The frequency of extremely low serum pepsinogen, indicative of corpus gastritis with severe atrophy, in rheumatoid arthritis, other chronic rheumatic diseases and non-rheumatic diseases

The aim of this study was to assess the frequency of corpus gastritis with severe atrophy (CGA), pernicious anaemia and combined severe atrophy of antrum and corpus by non-invasive methods (i.e. determination of low serum pepsinogen A (PgA) and serum gastrin) in outpatients with RA (n = 249), compared to outpatients with other rheumatic diseases (n = 181) and outpatients with chronic non-rheumatic diseases (n = 429). In addition we investigated whether NSAIDs could cause or prevent CGA. A low serum PgA level (< 17 micrograms/l), indicating pentagastrin-refractory achlorhydria in patients without gastric resection, was found in 13 patients (5.2%; 95% Confidence Interval (CI) 2.4-8.0) with RA, in 11 (6.1%; 95% CI 2.6-9.5) with other rheumatic diseases and in 12 patients (2.8%; 95% CI 1.2-4.4) with chronic non-rheumatic diseases (NS). Low serum PgA values were more frequent in older patients (P < 0.005) and females (P < 0.05). Pernicious anaemia occurred in RA in 1.2% (95% CI 0-2.6) of the patients while for other rheumatic diseases the frequency was 1.7% (95% CI 0-3.5) and for chronic non-rheumatic diseases 0.2% (95% CI 0-3.6) (NS). In patients with a serum PgA below 17 micrograms/l, normal serum gastrin levels (< 90 ng/l) as an indication of combined severe atrophy of antrum and corpus, were found in 1/13 patients with RA, in 3/11 with other rheumatic diseases and 2/12 with chronic non-rheumatic diseases (NS). The frequency of low serum PgA levels was no different between patients on NSAIDs 17/355 (4.8%) and those without NSAIDs 19/502 (3.8%).(ABSTRACT TRUNCATED AT 250 WORDS)

Primary Sjögren's syndrome associated with chronic atrophic gastritis and pernicious anemia

Sjögren's syndrome (SS) is a systemic, autoimmune exocrinopathy in which destructive, inflammatory-cell infiltration can affect any gland. Although chronic atrophic gastritis is the most common form of gastrointestinal involvement in SS, pernicious anemia develops in rare cases. We therefore report a patient with these three associated diseases.

[Gastric carcinoid associated with pernicious anemia]

A clinical case of a patient with pernicious anaemia and a carcinoid tumor of the gastric fundus is described. In the context of the case the relationship between pernicious anaemia, achlorhydria, atrophic gastritis and gastric carcinoid is discussed. The gastric neuroendocrine tumours and their structural and functional characteristics were reviewed in an attempt to clarify the nomenclature and the diagnostic and therapeutic approach in these situations.

[Pernicious anemias with subtle or atypical presentation]

PURPOSE

To assess the prevalence and clinico-biologic characteristics of pernicious anaemia (PA) showing subtle or atypical onset.

MATERIAL AND METHODS

One-hundred and twenty-four patients were found to fulfill criteria for PA (serum vitamin B12 deficiency due to absence of intrinsic factor secretion because of severe gastric atrophy). Of them were disclosed those lacking macrocytosis (MCV less than 98 fL), with or without anaemia (Hb less than 120 g/L in women and less than 14 f/L in men), but showing decreased serum B12 rates (less than 150 pmol/L).

RESULTS

Macrocytosis was absent in 15 out of the 124 cases (12.1%); either they had anaemia or not, serum B12 rates were decreased in all cases. Eight patients had concurrent iron deficiency, one had secondary anaemia, two had polycythaemia and four were normal from a haematological standpoint. Serum B12 assays were performed because of neuropsychiatric impairment (2 cases), polycythaemia study (3 cases), or positive anti-parietal cell antibodies found in an immunologic study (4 cases). The remaining patients were studied for chronic atrophy of the gastric mucosa (2 cases), and Plummer-Vinson syndrome, leucopenia and nutritional assessment (1 case of each condition).

