Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

at risk of stress gastritis

1st line – anti-secretory agents: preventive therapy

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INITIAL
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at risk of stress gastritis
1st line – 

anti-secretory agents: preventive therapy

Critically ill patients are at risk of developing stress-induced gastrointestinal (GI) bleeding.[9] The main risk factors are mechanical ventilation for >48 hours and coagulopathy (platelet count < 50 × 10⁹/L [50 × 10³/microlitre], partial thromboplastin time >2 times the upper limit of the normal range, international normalised ratio >1.5).

For patients at risk, treatment with H₂ antagonists or a proton-pump inhibitor (PPI) is indicated. Sucralfate or misoprostol are alternatives.[9]

Primary options

famotidine: 20 mg intravenously every 12 hours

OR

pantoprazole: 40 mg intravenously every 12 hours

OR

esomeprazole: 20-40 mg intravenously every 24 hours

OR

cimetidine: 300 mg orally/intravenously every 6 hours

Secondary options

sucralfate: 1 g orally four times daily

OR

misoprostol: 100-200 micrograms orally four times daily

ACUTE

Helicobacter pylori associated

1st line – H pylori eradication therapy

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ACUTE
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Helicobacter pylori associated
1st line – 

H pylori eradication therapy

Therapy that offers the greatest likelihood of eradicating H pylori infection is used.[4]

First-line treatment options include triple therapy (a proton-pump inhibitor [PPI] plus 2 antibiotics) or quadruple therapy (a PPI plus bismuth plus 2 antibiotics).[4][32] Eradication in 70% to 80% of patients is reported.[49][50]

A systematic review evaluated different treatment regimens, as well as duration of treatment, and concluded that longer duration of therapy, up to 14 days compared to 7 days, is associated with better eradication of the bacteria.[51] [ Cochrane Clinical Answers logo ]

Duration of therapy is usually 14 days when giving triple therapy with a PPI, clarithromycin, and amoxicillin, or substituting amoxicillin with metronidazole in penicillin-allergic patients.[4][52] ​An increased risk of neuropsychiatric events has been described with H pylori eradication therapy containing clarithromycin.[55]

In patients who have previously taken a macrolide antibiotic or metronidazole, a 7- to 14-day course of bismuth-based quadruple therapy (with tetracycline, metronidazole, and a PPI) is recommended.[4][32]

This regimen can also be used in penicillin-allergic patients.[4] The frequency of adverse effects is no greater with quadruple therapy than with triple therapy.[53]

If the patient is taking non-steroidal anti-inflammatory drugs (NSAIDs), they should be discontinued if possible.

A large, community-based, randomised controlled trial evaluated factors that impact on eradication therapy among H pylori-positive residents of Linqu County, China.[54] Sex, body mass index, change over baseline value of the 13C-urea breath test, missed medication doses, smoking, and alcohol consumption were all independent predictors of eradication failure.[54]

Primary options

Triple therapy

lansoprazole: 30 mg orally twice daily for 14 days

or

omeprazole: 20 mg orally twice daily for 14 days

or

esomeprazole: 40 mg orally once daily for 14 days

or

rabeprazole: 20 mg orally twice daily for 14 days

-- AND --

clarithromycin: 500 mg orally twice daily for 14 days

-- AND --

amoxicillin: 1000 mg orally twice daily for 14 days

or

metronidazole: 500 mg orally twice daily for 14 days

Secondary options

Quadruple therapy

lansoprazole: 30 mg orally twice daily for 7-14 days

or

omeprazole: 20 mg orally twice daily for 7-14 days

or

esomeprazole: 40 mg orally once daily for 7-14 days

or

rabeprazole: 20 mg orally twice daily for 7-14 days

-- AND --

tripotassium dicitratobismuthate: 120 mg orally four times daily for 7-14 days

-- AND --

metronidazole: 500 mg orally four times daily for 7-14 days

-- AND --

tetracycline: 500 mg orally four times daily for 7-14 days

erosive

1st line – agent exposure discontinuation/reduction

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ACUTE
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erosive
1st line – 

agent exposure discontinuation/reduction

For most patients with non-steroidal anti-inflammatory drug (NSAID)-associated gastritis, NSAIDs should be discontinued if possible.[33] Factors identified as placing patients at increased risk for NSAID-related gastrointestinal (GI) complications include prior history of a GI event (ulcer, haemorrhage), age >60 years, high dosage of NSAID, and concurrent use of corticosteroids or anticoagulants.[22][23]

Reduction in or abstinence from alcohol use should be encouraged in patients with alcohol-associated gastritis.[21]

Consider – H₂ antagonist or proton-pump inhibitor

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ACUTE
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erosive
Consider – 

