Acute Gastritis Treatment & Management

Updated: Jul 12, 2020
  • Author: Sarah El-Nakeep, MD; Chief Editor: BS Anand, MD  more...
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Treatment

Approach Considerations

Surgical intervention is not necessary for gastritis, except in the case of phlegmonous gastritis or acute necrotizing gastritis. With the latter entity, surgical intervention with resection of the affected area may be the most effective form of treatment.

Consult a gastroenterologist in complicated cases.

In cases of suspected upper gastrointestinal (GI) bleeding (decreased hemoglobin, melena, hematemesis), diagnostic endoscopy is mandatory to exclude bleeding ulcers, angiomatous malformations, erosions and malignant transformation. Severe cases with upper GI bleeding can be treated by cautery, hemoclips, local epinephrine injection, or hemostatic spraying of the bleeding area [9] along with an intravenous (IV) proton-pump inhibitor (PPI) bolus, then continuous infusion for 72 hours to stabilize the bleeding. [10]

Over-the-counter (OTC) drugs such as mucosal coating (sucralfate, antacids) agents or short-term histamine-2 antagonists can stabilize mild to moderate cases in the short term. [11] In the long term, treatment of the underlying cause (ie, avoid nonsteroidal anti-inflammatory drugs, caffeine, smoking; H Pylori eradication; etc.) is the most satisfactory course of action.

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Medical Care

Administer medical therapy for patients with acute gastritis as needed, depending on the underlying cause and the pathological findings.

The US Food and Drug Administration announced voluntary recalls of ranitidine from the market between December 2019 and February 2020 [3] after raising major concerns in September 2019 about drug contamination with the impurities of the carcinogenic molecule N-nitrosodimethylamine (NDMA). [12] A total withdrawal of all ranitidine products was requested in April 2020. [13]

No specific therapy exists for acute gastritis, except for cases caused by H pylori. The American College of Gastroenterology (ACG) guidelines suggest that the current evidence does not support the notion that treating H pylori worsens gastroesophageal reflux disease (GERD). [14] For patients who need eradication of H pylori, this should not be a concern.

First-line H pylori eradication therapy

First-line therapy for H pylori eradication consists of bismuth quadruple therapy with a proton-pump inhibitor (PPI), a nitroimidazole, and tetracycline for 10-14 days or  clarithromycin-based triple therapy with amoxicillin or amitronidazole and a PPI for 14 days (both strong recommendations). [14] Other first-line options are concomitant (14 days of clarithromycin, amoxicillin, and a nitroimidazole) or sequential (first week with amoxicillin and second week with clarithromycin and a nitroimidazole) or hybrid therapy (amoxicillin for 14 days, then adding clarithromycin and a nitroimidazole on the second week only). [14]

Note that the guidelines mention a nitroimidazole molecule in general (metronidazole or tindazole), as they have similar efficacy, although tinidazole is not recommended as first-line therapy to avoid drug resistance. [14] As for levofloxacin-containing regimens, the quality of evidence is very low; these regimens could be used for 10-14 days, on a triple regimen of levofloxacin, amoxicillin, and a PPI. Another first-line therapy regimen is a fluoroquinolone sequential therapy with amoxicillin in the first week, followed by a PPI, fluoroquinolone with nitroimidazole in the second week.

Second-line or salvage therapy

Second-line therapy or salvage therapy depends on the antibiotics used in the first course of treatment and the culture results in cases of resistant strains. Levofloxacin- and rifabutin-based salvage regimens have a better degree of evidence than bismuth- or clarithromycin-based regimens. [14, 15] See the table below.

Acute gastritis. Acute gastritis treatment options Acute gastritis. Acute gastritis treatment options according to latest American College of Gastroenterology (ACG) guidelines.

In a 2020 systematic review, investigators found nitazoxanide was effective in treatment-naïve patients as well as for salvage therapy. [16] This anti-protozoal drug increases the efficacy of multidrug regimens and could provide a good alternative in regions where multidrug resistance is endemic. Nitazoxanide is generally well tolerated and could also be of benefit in children. [16]

Other management

Administer fluids and electrolytes as required, particularly if the patient is vomiting.

Discontinue the use of drugs known to cause gastritis (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], alcohol). A long-term prospective study found that patients with arthritis who were older than 65 years and regularly took low-dose aspirin were at an increased risk for dyspepsia severe enough to necessitate the discontinuation of NSAIDs. [17] This suggests that better management of NSAID use should be discussed with older patients to reduce NSAID-associated upper gastrointestinal events.

There has been a growing concern in recent years regarding the interaction between PPIs and clopidogrel. A decrease in the antiplatelet activity of clopidogrel with a possible increase in adverse cardiac events is postulated. Pharmacokinetically, it has been shown that omeprazole and lansoprazole interact significantly with clopidogrel, and that omeprazole, rabeprazole, and esomeprazole interact with prasugrel. Pantoprazole has been shown to have the least interaction and, thus, pantoprazole has low CYP2C19-inhibiting properties. [18, 19]

PPIs when used with clopidogrel will increase the risk of mycocardial infarction and stent thrombosis, but this combination will not increase the risk of death or bleeding after percutaneous coronary intervention according to a 2019 meta-analysis. [20] Pantoprazole and lansoprazole have shown the least interaction with clopidogrel and appear to be safer than esomeprazole and omeprazole according to the latest FDA recommendations. [20]

Rebamipide is a drug that provides mucosal protection through activation of prostagrandins and inhibition of neutrophil response in the stomach lining, thus increasing the mucosal healing in NSAID-induced gastritis and H pylori infection. In separate 2018 and 2019 meta-analyses, rebamipide was effective when combined with H pylori eradication dual-therapy regimens, although its effect could be limited by ethnicity (ie, effective in Asian but not Caucasoid populations). This drug is not FDA approved, but it is used extensively in Korea, Japan, and Russia. [21, 22]

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Prevention

In patients with gastritis, it is recommended to eradicate H pylori infection before starting nonsteroidal anti-inflammatory drug (NSAIDs)/aspirin treatment for the first time, as this will decrease the possibility of inducing gastroduodenal ulceration. Unfortunately, this therapy's effectiveness decreases with chronic use. However, chronic NSAIDs/aspirin users with known history of peptic ulcer or gastrointestinal bleeding could benefit from H pylori eradication by reducing the rebleeding risk. [23]

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Long-Term Monitoring

H pylori eradication testing can be performed 4 weeks after completing therapy for gastritis. It is carried out using either rapid urease breath testing or stool antigen testing. However, this is not cost effective and is not always done.

The current recommendation is that patients with ulcers from H pylori, mucosa-associated lymphoid tissue (MALT) lymphoma, a history of gastric cancer, and those with no improvement of symptoms despite treatment must be checked for resolution of H pylori infection. [14]

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