CONCLUSIONS

Atypical presentation of pernicious anaemia, whose frequency is probably underestimated, was confirmed in our environment. This condition must be suspected and ruled out in patients with characteristics similar to those described above.

[Primary hypogammaglobulinemia in adults]

Intermittent or chronic diarrhea may be the initial symptom of hypogammaglobulinemia. In adult, that corresponds most frequently to common variable immunodeficiency. The pathogenesis of this syndrome is still undetermined. Diagnostic criteria are discussed as well as the therapeutic approach that can avoid multiple complications.

Pernicious anemia. Early identification to prevent permanent sequelae

Pernicious anemia can be confidently diagnosed in a patient who has megaloblastic hematopoiesis, low serum cobalamin level, and impaired vitamin B12 absorption correctable by administering intrinsic factor. Recent studies suggest that neurologic disorders in patients with pernicious anemia are less severe than in the past, highly responsive to therapy, and seen in the absence of anemia and macrocytosis. A low serum cobalamin level in the absence of anemia, particularly in a patient with a neurologic disorder, should not be ignored.

Molecular targets in pernicious anaemia

Autoimmune gastritis, leading to pernicious anaemia, is an organ-specific autoimmune disease characterized by chronic atrophic gastritis and circulating gastric parietal cell autoantibodies. The parietal cell autoantigens have recently been identified as the alpha and beta subunit of the gastric proton pump (H+, K+ ATPase). Here Paul Gleeson and Ban-Hock Toh discuss how the identification of these gastric parietal cell autoantigens and the development of a mouse model of autoimmune gastritis have paved the way for an understanding of the pathogenesis of the gastric lesion.

Association of infection due to Helicobacter pylori with specific upper gastrointestinal pathology

The association of infection with Helicobacter pylori and antral (type B) gastritis now is clear, and the development of sensitive and specific serologic assays for IgA and IgG allows for diagnosis of this infection by noninvasive means. With use of these assays, we studied the association of infection with H. pylori and four other upper gastrointestinal inflammatory conditions: Barrett's esophagus, pernicious anemia (which accompanies type A gastritis), and duodenal and gastric ulcers. H. pylori was present in only 39% of 41 patients with Barrett's esophagus whose gastric biopsy specimens were examined histologically. Each serologic assay correctly categorized 39 (95.1%) of the 41 patients. For both assays the frequency of seropositivity noted for 58 patients with Barrett's esophagus was not different from that noted for age- and sex-matched healthy controls. Among 40 patients with pernicious anemia, the results of assays for IgA and IgG were positive for 17.5% and 0%, respectively; these prevalences were significantly less than the 50% (IgA) and 40% (IgG) positivities noted for matched controls (P less than .01 for each; McNemar's test). Among 57 patients with documented duodenal or gastric ulcers, the results of assays for IgG and IgA were positive for 100% and 98.2%, respectively; these prevalences were significantly higher than the rate noted for matched controls (P less than .001 for duodenal ulcers and P = .02 for gastric ulcers for IgA assay). These data suggest that infection with H. pylori is strongly associated with duodenal and gastric ulcers, negatively associated with pernicious anemia, and independent of Barrett's esophagus.

H+,K-ATPase antibodies in autoimmune gastritis: observations on the development of pernicious anemia

The prevalence and development of antibodies to H+,K+-ATPase were investigated with a sensitive enzyme-linked immunosorbent assay in 86 patients with autoimmune atrophic gastritis (type A). Sixty-nine of the patients had pernicious anemia, and 17 had simple atrophic gastritis. Elevated titers were found in 93% of pernicious anemia probands. Women had higher levels than men: 3.24 versus 1.58 U/l (p = 0.002) (upper reference limit, 0.55 U/l). The antibody levels did not change over 1-4 years, but a gradual decrease in titers over decades was observed. All patients with pernicious anemia had low levels of pepsinogen A, a product of the gastric chief and mucous neck cells (median, 8.5 micrograms/l; reference range, 10-90 percentile, 64.4-195.5 micrograms/l), and elevated serum gastrin values (greater than 55 pmol/l) were found in 87%. Serum pepsinogen A, but not serum gastrin, correlated with H+,K(+)-ATPase antibody titers (r = 0.35, p = 0.01). In the 17 cases with simple atrophic gastritis, H+,K(+)-ATPase antibodies correlated inversely with fundic mucosal gland destruction. The data indicate that H+,K(+)-ATPase antibody titers reflect the immune responsiveness of a given patient as well as the antigenic amount, dependent on the degree of mucosal destruction and the duration of the disease.

