Treatment algorithm

Your Organizational Guidance

ebpracticenet urges you to prioritize the following organizational guidance:

MaagklachtenPublished by: NHGLast published: 2025

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 – antisecretory agents: preventive therapy

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INITIAL
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at risk of stress gastritis
1st line – 

antisecretory agents: preventive therapy

Critically ill patients are at risk of developing stress-induced gastrointestinal bleeding.[8] The main risk factors are mechanical ventilation for >48 hours and coagulopathy (platelet count <50 × 10³/microliter, partial thromboplastin time >2 times the upper limit of the normal range, international normalized ratio >1.5).[8]

For patients at risk, treatment with an H2 antagonist or a proton-pump inhibitor (PPI) is indicated. Sucralfate or misoprostol are alternatives.[8]

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.[3]​​

For treatment-naive patients, bismuth quadruple therapy (a proton-pump inhibitor [PPI] plus bismuth plus metronidazole plus tetracycline; preferably optimized) 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][22]​ 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]

US guidance advises against using clarithromycin-containing regimens without confirmed macrolide susceptibility due to rising clarithromycin resistance rates.[3]

For treatment-experienced patients, optimized bismuth quadruple therapy and rifabutin triple therapy are equally recommended for empiric treatment, depending on what the patient has received previously.[3]​ For patients with persistent infection after treatment with optimized 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 optimized PPI-clarithomycin triple therapy (e.g., a PPI plus clarithromycin plus either amoxicillin or metronidazole) or PCAB triple therapy (vonoprazan plus amoxicillin plus clarithromycin), 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]​​

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.[69] [ Cochrane Clinical Answers logo ] ​ All regimens are recommended for 14 days.[3]

One large, community-based, randomized controlled trial evaluated factors that impact on eradication therapy among H pylori-positive residents of Linqu County, China.[70] Gender, body mass index, change over baseline value of the 13C-urea breath test, missed drug doses, smoking, and alcohol consumption were all independent predictors of eradication failure.[70]

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; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[71]​ 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.[72]

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

Examples of eradication regimens are provided here. Specific regimens may be available as proprietary combination formulations. However, local guidelines should be consulted to aid selection of an appropriate regimen and determine treatment courses.

Primary options

Bismuth quadruple therapy

omeprazole: 20 mg orally twice daily

or

lansoprazole: 30 mg orally twice daily

or

rabeprazole: 20 mg orally twice daily

or

esomeprazole: 20 mg orally twice daily

-- AND --

bismuth subsalicylate: 300 mg orally four times daily

More

-- AND --

metronidazole: 500 mg orally three to four times daily

-- AND --

tetracycline: 500 mg orally four times daily

OR

Rifabutin triple therapy (treatment-naive)

omeprazole/amoxicillin/rifabutin: (10 mg omeprazole/250 mg amoxicillin/12.5 mg rifabutin per capsule) 4 capsules orally three times daily

OR

PCAB dual therapy

vonoprazan and amoxicillin: 20 mg (vonoprazan) orally twice daily and 1000 mg (amoxicillin) orally three times daily

Secondary options

Rifabutin triple therapy (treatment-experienced)

omeprazole: 20-40 mg orally twice daily

and

amoxicillin: 1000 mg orally twice or three times daily

and

rifabutin: 150 mg orally twice daily, or 300 mg orally once daily

OR

Levofloxacin triple therapy

omeprazole: 20 mg orally twice daily

or

lansoprazole: 30 mg orally twice daily

or

rabeprazole: 20 mg orally twice daily

or

esomeprazole: 20 mg orally twice daily

-- AND --

levofloxacin: 500 mg orally once daily

-- AND --

amoxicillin: 1000 mg orally twice daily

or

metronidazole: 500 mg orally twice daily

OR

PCAB triple therapy

vonoprazan and amoxicillin and clarithromycin: 20 mg (vonoprazan) orally twice daily and 1000 mg (amoxicillin) orally twice daily and 500 mg (clarithromycin) orally twice daily

OR

Clarithromycin triple therapy

omeprazole: 20-40 mg orally twice daily

or

lansoprazole: 30-60 mg orally twice daily

or

rabeprazole: 20-40 mg orally twice daily

or

esomeprazole: 20-40 mg orally twice daily

-- AND --

clarithromycin: 500 mg orally twice daily

-- AND --

amoxicillin: 1000 mg orally twice daily

or

metronidazole: 500 mg orally three times daily

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 nonsteroidal anti-inflammatory drug (NSAID)-associated gastritis, NSAIDs should be discontinued if possible.[40] Factors identified as placing patients at increased risk for NSAID-related gastrointestinal (GI) complications include prior history of a GI event (ulcer, hemorrhage), age >60 years, high dosage of NSAID, and concurrent use of corticosteroids or anticoagulants.[27][28]

Reduction in or abstinence from alcohol use should be encouraged in patients with alcohol-associated gastritis.[26]

Consider – H2 antagonist or proton-pump inhibitor (PPI)

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ACUTE
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erosive
Consider – 

H2 antagonist or proton-pump inhibitor (PPI)

Treatment recommended for SOME patients in selected patient group

Symptomatic therapy with either an H2 antagonist (e.g., famotidine) or a PPI (e.g., lansoprazole, omeprazole) may be effective. They may be beneficial when a nonsteroidal anti-inflammatory drug (NSAID) has to be continued.[39]

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 (vitamin B12)

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ACUTE
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autoimmune
1st line – 

cyanocobalamin (vitamin B12)

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.[31]

Primary options

cyanocobalamin (vitamin B12): 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.[4][5][6]

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.[7] However, surgery performed after the development of severe bile-reflux gastropathy does not reverse any associated gastric atrophy or intestinal metaplasia.[7]

phlegmonous gastritis

1st line – intensive care unit admission and supportive care

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ACUTE
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phlegmonous gastritis
1st line – 

intensive care unit admission and supportive care

Phlegmonous gastritis is a rare but life-threatening infection of the gastric submucosa and muscularis propria seen in debilitated patients.[10][11][12][13]​ Diagnosis is difficult to make preoperatively and initial stabilization of patients with sepsis requires vigorous fluid resuscitation and early empiric parenteral antibiotic therapy.[75]

Patients should be admitted to the intensive care unit for central-line placement and volume resuscitation.[10][11][12][13][76] Intravenous fluids should replace previous losses and any electrolyte imbalance should be corrected.[76]

Vasopressors are used as indicated in current guidelines. Norepinephrine (noradrenaline) is the vasopressor of choice.[76] Consult specialist for guidance on choice of vasopressor.

Nasogastric decompression may provide relief and also provide fluid for culture.[10][11][12][13]

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.[10][11][12][13]

Empiric treatment depends in part on local bacterial susceptibility patterns. Results of the gastric fluid culture and organism sensitivity will guide more specific therapy.[75] 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.[36][77]​

Systemic fluoroquinolone antibiotics, such as ciprofloxacin, 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; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[71]​ 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.

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

penicillin G sodium: 2-4 million units 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

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.[10][11][12][13]

Indications include deterioration despite optimal medical management, involvement of a large portion of stomach, presence of gastric infarction, or perforation.[75]

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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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