H₂ antagonist or proton-pump inhibitor

Additional treatment recommended for SOME patients in selected patient group

Symptomatic therapy with either H₂ antagonists (e.g., famotidine) or a proton-pump inhibitor (e.g., lansoprazole or omeprazole) may be effective. They may be beneficial when non-steroidal anti-inflammatory drug (NSAID) has to be continued.[32]

Primary options

famotidine: 20-40 mg orally once or twice daily

OR

lansoprazole: 30 mg orally once daily

OR

omeprazole: 20 mg orally once daily

autoimmune

1st line – cyanocobalamin

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ACUTE
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autoimmune
1st line – 

cyanocobalamin

Patients with autoimmune gastritis are at risk of or have an established vitamin B₁₂ malabsorption state. Patients with low serum vitamin B₁₂ should be treated with intramuscular cyanocobalamin (vitamin B₁₂) for repletion, followed by monthly injections. The duration of therapy has not been established but is likely to be long-term.[25]

Primary options

cyanocobalamin: 1000 micrograms intramuscularly once monthly

bile reflux

1st line – rabeprazole or sucralfate

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ACUTE
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bile reflux
1st line – 

rabeprazole or sucralfate

Symptomatic therapy with rabeprazole or sucralfate is appropriate for most patients as initial therapy.[5][6][7]

Primary options

rabeprazole: 20 mg orally once daily

OR

sucralfate: 1 g orally four times daily

2nd line – surgery

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ACUTE
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bile reflux
2nd line – 

surgery

Surgical Roux-en-Y diversion may be beneficial in patients with prior gastric surgery and persistent symptoms.[8] However, surgery performed after the development of severe bile-reflux gastropathy does not reverse any associated gastric atrophy or intestinal metaplasia.[8]

phlegmonous gastritis

1st line – ICU admission and supportive care

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ACUTE
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phlegmonous gastritis
1st line – 

ICU admission and supportive care

Phlegmonous gastritis is a rare but life-threatening infection of the gastric submucosa and muscularis propria seen in debilitated patients.[11][12][13][14] Diagnosis is difficult to make pre-operatively and initial stabilisation of the septic patients requires vigorous fluid resuscitation and early empirical parenteral antibiotic therapy.[58]

Patients should be admitted to intensive care unit for central-line placement and volume resuscitation.[11][12][13][14][59] Intravenous fluids should replace previous losses and any electrolyte imbalance should be corrected.[59]

Vasopressors are used as indicated in current guidelines. Noradrenaline (norepinephrine) is the vasopressor of choice.[59] Dopamine has been associated with higher mortality, is rarely used in the UK, and should be restricted to patients with low risk of tachyarrhythmias and bradycardia.[59][60] Consult specialist for guidance on choice of vasopressor.

Nasogastric decompression may provide relief and also provide fluid for culture.[11][12][13][14]

Plus – empiric broad-spectrum antibiotics

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ACUTE
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phlegmonous gastritis
Plus – 

empiric broad-spectrum antibiotics

Treatment recommended for ALL patients in selected patient group

Empiric broad-spectrum intravenous antibiotics should be given against Staphylococcus aureus, streptococci, Escherichia coli, Enterobacter, other gram-negative bacteria, and Clostridium welchii.[11][12][13][14]

Empiric treatment depends in part on local bacterial susceptibility patterns. Results of the gastric fluid culture and organism sensitivity will guide more specific therapy.[58] Duration of treatment depends on clinical response to therapy; once this is demonstrated, switching to oral therapy may be considered.

If the disease is diagnosed in early phase, it can be treated conservatively with antibiotics and intravenous fluid infusion.[29][61]

Primary options

ampicillin/sulbactam: 2 g intravenously every 6 hours

More

and

ciprofloxacin: 200-400 mg intravenously every 12 hours

OR

piperacillin/tazobactam: 3.375 g intravenously every 6-8 hours

More

and

clindamycin: 600-900 mg intravenously every 8 hours

OR

vancomycin: 15 mg/kg intravenously every 12 hours

and

cefepime: 2 g intravenously every 12 hours

and

clindamycin: 600-900 mg intravenously every 8 hours

OR

benzylpenicillin sodium: 1.2 to 2.4 g intravenously every 4-6 hours

or

metronidazole: 7.5 mg/kg intravenously every 6 hours

-- AND --

clindamycin: 600-900 mg intravenously every 8 hours

Consider – gastrectomy

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ACUTE
|
phlegmonous gastritis
Consider – 

gastrectomy

Additional treatment recommended for SOME patients in selected patient group

Although nasogastric drainage and antibiotic therapy may be sufficient, in many cases subtotal/total gastrectomy is necessary.[11][12][13][14]

Indications include deterioration despite optimal medical management, involvement of a large portion of stomach, presence of gastric infarction, or perforation.[58]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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