Treatment of Gastritis

1. H. pylori (Hp) Gastritis - Most Common Form

Principles

• Combine antibiotics with acid-reducing medications (PPI)
• The PPI promotes mucosal healing and improves the gastric pH to enhance antibiotic efficacy
• Eradication prevents recurrence; recurrence rates drop to ~2% after successful eradication
• Treatment duration: 14 days (shorter durations are associated with reduced effectiveness)
• Confirm eradication at 4-6 weeks post-therapy using a urea breath test or stool antigen test

First-Line Regimens

Second-Line Therapy (after first-line failure)

• Bismuth quadruple therapy (if not used first-line)
• Levofloxacin triple therapy (PPI + levofloxacin + amoxicillin)
• Ideally guided by susceptibility testing when available

Side Effects of Eradication Therapy

• Diarrhea, nausea/vomiting, altered taste, rash - generally mild, self-limiting
• Sabiston Textbook of Surgery, 11th Ed.
• Sleisenger and Fordtran's Gastrointestinal and Liver Disease

2. Acute Gastritis

Infectious (Phlegmonous / Emphysematous) Gastritis

• Rare, potentially life-threatening bacterial infection involving the gastric wall
• Treatment: broad-spectrum intravenous antibiotics
• Surgical gastrectomy may be required if antibiotics fail
• Causative organisms: gram-negative bacilli, group A streptococci, anaerobes, Clostridium perfringens, E. coli, S. aureus

Viral / Immunocompromised Gastritis

• CMV gastritis or herpetic gastritis (in AIDS/immunosuppressed patients): treat with antiviral therapy

3. Chronic Gastritis

Autoimmune Gastritis (Type A - parietal cell antibodies, body-predominant)

• Parenteral vitamin B12 supplementation for pernicious anemia - lifelong
• Serum B12 monitoring
• Endoscopic surveillance every 3 years if atrophic gastritis with intestinal metaplasia (without dysplasia) is present - due to cancer risk

H. pylori-Related Chronic/Atrophic Gastritis (Type B - antral-predominant)

• H. pylori eradication (as above) is recommended even in the absence of peptic ulcer disease or MALT lymphoma
• Eradication of H. pylori can resolve nodular gastritis endoscopically
• Surveillance endoscopy for atrophic gastritis with intestinal metaplasia (every 3 years)
• Harrison's Principles of Internal Medicine, 22nd Ed.

4. Gastric MALT Lymphoma (complication of H. pylori gastritis)

• H. pylori eradication as primary therapy - tumor often regresses completely (may take >1 year)
• Follow up with EUS every 2-3 months
• If tumor grows or becomes high-grade aggressive B-cell lymphoma, it loses responsiveness to eradication; systemic lymphoma therapy required

5. Special Forms of Gastritis

6. Stress Gastritis (ICU/Critical Illness)

• Prevention is primary: IV PPIs or H2 receptor antagonists in critically ill patients (mechanical ventilation, coagulopathy)
• Stress ulcer prophylaxis reduces bleeding risk
• Active bleeding: endoscopic hemostasis; surgical intervention if refractory

Lifestyle and General Measures (across types)

• Avoid NSAIDs, aspirin, and COX-2 inhibitors where possible
• Avoid alcohol, smoking (accelerates mucosal injury and progression of atrophy)
• Dietary modification: reduce salt, avoid known irritants
• H. pylori: there is no approved vaccine; hygiene and sanitation reduce transmission

Recent Evidence Note: A 2025 systematic review (PMID 38602137) examined intravenous antibiotics for refractory H. pylori, relevant when oral regimens fail. Clarithromycin resistance rates are rising globally and now drive a shift away from standard triple therapy toward bismuth quadruple regimens as first-line in many regions.