Gastritis Treatment Guidelines

First-Line Treatments

• The American Gastroenterological Association recommends proton pump inhibitors (PPIs) as the first-line treatment for gastritis, with high-potency options like esomeprazole or rabeprazole (20-40 mg twice daily) being most effective for symptom relief and healing 1, 2, 3
• Rabeprazole is recommended at a dose of 20 mg twice daily, equivalent to 36 mg of omeprazole, for the treatment of gastritis 1, 3
• Esomeprazole is recommended at a dose of 20-40 mg twice daily, equivalent to 32 mg of omeprazole, for the treatment of gastritis 1, 3
• Lansoprazole is recommended at a dose of 30 mg twice daily, equivalent to 27 mg of omeprazole, for the treatment of gastritis 1, 3
• Pantoprazole should be avoided when possible due to lower potency, with 40 mg pantoprazole being equivalent to 9 mg omeprazole 1, 3

Treatment for H. pylori-Associated Gastritis

• The American College of Gastroenterology recommends bismuth quadruple therapy for 14 days as the preferred first-line treatment for H. pylori-associated gastritis due to increasing antibiotic resistance 4
• Concomitant 4-drug therapy is an alternative first-line option when bismuth is unavailable 4
• Clarithromycin triple therapy, metronidazole triple therapy, and levofloxacin triple therapy are options for H. pylori treatment, with the choice of therapy guided by local resistance patterns and previous treatment attempts 2, 4
• Higher-potency PPIs, such as rabeprazole or esomeprazole, improve eradication rates of H. pylori 1, 2, 3

Adjunctive Treatments

• Antacids provide rapid, temporary relief of symptoms and can be used on-demand for breakthrough symptoms 5, 6
• Misoprostol, a synthetic PGE1, reduces NSAID-associated gastric ulcers by 74% and duodenal ulcers by 53%, but its use is limited by side effects such as diarrhea, abdominal pain, and nausea 6, 7

Special Considerations

• The American Heart Association recommends using the lowest effective NSAID dose for the shortest duration to minimize the risk of NSAID-induced gastritis 7
• PPI therapy should be added for gastroprotection in high-risk patients taking NSAIDs 7
• H. pylori eradication should be considered before starting long-term NSAID therapy 6
• Inadequate PPI dosing and premature discontinuation of treatment are common pitfalls to avoid in the treatment of gastritis 1, 3, 5
• Failure to address H. pylori infection is a common pitfall to avoid in the treatment of gastritis 4

Treatment of H. pylori-Associated Gastritis

Diagnosis and Treatment

• Testing for H. pylori should be performed using non-invasive tests such as urea breath test (UBT) or monoclonal stool antigen tests, as recommended by the European Society of Gastrointestinal Endoscopy 8
• H. pylori eradication produces long-term relief of dyspepsia in approximately 1 in 12 patients with functional dyspepsia, according to the American Gastroenterological Association 8
• H. pylori eradication is beneficial and should be performed before starting NSAID treatment, especially in patients with a history of peptic ulcers, as suggested by the European Helicobacter Study Group 9, 10
• Eradication of H. pylori in patients receiving long-term PPIs heals gastritis and prevents progression to atrophic gastritis, as recommended by the American College of Gastroenterology 10

Special Considerations

• Relying solely on symptom resolution without confirming H. pylori eradication can lead to persistent infection and complications, as warned by the World Gastroenterology Organisation 8, 10
• Long-term PPI treatment in H. pylori-positive patients is associated with the development of corpus-predominant gastritis, which accelerates the progression to atrophic gastritis, according to the European Society of Gastrointestinal Endoscopy 9, 10

Management of Recurring Gastritis After H. pylori Eradication

Understanding Post-H. pylori Eradication Gastritis

• Residual symptoms following successful H. pylori eradication are common, with many patients continuing to experience dyspeptic symptoms despite confirmed eradication of the infection 11, 12
• The Maastricht consensus guidelines acknowledge that a significant proportion of patients with functional dyspepsia will continue to have symptoms following successful eradication of H. pylori and will require effective therapy 13
• H. pylori eradication does not guarantee complete symptom resolution, as it eliminates the risk of peptic ulcer mortality but may not address all underlying gastric inflammation 11

Appropriate Management of Recurring Symptoms

• For patients with residual symptoms following successful H. pylori eradication therapy (confirmed by negative tests), treatment should be individualized based on the predominant symptom 11, 13
• Full-dose PPI therapy (such as pantoprazole 40 mg once daily) is the recommended first-line treatment for patients with epigastric pain or reflux symptoms after H. pylori eradication 11

Rationale for PPI Therapy

• For patients with ulcer-like dyspepsia (epigastric pain) or reflux symptoms, PPI therapy confirms the acid-related nature of the symptoms 11
• The Genval guidelines recommend initial first-line therapy with full-dose PPI therapy for symptomatic gastroesophageal reflux disease (GORD), which may be present after H. pylori eradication 11

Follow-up and Monitoring

• Gradual improvement of symptoms with fluctuations is expected with appropriate treatment 11
• The absence of alarm symptoms (bleeding, vomiting, weight loss) is reassuring and suggests a benign course 11

Common Pitfalls to Avoid

• Inadequate PPI dosing (timing relative to meals) can reduce effectiveness - PPIs should be taken 30 minutes before eating 14

Treatment of Acute Gastritis

First-Line Medication Options

• H2-Receptor Antagonists (H2RAs) are less effective than PPIs for healing gastric lesions but provide faster symptom relief, according to the American Academy of Pediatrics 15
• H2RAs decrease the risk of duodenal ulcers but are less effective for gastric ulcers, as stated by the American Gastroenterological Association 16

Special Considerations

If H. pylori Infection is Present

• The American Gastroenterological Association recommends bismuth quadruple therapy for 14 days (PPI + bismuth + metronidazole + tetracycline) for H. pylori positive patients 17

If NSAID-Induced Gastritis

• The American Gastroenterological Association advises discontinuing NSAIDs if possible, and if NSAIDs must be continued, adding PPI therapy for gastroprotection 16

General Treatment

• The American College of Cardiology states that PPIs have been proven superior to both H2RAs and misoprostol in preventing ulcer recurrence and overall symptom control, making them the rational first choice for treatment of acute gastritis 18