The goal of treatment is to reduce gastric inflammation, relieve symptoms, and eliminate the underlying cause.[2]Glickman JN, Antonioli DA. Gastritis. Gastrointest Endosc Clin N Am. 2001 Oct;11(4):717-40.
http://www.ncbi.nlm.nih.gov/pubmed/11689363?tool=bestpractice.com
[40]Moayyedi PM, Lacy BE, Andrews CN, et al. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017;112(7):988-1013.
https://journals.lww.com/ajg/fulltext/2017/07000/acg_and_cag_clinical_guideline__management_of.10.aspx
http://www.ncbi.nlm.nih.gov/pubmed/28631728?tool=bestpractice.com
Emergence of antibiotic resistant strains of Helicobacter pylori has resulted in a variety of strategies to enhance eradication. These include the addition of a bismuth-containing salt to the antibiotic regimen, altering the duration of therapy, and use of sequential therapy, which is still considered an emerging treatment.
Helicobacter pylori gastritis
Therapy that offers the greatest likelihood of eradicating H pylori infection is used.[3]Chey WD, Howden CW, Moss SF, et al. ACG clinical guideline: treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep 1;119(9):1730-53.
https://journals.lww.com/ajg/fulltext/2024/09000/acg_clinical_guideline__treatment_of_helicobacter.13.aspx
http://www.ncbi.nlm.nih.gov/pubmed/39626064?tool=bestpractice.com
For treatment-naive patients, bismuth quadruple therapy (a proton-pump inhibitor [PPI] plus bismuth plus metronidazole plus tetracycline; preferably optimised) is recommended as the first-line option when antibiotic susceptibility is unknown. This regimen is also the recommended option for patients with penicillin allergy.[3]Chey WD, Howden CW, Moss SF, et al. ACG clinical guideline: treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep 1;119(9):1730-53.
https://journals.lww.com/ajg/fulltext/2024/09000/acg_clinical_guideline__treatment_of_helicobacter.13.aspx
http://www.ncbi.nlm.nih.gov/pubmed/39626064?tool=bestpractice.com
[22]Centers for Disease Control and Prevention. CDC yellow book 2026: health information for international travel. Section 4: travel-associated infections and diseases. Apr 2025 [internet publication].
http://wwwnc.cdc.gov/travel/yellowbook/2024/infections-diseases/helicobacter-pylori
Rifabutin triple therapy (a PPI plus rifabutin plus amoxicillin) or potassium-competitive acid blocker (PCAB) dual therapy (vonoprazan plus amoxicillin) are other first-line options that may be considered in patients with unknown antibiotic susceptibility and no history of macrolide exposure or penicillin allergy.[3]Chey WD, Howden CW, Moss SF, et al. ACG clinical guideline: treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep 1;119(9):1730-53.
https://journals.lww.com/ajg/fulltext/2024/09000/acg_clinical_guideline__treatment_of_helicobacter.13.aspx
http://www.ncbi.nlm.nih.gov/pubmed/39626064?tool=bestpractice.com
While UK guidelines also recommend PPI-clarithromycin triple therapy (e.g., a PPI plus amoxicillin plus either clarithromycin or metronidazole, or a PPI plus clarithromycin plus metronidazole) as a first-line option for treatment-naive patients, US guidance prefers PCAB triple therapy (vonoprazan plus amoxicillin plus clarithromycin) over PPI-clarithromycin triple therapy.[3]Chey WD, Howden CW, Moss SF, et al. ACG clinical guideline: treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep 1;119(9):1730-53.
https://journals.lww.com/ajg/fulltext/2024/09000/acg_clinical_guideline__treatment_of_helicobacter.13.aspx
http://www.ncbi.nlm.nih.gov/pubmed/39626064?tool=bestpractice.com
[60]National Institute for Health and Care Excellence. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Oct 2019 [internet publication].
https://www.nice.org.uk/guidance/cg184
However, US guidance advises against using clarithromycin-containing regimens without confirmed macrolide susceptibility due to rising clarithromycin resistance rates.[3]Chey WD, Howden CW, Moss SF, et al. ACG clinical guideline: treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep 1;119(9):1730-53.
