What is the appropriate management for an 11‑year‑old female with acute or chronic gastritis, including evaluation, pharmacologic therapy, Helicobacter pylori testing, and dietary recommendations?

Management of Gastritis in an 11-Year-Old Female

For an 11-year-old with gastritis, test for H. pylori using urea breath test or stool antigen test, and if positive, treat with 14-day bismuth quadruple therapy (PPI + bismuth + metronidazole + tetracycline); if H. pylori-negative or symptoms persist after eradication, use a PPI for 4-8 weeks. 1, 2

Initial Evaluation and H. pylori Testing

When to Test for H. pylori

• Test all children with confirmed gastritis or peptic ulcer disease for H. pylori infection, as this is the primary bacterial cause responsible for chronic gastritis in pediatric patients. 3, 4
• H. pylori is found in approximately 70% of pediatric patients with dyspepsia and gastritis, making it the most important treatable cause. 2
• The lifetime risk of peptic ulcer disease is approximately 17% in H. pylori-infected individuals, and early treatment alters the natural history by reducing ulcer recurrence to <5%. 3, 5

Optimal Testing Methods

• Use urea breath test (UBT) or monoclonal stool antigen test as the preferred non-invasive diagnostic methods in children. 6, 2
• Avoid serology testing, as it remains positive after eradication and cannot confirm active infection or treatment success. 2
• Critical pitfall to avoid: Ensure the patient is off PPIs for at least 2 weeks before testing, as acid suppression causes false-negative results by reducing bacterial load in the antrum. 3, 2

If Endoscopy is Performed

• Obtain at least two biopsies from the antrum and two from the body, plus one for rapid urease testing, to account for patchy bacterial distribution. 3
• The antrum has higher bacterial density due to its higher pH environment, making it the optimal site for diagnostic sampling. 3

Treatment Strategy

For H. pylori-Positive Gastritis

First-line eradication regimen (14 days): 1

• Bismuth quadruple therapy: High-potency PPI (esomeprazole 20-40 mg or rabeprazole 20 mg) twice daily + bismuth subsalicylate + metronidazole + tetracycline
• The 14-day duration is crucial and significantly outperforms shorter courses for optimal eradication rates. 1
• Take PPIs 30 minutes before meals to maximize acid suppression and improve eradication rates. 1

Why bismuth quadruple therapy?

• Effective against metronidazole-resistant strains and avoids clarithromycin, which has resistance rates exceeding 15% in most regions. 1
• Higher-potency PPIs (rabeprazole, esomeprazole) improve eradication rates compared to lower-potency options; avoid pantoprazole due to inferior potency. 6, 1

Post-Treatment Confirmation (Mandatory)

• Confirm eradication at least 4 weeks after completing antibiotics and 2 weeks after stopping PPI therapy using UBT or stool antigen test. 1
• Approximately 15-20% of patients fail first-line therapy and require retreatment. 1

If First-Line Therapy Fails

• Use levofloxacin-based triple therapy or alternative bismuth quadruple therapy based on what was used initially. 1
• Antibiotic susceptibility testing should guide retreatment when available. 1

For H. pylori-Negative Gastritis or Persistent Symptoms After Eradication

• Prescribe empirical PPI therapy for 4-8 weeks to manage acid-related symptoms. 6
• H2-receptor antagonists (H2RAs) are an alternative but have significant limitations: tachyphylaxis develops within 6 weeks, and they are less effective than PPIs for symptom relief and healing erosive gastritis. 6
• H2RAs (cimetidine, nizatidine) can be used 2-3 times daily if PPIs are not tolerated, with acid-inhibiting effects lasting approximately 6 hours. 6

Special Considerations for Pediatric Patients

Age-Appropriate Dosing

• PPIs are FDA-approved for children ≥1 year old (omeprazole, lansoprazole, esomeprazole) and ≥12 years old (rabeprazole). 6
• Effective PPI dosing ranges from 0.7 to 3.3 mg/kg daily based on clinical response. 6

Risk Stratification and Surveillance

• Assess for atrophic gastritis, corpus-predominant gastritis, or intestinal metaplasia, as these significantly increase gastric cancer risk. 1, 2
• Patients with severe atrophy or corpus-predominant gastritis require endoscopic surveillance every 3 years after H. pylori eradication. 1
• Screen first-degree relatives if there is family history of gastric cancer, as they have 2-3 times increased risk. 6, 2

Important Caveats

• CagA-positive H. pylori strains (approximately 70% of European strains) carry higher risk for peptic ulcer disease, atrophic gastritis, and gastric cancer, though routine testing for CagA is not recommended for clinical management. 3, 2
• Long-term PPI use in H. pylori-positive patients accelerates progression to corpus-predominant and atrophic gastritis, making eradication particularly important before chronic acid suppression. 1, 2

Dietary and Lifestyle Recommendations

• Avoid NSAIDs, as up to 25% of chronic NSAID users develop upper gastrointestinal adverse effects including gastritis. 2
• While specific dietary modifications are not strongly evidence-based for gastritis management, avoiding known gastric irritants (spicy foods, alcohol, smoking) is reasonable in older adolescents.

When Symptoms Persist Despite Treatment

• Do not routinely perform endoscopy in young patients without alarm features (weight loss, progressive dysphagia, recurrent vomiting, gastrointestinal bleeding, family history of gastric cancer) who fail empirical therapy, as the probability of finding relevant organic disease is very low. 6
• Consider endoscopy if alarm features are present or if there is diagnostic uncertainty after failed H. pylori eradication and PPI trial. 6
• Reevaluate the diagnosis and consider alternative causes of symptoms, including functional dyspepsia, which accounts for more than 50% of patients with upper gastrointestinal symptoms. 6