[Association of primary autoimmune hypothyroidism with Addison's anemia]

Intestinal absorption of vitamin B12 as measured by the Schillin test was studied in 50 patients with primary hypothyroidism of autoimmune origin. The impaired absorption of vitamin B12 was found in 24% of the patients studied, and in 6% a clinically evident form of pernicious anemia was diagnosed. The patients with hypothyroidism and simultaneous defect in absorption of vitamin B12 were characterized by more frequent occurrence of the high titer of antithyroid microsomal antibodies, higher blood serum concentration of TSH and lower blood content of hemoglobin as compared with hypothyroid patients having normal intestinal absorption of vitamin B12.

The occurrence of auto-antibodies in patients with gastro-duodenal lesions

The occurrence of auto-antibodies in patients with the autoimmune disease pernicious anaemia and in patients with active duodenal ulcers was investigated. In order to characterize antigenic structures, various cellular and subcellular fractions were prepared from pig gastric mucosa and from a homogenate of duodenal mucosa. By means of an enzyme-linked immunosorbent assay and immunoblotting, both the H+,K(+)-ATPase and pepsinogen/pepsin were shown to constitute the major antigens. All of the seven pernicious-anaemia sera that were tested contained auto-antibodies against both antigens, and the epitopes of the H+,K(+)-ATPase were shown to be localized on its cytoplasmic face. In 75% (18/24) of the sera from patients with duodenal ulcers, auto-antibodies were detected when using purified antigens. Six sera reacted with H+,K(+)-ATPase and twelve reacted with pepsinogen, one reacted with both antigens, and four sera reacted with the duodenal mucosal antigen. The occurrence of auto-antibodies indicates that there is a mucosal lesion and that immunological factors may be involved in the pathogenesis of the disease in some patients.

Pernicious anemia in a patient with hypogammaglobulinemia

A 19-year-old male with pernicious anemia and hypogammaglobulinemia (common variable immunodeficiency: CVID) is reported in comparison with classical pernicious anemia. This case was characterized by an earlier onset of anemia, the absence of autoantibodies to intrinsic factor or gastric parietal cells and involvement of the pyloric antrum as well as the gastric corpus. It is suggested that dysregulation of cellular immunity produces the autoimmune lesion in the gastric mucosa, including the pyloric antrum, in a patient with CVID, and that some of such cases develop pernicious anemia.

[Long-term follow up of patients with pernicious anemia]

The authors give several data of 357 patients with megaloblastic anaemia diagnosed, treated and controlled between 1958-1988. 334 of the patients had anaemia perniciosa and 23 of them had postresectional megaloblastic anaemia. After listing the criteria of the diagnosis the authors detail the mean age of the patients at the time of diagnosis, the distribution of sexes, age and blood groups among the patients, the number of new cases per year, the frequency of relapsus of the disease and its association with other autoimmune diseases. They also deal with the characteristic seasonal fluctuation and the accumulated cases in families. Its association with malignant tumours, especially with stomach carcinoma was examined.

Possible correlation between the zinc and copper concentrations involved in the pathogenesis of various forms of anemia

The concentrations of three trace elements (iron, copper and zinc) involved in hematopoiesis were studied in 200 patients with iron-deficit anemia, hemolytic anemia and Biermer's anemia, in comparison with a group of normal subjects. The method used was atomic absorption spectrophotometry. The results obtained showed that in iron-deficit anemia resistant to iron therapy the copper and ceruloplasmin serum concentrations are at the lowest limit of normal. This copper deficit has a negative effect on the disease by preventing hemoglobin synthesis. In iron-deficit anemias responding to iron therapy the relatively low (about 90 gamma %) zinc values have a negative effect by blocking the iron in the iron reserve. In hemolytic anemia the very high zinc serum concentrations (over 200 gamma %) may lead to a shortening of the erythrocytes life span due to its "entatic state". In Biermer's anemia zinc by its high concentration has a positive role owing to carbonic anhydrase which eliminates more rapidly carbon dioxide from the organism.