https://journals.lww.com/ajg/fulltext/2024/09000/acg_clinical_guideline__treatment_of_helicobacter.13.aspx
http://www.ncbi.nlm.nih.gov/pubmed/39626064?tool=bestpractice.com
For treatment-experienced patients, optimised bismuth quadruple therapy and rifabutin triple therapy are equally recommended for empirical treatment, depending on what the patient has received previously.[3]Chey WD, Howden CW, Moss SF, et al. ACG clinical guideline: treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep 1;119(9):1730-53.
https://journals.lww.com/ajg/fulltext/2024/09000/acg_clinical_guideline__treatment_of_helicobacter.13.aspx
http://www.ncbi.nlm.nih.gov/pubmed/39626064?tool=bestpractice.com
For patients with persistent infection after treatment with optimised bismuth quadruple therapy and/or rifabutin triple therapy or those who cannot tolerate rifabutin, antibiotic susceptibility testing is recommended to guide targeted salvage therapy with clarithromycin or levofloxacin. Patients with clarithromycin-sensitive H pylori who have not received clarithromycin therapy previously may be treated with optimised PPI-clarithromycin triple therapy (e.g., a PPI plus clarithromycin plus either amoxicillin or metronidazole) or PCAB triple therapy, while patients with levofloxacin-sensitive H pylori who have not received levofloxacin therapy previously may be treated with levofloxacin triple therapy (a PPI plus levofloxacin plus amoxicillin or metronidazole).[3]Chey WD, Howden CW, Moss SF, et al. ACG clinical guideline: treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep 1;119(9):1730-53.
https://journals.lww.com/ajg/fulltext/2024/09000/acg_clinical_guideline__treatment_of_helicobacter.13.aspx
http://www.ncbi.nlm.nih.gov/pubmed/39626064?tool=bestpractice.com
One systematic review evaluated different treatment regimens, as well as duration of treatment, and concluded that longer duration of therapy, up to 14 days compared with 7 days, is associated with better eradication of the bacteria.[61]Yuan Y, Ford AC, Khan KJ, et al. Optimum duration of regimens for Helicobacter pylori eradication. Cochrane Database Syst Rev. 2013 Dec 11;(12):CD008337.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008337.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/24338763?tool=bestpractice.com
[
]
Is there randomized controlled trial evidence to determine the optimum duration of triple therapy (proton pump inhibitor and two antibiotics) for Helicobacter pylori eradication?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.498/fullShow me the answer All regimens are recommended for 14 days.[3]Chey WD, Howden CW, Moss SF, et al. ACG clinical guideline: treatment of Helicobacter pylori Infection. Am J Gastroenterol. 2024 Sep 1;119(9):1730-53.
https://journals.lww.com/ajg/fulltext/2024/09000/acg_clinical_guideline__treatment_of_helicobacter.13.aspx
http://www.ncbi.nlm.nih.gov/pubmed/39626064?tool=bestpractice.com
One large, community-based, randomised controlled trial evaluated factors that impact on eradication therapy among H pylori-positive residents of Linqu County, China.[62]Pan KF, Zhang L, Gerhard M, et al. A large randomised controlled intervention trial to prevent gastric cancer by eradication of Helicobacter pylori in Linqu County, China: baseline results and factors affecting the eradication. Gut. 2016 Jan;65(1):9-18.
http://gut.bmj.com/content/65/1/9.long
http://www.ncbi.nlm.nih.gov/pubmed/25986943?tool=bestpractice.com
Sex, body mass index, change over baseline value of the 13C-urea breath test, missed drug doses, smoking, and increased alcohol intake were all independent predictors of eradication failure.[62]Pan KF, Zhang L, Gerhard M, et al. A large randomised controlled intervention trial to prevent gastric cancer by eradication of Helicobacter pylori in Linqu County, China: baseline results and factors affecting the eradication. Gut. 2016 Jan;65(1):9-18.
http://gut.bmj.com/content/65/1/9.long
http://www.ncbi.nlm.nih.gov/pubmed/25986943?tool=bestpractice.com
Systemic fluoroquinolone antibiotics, such as levofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[63]Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804.
https://pmc.ncbi.nlm.nih.gov/articles/PMC10056716
http://www.ncbi.nlm.nih.gov/pubmed/36986665?tool=bestpractice.com
Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).
Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.
An increased risk of neuropsychiatric events has been described with H pylori eradication therapy containing clarithromycin.[64]Wong AY, Wong IC, Chui CS, et al. Association between acute neuropsychiatric events and helicobacter pylori therapy containing clarithromycin. JAMA Intern Med. 2016 Jun 1;176(6):828-34.
http://www.ncbi.nlm.nih.gov/pubmed/27136661?tool=bestpractice.com
Erosive gastritis
Reducing exposure to the associated agent is essential. For patients with non-steroidal anti-inflammatory drug (NSAID)-associated gastritis, NSAIDs should be discontinued if possible.[38]Chamberlain CE. Acute hemorrhagic gastritis. Gastroenterol Clin North Am. 1993 Dec;22(4):843-73.
http://www.ncbi.nlm.nih.gov/pubmed/7905865?tool=bestpractice.com
Factors identified as placing patients at increased risk for NSAID-related gastrointestinal (GI) complications include prior history of GI event (ulcer, haemorrhage), age >60 years, high dosage of NSAID, and concurrent use of corticosteroids or anticoagulants.[27]Hernández-Díaz S, Rodríguez LA. Association between nonsteroidal anti-inflammatory drugs and upper gastrointestinal tract bleeding/perforation: an overview of epidemiologic studies published in the 1990s. Arch Intern Med. 2000 Jul 24;160(14):2093-9.
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/485416
http://www.ncbi.nlm.nih.gov/pubmed/10904451?tool=bestpractice.com
[28]Masclee GM, Valkhoff VE, Coloma PM, et al. Risk of upper gastrointestinal bleeding from different drug combinations. Gastroenterology. 2014;147(4):784-92.
https://www.gastrojournal.org/article/S0016-5085(14)00768-9/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/24937265?tool=bestpractice.com
Reduction in or abstinence from alcohol use should be encouraged in patients with alcohol-associated gastritis.[26]MacMath TL. Alcohol and gastrointestinal bleeding. Emerg Med Clin North Am. 1990 Nov;8(4):859-72.
http://www.ncbi.nlm.nih.gov/pubmed/2226291?tool=bestpractice.com
Symptomatic therapy with either an H2 antagonist or a PPI is effective and is essential when NSAID use has to be continued.[39]National Institute for Health and Care Excellence. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Oct 2019 [internet publication].
https://www.nice.org.uk/guidance/cg184
H pylori eradication in patients on long-term NSAIDs may lead to a healing of gastritis despite ongoing NSAID therapy.[65]De Leest HT, Steen KS, Bloemena E, et al. Helicobacter pylori eradication in patients on long-term treatment with NSAIDs reduces the severity of gastritis: a randomized controlled trial. J Clin Gastroenterol. 2009 Feb;43(2):140-6.
http://www.ncbi.nlm.nih.gov/pubmed/18797408?tool=bestpractice.com
Autoimmune gastritis
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.[32]Torbenson M, Abraham SC, Boitnott J, et al. Autoimmune gastritis: distinct histological and immunohistochemical findings before complete loss of oxyntic glands. Mod Pathol. 2002 Feb;15(2):102-9.
http://www.nature.com/modpathol/journal/v15/n2/full/3880499a.html
http://www.ncbi.nlm.nih.gov/pubmed/11850538?tool=bestpractice.com
Oral crystalline cyanocobalamin may have a role in vitamin B12 maintenance therapy in these patients, but further studies are required.
