Treatment of Antral Gastritis
Identify and Treat the Underlying Cause
- The primary treatment for antral gastritis is H. pylori eradication using bismuth quadruple therapy for 14 days, which addresses the underlying cause in the vast majority of cases and leads to resolution of inflammation 1
- Test all patients with antral gastritis for H. pylori infection using non-invasive methods such as urea breath test or monoclonal stool antigen tests 2, 1
- Eradication of H. pylori provides significant improvement in symptom resolution with a number needed to treat of 12 for functional dyspepsia 2
First-Line Eradication Regimen
- Bismuth quadruple therapy for 14 days is the preferred treatment due to increasing antibiotic resistance 1
- Bismuth subcitrate 120 mg four times daily, plus two antibiotics from the "Access group" (amoxicillin, tetracycline, metronidazole), plus high-potency proton pump inhibitor 1
Acid Suppression Therapy
- High-potency PPIs are first-line for symptom relief and mucosal healing 1
- Esomeprazole 20-40 mg twice daily, OR Rabeprazole 20 mg twice daily, OR Lansoprazole 30 mg twice daily 1
- Continue PPI therapy during and after H. pylori eradication (typically 4-8 weeks total) 1
- Confirm H. pylori eradication 4-6 weeks after completing antibiotic therapy using non-invasive testing 1
Special Considerations for Atrophic Changes
- Antral atrophy with intestinal metaplasia indicates H. pylori-associated atrophic gastritis (HpAG) that begins in the antrum and can progress to involve the corpus 3, 4, 5
- All patients with intestinal metaplasia should receive H. pylori eradication (strong recommendation, moderate quality evidence) 6
- Extensive atrophy and metaplasia are associated with increased gastric cancer risk 3, 4
- Incomplete (colonic-type) intestinal metaplasia carries 3-fold higher cancer risk than complete type 6
Micronutrient Management
- Screen for and treat iron and vitamin B-12 deficiencies, particularly in patients with extensive atrophic changes 7, 8, 9
Common Pitfalls to Avoid
- Do not use inadequate PPI dosing or premature discontinuation of treatment 1
- Do not use insufficient duration of antibiotic therapy - must be 14 days, not 7 days 1
- Do not rely solely on symptom resolution without confirming H. pylori eradication 1
- Do not fail to obtain separate antral and corpus biopsies in labeled jars to assess extent of atrophic changes 4, 6