What is the appropriate management for alcoholic gastritis?

Management of Alcoholic Gastritis

Immediate and complete alcohol abstinence combined with proton pump inhibitor therapy forms the cornerstone of alcoholic gastritis management, supplemented by aggressive nutritional support and vitamin replacement. 1

Immediate Interventions

Alcohol Cessation

• Alcohol abstinence is the single most critical intervention and must be initiated immediately, as continued alcohol consumption perpetuates mucosal damage and inflammation. 1
• Implement brief alcohol intervention during the acute presentation, which reduces alcohol consumption by approximately 41 grams per week and is as effective as intensive treatments. 1
• Assess for alcohol withdrawal severity using standardized scoring systems, as withdrawal may require specific management protocols. 1
• Arrange extended alcohol counseling after discharge to maintain long-term abstinence. 1

Acid Suppression Therapy

• Prescribe proton pump inhibitors (PPIs) as first-line pharmacologic therapy to reduce gastric acid secretion and promote mucosal healing. 1
• Continue PPI therapy until mucosal healing is confirmed and symptoms resolve. 1
• PPIs are more effective than H2-receptor antagonists, which are superior to placebo for symptomatic relief. 1
• Do not use metoclopramide as monotherapy for GERD-like symptoms in alcoholic gastritis patients, as evidence shows it is ineffective. 1

Nutritional Management

Caloric and Protein Requirements

• Provide 35-40 kcal/kg/day with protein intake of 1.2-1.5 g/kg/day for all patients. 1
• For severely ill patients, increase protein intake to 1.5 g/kg/day. 1
• Consider enteral nutrition via nasogastric or nasoenteral tube if oral intake is inadequate. 1

Vitamin and Mineral Supplementation

• Administer thiamine 100-300 mg/day IV for 3-4 days to prevent Wernicke's encephalopathy, particularly before any glucose-containing solutions. 1
• Thiamine can be given orally or enterally in stable patients, though IV route is most efficient for acute deficiency. 1
• Supplement with B-complex vitamins (especially vitamin B12, folic acid, pyridoxine), vitamin A, vitamin D, vitamin E, and zinc. 1
• These micronutrient deficiencies are common in alcoholic patients and can worsen outcomes if left untreated. 1

Management of Complications

Gastrointestinal Bleeding

• For active bleeding related to alcoholic gastritis, perform endoscopic therapy as the primary intervention. 1
• Consider angiographic embolization techniques when endoscopy is not effective or feasible. 1

Symptom Control

• For nausea and vomiting, use dopamine receptor antagonists (prochlorperazine, haloperidol, metoclopramide). 1
• For persistent symptoms despite initial therapy, add 5-HT3 receptor antagonists or anticholinergic agents. 1

Helicobacter pylori Considerations

While not emphasized in current guidelines, research evidence suggests:

• H. pylori infection occurs in approximately 29-33% of alcoholics and is strongly associated with active chronic antral gastritis. 2, 3
• When H. pylori is present, triple therapy (bismuth subsalicylate, amoxicillin, and metronidazole) results in almost complete normalization of histologic findings and significant improvement in dyspeptic symptoms. 3
• Consider testing for H. pylori in patients with persistent symptoms despite standard therapy, as eradication improves both histological and symptomatic outcomes. 4, 3

Critical Pitfalls to Avoid

• Monitor closely for nutritional deficiencies, which are present in nearly all patients with severe alcohol-related conditions and significantly worsen outcomes. 1
• Be vigilant for signs of alcohol withdrawal, which may develop during hospitalization and require specific management. 1
• Recognize coexisting alcohol-related conditions, particularly alcoholic liver disease, which often accompanies alcoholic gastritis and requires additional management strategies. 1
• Do not assume symptoms will resolve with alcohol cessation alone—active pharmacologic and nutritional interventions are essential. 1
• Avoid nephrotoxic agents including diuretics during acute presentation, as they increase risk of acute kidney injury. 5

Long-Term Management

• Addiction treatment must be systematically offered after the acute episode to prevent recurrence. 6
• For alcohol-dependent patients without advanced liver disease, consider naltrexone or acamprosate combined with counseling to reduce relapse risk. 1
• Recommend complete abstinence, as even moderate continued alcohol consumption increases mortality risk in patients with established gastric or liver disease. 5
• Schedule follow-up to assess symptom resolution, confirm mucosal healing, and reinforce abstinence strategies. 1