Bile reflux gastritis
For patients with primary bile reflux, or reflux following gastric or biliary surgery, symptomatic therapy with rabeprazole or sucralfate as an initial therapy is preferred to surgical intervention.[4]Bondurant FJ, Maull KI, Nelson HS Jr, et al. Bile reflux gastritis. South Med J. 1987 Feb;80(2):161-5.
http://www.ncbi.nlm.nih.gov/pubmed/3810208?tool=bestpractice.com
[5]Niemala S. Duodenogastric reflux in patients with upper abdominal complaints or gastric ulcer with particular reference to reflux-associated gastritis. Scand J Gastroenterol Suppl. 1985;115:1-56.
http://www.ncbi.nlm.nih.gov/pubmed/3863229?tool=bestpractice.com
[6]Niemala S, Karttunen T, Heikkila J, et al. Characteristics of reflux gastritis. Scand J Gastroenterol. 1987 Apr;22(3):349-54.
http://www.ncbi.nlm.nih.gov/pubmed/3589504?tool=bestpractice.com
Addition of hydrotalcite (aluminium magnesium carbonate hydroxide hydrate) to rabeprazole may further decrease the number of reflux episodes including episodes lasting longer than 5 minutes, with no difference in endoscopic hyperaemia or histological inflammation.[66]Chen H, Li X, Ge Z, et al. Rabeprazole combined with hydrotalcite is effective for patients with bile reflux gastritis after cholecystectomy. Can J Gastroenterol. 2010 Mar;24(3):197-201.
http://www.ncbi.nlm.nih.gov/pubmed/20352149?tool=bestpractice.com
Surgical Roux-en-Y diversion is considered in patients with prior gastric surgery and persistent symptoms.[7]McAlhany JC Jr, Hanover TM, Taylor SM, et al. Long-term follow-up of patients with Roux-en-Y gastrojejunostomy for gastric disease. Ann Surg. 1994 May;219(5):451-5.
http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1243166&blobtype=pdf
http://www.ncbi.nlm.nih.gov/pubmed/8185395?tool=bestpractice.com
However, surgery performed after the development of severe bile-reflux gastropathy does not reverse any associated gastric atrophy or intestinal metaplasia.[7]McAlhany JC Jr, Hanover TM, Taylor SM, et al. Long-term follow-up of patients with Roux-en-Y gastrojejunostomy for gastric disease. Ann Surg. 1994 May;219(5):451-5.
http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1243166&blobtype=pdf
http://www.ncbi.nlm.nih.gov/pubmed/8185395?tool=bestpractice.com
Phlegmonous gastritis
Phlegmonous gastritis is a rare but life-threatening infection of the gastric submucosa and muscularis propria seen in debilitated patients.[10]Shipman PJ, Drury P. Emphysematous gastritis: case report and literature review. Australas Radiol. 2001 Feb;45(1):64-6.
http://www.ncbi.nlm.nih.gov/pubmed/11259977?tool=bestpractice.com
[11]Dharap SB, Ghag G, Biswas A. Acute necrotizing gastritis. Indian J Gastroenterol. 2003 Jul-Aug;22(4):150-1.
http://www.ncbi.nlm.nih.gov/pubmed/12962444?tool=bestpractice.com
[12]Carlson AP, Chan WH, Ketai LH, et al. Emphysematous gastritis in a severely burned patient: case report and literature review. J Trauma. 2007 Mar;62(3):765-7.
http://www.ncbi.nlm.nih.gov/pubmed/17414363?tool=bestpractice.com
[13]Loi T, See JY, Diddapur RK, et al. Emphysematous gastritis: a case report and a review of literature. Ann Acad Med Singapore. 2007 Jan;36(1):72-3.
http://www.ncbi.nlm.nih.gov/pubmed/17285190?tool=bestpractice.com
Diagnosis is difficult to make preoperatively and initial stabilisation of patients with sepsis requires vigorous fluid resuscitation and early empirical parenteral antibiotic therapy.[67]Jung JH, Choi HJ, Yoo J, et al. Emphysematous gastritis associated with invasive gastric mucormycosis: a case report. J Korean Med Sci. 2007 Oct;22(5):923-7.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693866
http://www.ncbi.nlm.nih.gov/pubmed/17982248?tool=bestpractice.com
Patients should be admitted to the intensive care unit for central-line placement and volume resuscitation.[10]Shipman PJ, Drury P. Emphysematous gastritis: case report and literature review. Australas Radiol. 2001 Feb;45(1):64-6.
