How should I manage an alcoholic patient with alcohol‑related gastritis or ulcer?

Management of Alcohol-Related Gastritis

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

Immediate First-Line Treatment

Alcohol Abstinence

• Complete alcohol cessation is the single most important intervention, as continued alcohol consumption perpetuates mucosal damage and inflammation 1
• Brief alcohol intervention during hospitalization reduces future alcohol consumption by approximately 41 g/week and should be initiated immediately 1
• Extended alcohol counseling must be arranged after discharge to maintain abstinence 1

Acid Suppression Therapy

• Start proton pump inhibitors (PPIs) immediately to reduce gastric acid secretion and promote mucosal healing 1
• PPIs should be taken 30-60 minutes before meals, not at bedtime or with meals, as improper timing reduces efficacy by 30-50% 2
• Continue PPI therapy until mucosal healing is confirmed and symptoms resolve 3
• If partial response occurs, escalate to twice-daily dosing (before breakfast and dinner) 3
• PPIs are more effective than H2-receptor antagonists, which are more effective than placebo for symptomatic relief 1

Nutritional Therapy (Critical Component)

Caloric and Protein Requirements

• 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
• Small, frequent meals are preferred over large meals 3

Essential Vitamin and Mineral Supplementation

• B-complex vitamins are especially important in alcohol users and must be provided 1
• Specific supplementation should include: vitamin A, thiamine (100-300 mg/day IV for 3-4 days if acute deficiency, then oral/enteral), vitamin B12, folic acid, pyridoxine, vitamin D, and zinc 1
• Thiamine can be administered orally or enterally in stable patients, though IV route is most efficient for acute deficiency 1

Management of Complications

Gastrointestinal Bleeding

• Endoscopic therapy is necessary for active bleeding related to alcoholic gastritis 1
• Angiographic embolization techniques should be considered when endoscopy is not effective 1

Symptom Management

• For nausea and vomiting, use dopamine receptor antagonists (prochlorperazine, haloperidol, metoclopramide) 1
• For persistent symptoms, add 5-HT3 receptor antagonists or anticholinergic agents 1
• Do not use metoclopramide as monotherapy for GERD-like symptoms, as it has fair evidence of being ineffective 1

Adjunctive Lifestyle Modifications

• Elevate head of bed 6-8 inches for nighttime regurgitation symptoms 3
• Avoid lying down for 2-3 hours after meals 3
• Weight loss if overweight or obese (reduces symptoms significantly) 2

Helicobacter pylori Considerations

While H. pylori infection is common in alcoholics and can contribute to gastritis 4, 5, the primary pathology in acute alcohol-related gastritis is direct ethanol-induced mucosal damage 6. However, if H. pylori is detected on endoscopy:

• Triple therapy (bismuth subsalicylate, amoxicillin, and metronidazole) results in almost complete normalization of histologic findings 5
• Antibiotic treatment eradicates ammonia production and results in histological and symptomatic improvement in the majority of patients 4

Critical Pitfalls to Avoid

Monitoring Requirements

• Monitor closely for nutritional deficiencies, which are common in alcoholic patients and worsen outcomes 1
• Be vigilant for signs of alcohol withdrawal, which may require specific management protocols 1
• Recognize that alcoholic gastritis often coexists with other alcohol-related conditions, such as alcoholic liver disease, requiring additional management 1

PPI Safety Considerations

• PPIs have safety profiles comparable to placebo for short-term use 3
• Long-term PPI therapy requires monitoring, but benefits typically outweigh risks in symptomatic patients 3
• Assess response at 4-8 weeks; if symptoms resolve, taper to lowest effective dose 3

Alcohol Dependence Management

• In alcohol-dependent patients without advanced liver disease, consider naltrexone or acamprosate combined with counseling to reduce relapse risk 1
• Systematic alcohol consumption assessment must occur in both general practice and specialist consultations 7