[Achlorhydria and stomach carcinoma]

Patients with achlorhydria are suspected to have an increased risk of developing gastric adenocarcinoma. However, in the literature the reported risk varies considerably. In The Netherlands no such data are available. The risk of developing gastric adenocarcinoma was investigated in 129 achlorhydric patients. During a mean observation period of 12.3 yrs gastric adenocarcinoma was diagnosed in six patients. The expected incidence was 1,275, calculated by making use of age, sex and calendar specific incidence and mortality rates of gastric cancer in the Dutch population. The relative risk to develop gastric cancer was 4.7 (95% confidence limits: 1.7-10.2; p less than 0.05). Despite a significantly increased risk, screening of achlorhydric patients for gastric cancer is not advised.

Hypothesis: a history of hypothyroidism or a family history of pernicious anaemia are useful in identifying masked pernicious anaemia in elderly patients with microcytic hypochromic anaemia

Of 2200 consecutive patients admitted to an acute geriatric unit, 58 had microcytic hypochromic anaemia. Twenty of these (34%) had serum vitamin B12 below the normal range. Eleven (19%) had malabsorption of vitamin B12 in eight of whom (14%) this was due to pernicious anaemia (PA). This study re-emphasizes the need for screening for PA in patients with microcytic hypochromic anaemia, particularly those with a family history or who have recognized associated diseases.

Low serum cobalamin levels in a population study of 70- and 75-year-old subjects. Gastrointestinal causes and hematological effects

We examined causes and hematological consequences of low serum cobalamin (vitamin B12) concentration in two representative population samples of 70-year-old (N = 293) and 75-year-old subjects (N = 486). Subjects with values below 130 pmol/liter (4.8% and 5.6%, respectively) were investigated with Schilling test, upper gastrointestinal endoscopy, determination of serum gastrin and group I pepsinogens, and bone marrow examination. Gastrointestinal abnormalities of etiologic significance were found in 26 of the 32 examined subjects: atrophy of the gastric body mucosa (N = 16, with pernicious anemia in six), partial gastrectomy (N = 6), and intestinal malabsorption (N = 4). Megaloblastic hematopoiesis was found in 10 individuals, four of whom had macrocytic anemia. Our results indicate that low serum cobalamin concentration in the elderly is usually a consequence of disease rather than of high age per se and that gastric mucosal atrophy is a major etiologic factor.

Pernicious anemia. The expected findings of very low serum cobalamin levels, anemia, and macrocytosis are often lacking

When patients are examined for possible cobalamin deficiency, great stress is often placed on the presence or absence of macrocytosis and anemia and on how low the serum cobalamin level is. The present study, however, shows that only 45 (64%) of 70 consecutively diagnosed patients with pernicious anemia, the most common cause of cobalamin deficiency, had very low cobalamin levels (less than 74 pmol/L [or less than 100 ng/L]). Anemia was absent in 13 (19%) of the patients, and macrocytosis was absent in 23 (33%) of the patients; such absence was particularly common when cobalamin levels were only slightly or moderately low (74 to 184 pmol/L). Coexisting iron deficiency was responsible for the absence of macrocytosis in nine patients. Of the ten patients with neither anemia nor macrocytosis, neurological disturbance was prominent in six, including four whose only noticeable abnormality was cerebral. These observations indicate that macrocytosis and anemia, two classic features of pernicious anemia, may be overstressed in our diagnostic approach. All subnormal serum cobalamin results are best viewed as pathological until proved otherwise. Emphasis on only very low cobalamin levels risks delaying the diagnosis of pernicious anemia in a substantial proportion of cases, particularly in those without anemia or macrocytosis.