http://www.ncbi.nlm.nih.gov/pubmed/11259977?tool=bestpractice.com
[11]Dharap SB, Ghag G, Biswas A. Acute necrotizing gastritis. Indian J Gastroenterol. 2003 Jul-Aug;22(4):150-1.
http://www.ncbi.nlm.nih.gov/pubmed/12962444?tool=bestpractice.com
[12]Carlson AP, Chan WH, Ketai LH, et al. Emphysematous gastritis in a severely burned patient: case report and literature review. J Trauma. 2007 Mar;62(3):765-7.
http://www.ncbi.nlm.nih.gov/pubmed/17414363?tool=bestpractice.com
[13]Loi T, See JY, Diddapur RK, et al. Emphysematous gastritis: a case report and a review of literature. Ann Acad Med Singapore. 2007 Jan;36(1):72-3.
http://www.ncbi.nlm.nih.gov/pubmed/17285190?tool=bestpractice.com
[68]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-247.
https://www.doi.org/10.1007/s00134-021-06506-y
http://www.ncbi.nlm.nih.gov/pubmed/34599691?tool=bestpractice.com
Intravenous fluids should replace previous losses and any electrolyte imbalance should be corrected.[68]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-247.
https://www.doi.org/10.1007/s00134-021-06506-y
http://www.ncbi.nlm.nih.gov/pubmed/34599691?tool=bestpractice.com
Vasopressors are used as indicated in current guidelines. Noradrenaline (norepinephrine) is the vasopressor of choice.[68]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-247.
https://www.doi.org/10.1007/s00134-021-06506-y
http://www.ncbi.nlm.nih.gov/pubmed/34599691?tool=bestpractice.com
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.[68]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-247.
https://www.doi.org/10.1007/s00134-021-06506-y
http://www.ncbi.nlm.nih.gov/pubmed/34599691?tool=bestpractice.com
[69]De Backer D, Aldecoa C, Njimi H, et al. Dopamine versus norepinephrine in the treatment of septic shock: a meta-analysis. Crit Care Med. 2012 Mar;40(3):725-30.
https://www.doi.org/10.1097/CCM.0b013e31823778ee
http://www.ncbi.nlm.nih.gov/pubmed/22036860?tool=bestpractice.com
Nasogastric decompression may provide relief and also provide fluid for culture.[10]Shipman PJ, Drury P. Emphysematous gastritis: case report and literature review. Australas Radiol. 2001 Feb;45(1):64-6.
http://www.ncbi.nlm.nih.gov/pubmed/11259977?tool=bestpractice.com
[11]Dharap SB, Ghag G, Biswas A. Acute necrotizing gastritis. Indian J Gastroenterol. 2003 Jul-Aug;22(4):150-1.
http://www.ncbi.nlm.nih.gov/pubmed/12962444?tool=bestpractice.com
[12]Carlson AP, Chan WH, Ketai LH, et al. Emphysematous gastritis in a severely burned patient: case report and literature review. J Trauma. 2007 Mar;62(3):765-7.
http://www.ncbi.nlm.nih.gov/pubmed/17414363?tool=bestpractice.com
[13]Loi T, See JY, Diddapur RK, et al. Emphysematous gastritis: a case report and a review of literature. Ann Acad Med Singapore. 2007 Jan;36(1):72-3.
http://www.ncbi.nlm.nih.gov/pubmed/17285190?tool=bestpractice.com
Empirical broad-spectrum intravenous antibiotics should be given against Staphylococcus aureus, streptococci, Escherichia coli, Enterobacter, other gram-negative bacteria, and Clostridium welchii.[10]Shipman PJ, Drury P. Emphysematous gastritis: case report and literature review. Australas Radiol. 2001 Feb;45(1):64-6.
http://www.ncbi.nlm.nih.gov/pubmed/11259977?tool=bestpractice.com
[11]Dharap SB, Ghag G, Biswas A. Acute necrotizing gastritis. Indian J Gastroenterol. 2003 Jul-Aug;22(4):150-1.
http://www.ncbi.nlm.nih.gov/pubmed/12962444?tool=bestpractice.com
[12]Carlson AP, Chan WH, Ketai LH, et al. Emphysematous gastritis in a severely burned patient: case report and literature review. J Trauma. 2007 Mar;62(3):765-7.
