief and can be used on-demand for breakthrough symptoms 1, 2, 3
• For patients with residual symptoms after successful H. pylori eradication (confirmed by negative testing), continue full-dose PPI therapy 1, 3

Critical Pitfalls to Avoid

• Inadequate PPI dosing or taking PPIs at the wrong time—must be taken 30 minutes before meals 1, 2
• Antibiotic therapy duration <14 days—this significantly reduces eradication rates 1, 2
• Failure to confirm H. pylori eradication with non-serological testing—symptom resolution does not equal eradication 2, 3
• Combining multiple NSAIDs—this dramatically increases GI risk 3
• Using H2-receptor antagonists for gastroprotection—they are inadequate as they decrease duodenal but not gastric ulcer risk 3
• Failure to evaluate for vitamin B-12 and iron deficiencies in atrophic gastritis 3