http://www.ncbi.nlm.nih.gov/pubmed/17414363?tool=bestpractice.com
[13]Loi T, See JY, Diddapur RK, et al. Emphysematous gastritis: a case report and a review of literature. Ann Acad Med Singapore. 2007 Jan;36(1):72-3.
http://www.ncbi.nlm.nih.gov/pubmed/17285190?tool=bestpractice.com
Empirical treatment depends in part on local bacterial susceptibility patterns. Results of the gastric fluid culture and organism sensitivity will guide more specific therapy.[67]Jung JH, Choi HJ, Yoo J, et al. Emphysematous gastritis associated with invasive gastric mucormycosis: a case report. J Korean Med Sci. 2007 Oct;22(5):923-7.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693866
http://www.ncbi.nlm.nih.gov/pubmed/17982248?tool=bestpractice.com
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 an early phase, it can be treated conservatively with antibiotics and intravenous fluid infusion.[36]Park CW, Kim A, Cha SW, et al. A case of phlegmonous gastritis associated with marked gastric distension. Gut Liver. 2010 Sep;4(3):415-8.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2956360
http://www.ncbi.nlm.nih.gov/pubmed/20981225?tool=bestpractice.com
[70]Rajendran S, Baban C, Lee G, et al. Rapid resolution of phlegmonous gastritis using antibiotics alone. BMJ Case Rep. 2009;2009:bcr02.2009
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3027927
http://www.ncbi.nlm.nih.gov/pubmed/21789106?tool=bestpractice.com
Although nasogastric drainage and antibiotic therapy may be sufficient, in many cases subtotal/total gastrectomy is necessary.[10]Shipman PJ, Drury P. Emphysematous gastritis: case report and literature review. Australas Radiol. 2001 Feb;45(1):64-6.
http://www.ncbi.nlm.nih.gov/pubmed/11259977?tool=bestpractice.com
[11]Dharap SB, Ghag G, Biswas A. Acute necrotizing gastritis. Indian J Gastroenterol. 2003 Jul-Aug;22(4):150-1.
http://www.ncbi.nlm.nih.gov/pubmed/12962444?tool=bestpractice.com
[12]Carlson AP, Chan WH, Ketai LH, et al. Emphysematous gastritis in a severely burned patient: case report and literature review. J Trauma. 2007 Mar;62(3):765-7.
http://www.ncbi.nlm.nih.gov/pubmed/17414363?tool=bestpractice.com
[13]Loi T, See JY, Diddapur RK, et al. Emphysematous gastritis: a case report and a review of literature. Ann Acad Med Singapore. 2007 Jan;36(1):72-3.
http://www.ncbi.nlm.nih.gov/pubmed/17285190?tool=bestpractice.com
Indications for surgery include deterioration despite optimal medical management, involvement of a large portion of stomach, presence of gastric infarction, or perforation.[67]Jung JH, Choi HJ, Yoo J, et al. Emphysematous gastritis associated with invasive gastric mucormycosis: a case report. J Korean Med Sci. 2007 Oct;22(5):923-7.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693866
http://www.ncbi.nlm.nih.gov/pubmed/17982248?tool=bestpractice.com
Prevention of stress gastritis
Critically ill patients are at risk of developing stress-induced GI bleeding.[8]Martindale RG. Contemporary strategies for the prevention of stress-related mucosal bleeding. Am J Health Syst Pharm. 2005 May 15;62(10 Suppl 2):S11-7.
http://www.ncbi.nlm.nih.gov/pubmed/15905595?tool=bestpractice.com
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).[8]Martindale RG. Contemporary strategies for the prevention of stress-related mucosal bleeding. Am J Health Syst Pharm. 2005 May 15;62(10 Suppl 2):S11-7.
http://www.ncbi.nlm.nih.gov/pubmed/15905595?tool=bestpractice.com
For patients at risk, treatment with an H2 antagonist or a PPI is indicated. Sucralfate or misoprostol are alternatives.[8]Martindale RG. Contemporary strategies for the prevention of stress-related mucosal bleeding. Am J Health Syst Pharm. 2005 May 15;62(10 Suppl 2):S11-7.
http://www.ncbi.nlm.nih.gov/pubmed/15905595?tool=bestpractice.com
Potential effects of long-term PPI therapy
Retrospective analyses suggest an association between PPI use and:[71]Yuan J, He Q, Nguyen LH, et al. Regular use of proton pump inhibitors and risk of type 2 diabetes: results from three prospective cohort studies. Gut. 2021 Jun;70(6):1070-7.
http://www.ncbi.nlm.nih.gov/pubmed/32989021?tool=bestpractice.com
[72]Heidelbaugh JJ, Kim AH, Chang R, et al. Overutilization of proton-pump inhibitors: what the clinician needs to know. Therap Adv Gastroenterol. 2012 Jul;5(4):219-32.
https://pmc.ncbi.nlm.nih.gov/articles/PMC3388523
http://www.ncbi.nlm.nih.gov/pubmed/22778788?tool=bestpractice.com
[73]Wilhelm SM, Rjater RG, Kale-Pradhan PB. Perils and pitfalls of long-term effects of proton pump inhibitors. Expert Rev Clin Pharmacol. 2013 Jul;6(4):443-51.
http://www.ncbi.nlm.nih.gov/pubmed/23927671?tool=bestpractice.com
[74]Koggel LM, Lantinga MA, Büchner FL, et al. Predictors for inappropriate proton pump inhibitor use: observational study in primary care. Br J Gen Pract. 2022 Dec;72(725):e899-906.
https://pmc.ncbi.nlm.nih.gov/articles/PMC9512410
http://www.ncbi.nlm.nih.gov/pubmed/36127156?tool=bestpractice.com
[75]Farrell B, Lass E, Moayyedi P, et al. Reduce unnecessary use of proton pump inhibitors. BMJ. 2022 Oct 24;379:e069211.
http://www.ncbi.nlm.nih.gov/pubmed/36280250?tool=bestpractice.com
[76]Ciardullo S, Rea F, Savaré L, et al. Prolonged use of proton pump inhibitors and risk of type 2 diabetes: results from a large population-based nested case-control study. J Clin Endocrinol Metab. 2022 Jun 16;107(7):e2671-9.
https://pmc.ncbi.nlm.nih.gov/articles/PMC9202701
http://www.ncbi.nlm.nih.gov/pubmed/35428888?tool=bestpractice.com
[77]Savarino E, Anastasiou F, Labenz J, et al. Holistic management of symptomatic reflux: rising to the challenge of proton pump inhibitor overuse. Br J Gen Pract. 2022 Nov;72(724):541-4.
https://pmc.ncbi.nlm.nih.gov/articles/PMC9591095
http://www.ncbi.nlm.nih.gov/pubmed/36302677?tool=bestpractice.com
However, these studies have been unable to establish a causal relationship.
PPIs should, therefore, only be prescribed for appropriate indications and should be limited to the warranted therapeutic duration.[74]Koggel LM, Lantinga MA, Büchner FL, et al. Predictors for inappropriate proton pump inhibitor use: observational study in primary care. Br J Gen Pract. 2022 Dec;72(725):e899-906.
https://pmc.ncbi.nlm.nih.gov/articles/PMC9512410
http://www.ncbi.nlm.nih.gov/pubmed/36127156?tool=bestpractice.com
[75]Farrell B, Lass E, Moayyedi P, et al. Reduce unnecessary use of proton pump inhibitors. BMJ. 2022 Oct 24;379:e069211.
http://www.ncbi.nlm.nih.gov/pubmed/36280250?tool=bestpractice.com
[76]Ciardullo S, Rea F, Savaré L, et al. Prolonged use of proton pump inhibitors and risk of type 2 diabetes: results from a large population-based nested case-control study. J Clin Endocrinol Metab. 2022 Jun 16;107(7):e2671-9.
https://pmc.ncbi.nlm.nih.gov/articles/PMC9202701
http://www.ncbi.nlm.nih.gov/pubmed/35428888?tool=bestpractice.com
As PPIs are part of first-line therapy for gastritis, judicious use is warranted and appropriate protocols should be followed.