Question 1 of 10

    Atrophic Gastritis (Atrophic Gastritides)

    Атрофический гастрит[1]

    Atrophic gastritis is a chronic inflammatory condition characterized by destruction of gastric cells and replacement with fibrous and intestinal-type tissues.

    This disorder is triggered by the following process: degenerative.

    Presentation

    Both forms of atrophic gastritis end in gastric atrophy. Symptoms of atrophic gastritis are, however, similar to those of chronic gastritis.

    H pylori-associated atrophic gastritis is often clinically asymptomatic. Symptomatic cases present with epigastric pain, malaise, nausea, vomiting, flatulence, and, occasionally, fever. The symptoms usually disappear, spontaneously, but a persistence of the infection leads to atrophic gastritis which presents just as above and also with considerable weight loss.

    In the course of the disease, however, complications of atrophic gastritis due to H. pylori such as gastric carcinoma present with symptoms such as upper gastrointestinal (GI) bleeding.

    In autoimmune gastritis, consequent to IF deficiency and destruction, vitamin B12 is inadequately transported and absorbed. This results in a number of complications including megaloblastic anemia and certain neurological impairments.

    Megaloblastic anemia is the most important manifestation of vitamin B12 deficiency. It presents with lightheadedness, fatigue, palpitations , angina pectoris, and heart failure, in severe cases.

    Vitamin B12 deficiency is also associated with epithelial megaloblastosis in the GI tract characterized by glossitis and malabsorption.

    Neurologic sequelae of vitamin B12 deficiency occur consequent to neuronal death and axonal degeneration primarily affecting the anterior and posterior spinal cord columns, the cerebrum and peripheral nerves. This, typically, manifests as paresthesias, weakness, and numbness of the limbs, ataxia and loss of sphincteric control. Cognitive impairments could occur, ranging from mild disturbances to psychosis.

    There is a considerable increase in the risks of gastric polyps and carcinoma in patients with pernicious anemia. Iron deficiency anemia which is unresponsive to iron therapy is also a complication of autoimmune gastritis. Patients with pernicious anemia have an increased frequency of gastric polyps and carcinoma in patients with autoimmune gastritis.

    Massironi et al in their research found a relationship between primary hyperthyroidism and autoimmune atrophic gastritis, such that the presence of one condition increases the risk of the other [12].

    Physical examination is not critical in the diagnosis of atrophic gastritis. General signs include epigastric tenderness, signs of anemia including pallor, palpitations and in severe cases, signs of congestive cardiac failure. In autoimmune gastritis, neurologic complications of vitamin B12 deficiency such as ataxia may also be elicited.

    Entire body system
    Anemia
    • Type A gastritis primarily affects the body/fundus of the stomach, and is more common with pernicious anemia.[en.wikipedia.org]
    • Pernicious anemia is a type of vitamin B12 anemia.[medlineplus.gov]
    • The testing algorithms for diagnosing pernicious anemia may not always apply to the diagnosis of early AMAG.[mayoclinic.pure.elsevier.com]
    • Abstract It is well recognized that anemia and hypochlorhydria or achlorhydria are frequently present in patients having hypothyroidism or myxedema. 1 Gastroscopy has demonstrated that atrophy of the gastric mucosa is also frequently associated with anemia[annals.org]
    • Lack of iron can cause iron deficiency anemia and vitamin B12 deficit can cause megaloblastic anemia.[allhealthsite.com]
    Inflammation
    • […] involves chronic inflammation of your dog’s stomach which will cause large coiled ridges to form in its inner wall Lymphocytic-plasmacytic Gastritis - This condition involves chronic stomach inflammation as a result of inflammatory bowel disease Causes[wagwalking.com]
    • Alcohol can limit stomach’s ability to produce acids, which often results in inflammation.[plushcare.com]
    • . gastritis [ gas-tri tis ] inflammation of the lining of the stomach.[medical-dictionary.thefreedictionary.com]
    • Finally, avoid aspirin or ibuprofen as they can cause inflammation or make existing irritation worse.[livestrong.com]
    • INTRODUCTION Gastritis is a term used to denote inflammation-associated mucosal injury.[uptodate.com]
    Malnutrition
    • Wall AJ, Ungar B, Baird CW, et al: Malnutrition after partial gastrectomy: influence of site of ulcer and type of anastomosis and role of gastritis.[link.springer.com]
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  • Skin
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  • gastrointestinal
    Dyspepsia
    • Can Helicobacter pylori-associated dyspepsia be categorized as functional dyspepsia?.[jnmjournal.org]
    • The aim of this group of specialists is to develop the safety and cost-efficiency of the diagnosis, prevention and treatment of dyspepsia, H. pylori infection and atrophic gastritis through international co-operation (www.biohit.fi/ GastroPanel biomarkers[biohithealthcare.com]
    • […] at twice the standard dose 2 antibiotics ( possibly bismuth) for a minimum of 7 (possibly 10) days , thereafter continue one PPI at standard dose Indications ; Test-and-treat strategy : for patients that are 55 years old, suffer from uninvestigated dyspepsia[amboss.com]
    • Although hyperplastic endocrine cell changes have been noted to occur in chronic gastritis associated with Helicobacter pylori and ulcer disease/dyspepsia, progression to dysplasia and/or neoplasia has not been observed.[propath.com]
    • ., when the symptoms of digestive disorders and chronic gastritis The relationship is not clear, so the treatment is actually for the functional dyspepsia of the empirical treatment, may have a certain role in the repair of gastric mucosa.[healthfrom.com]
    Epigastric Pain
    • Lymphocytic gastritis Etiology : obscure Clinical signs : epigastric pain , bleeding from the upper gastrointestinal tract, iron deficiency anemia Diagnostics : gastroscopy including biopsy samples from gastric corpus , gastric antrum, and duodenum H.[amboss.com]
    • One-week acid suppression trial in uninvestigated dyspepsia patients with epigastric pain or burning to predict response to 8 weeks’ treatment with esomeprazole: a randomized, placebo-controlled study.[jnmjournal.org]
    • In moderate to severe cases, patients may have upper abdominal (epigastric) pain, nausea, and might even vomit blood.[plushcare.com]
    • Autoimmune atrophic gastritis is seen in elderly patients and in persons with pernicious anemia; it rarely causes epigastric pain.[medical-dictionary.thefreedictionary.com]
    Gastropathy
    • Iron deficiency Loss of pepsin Associated with development of intestinal type gastric adenocarcinoma Risk is very low in USA Risk significantly increased only in regions with a high endemic risk of gastric carcinoma Classification/Lists Gastritis / Gastropathy[surgpathcriteria.stanford.edu]
    • The other forms of gastritis and gastropathy are presented separately.[uptodate.com]
    • Autoimmune gastropathy in type 1 diabetic patients with parietal cell antibodies: histological and clinical findings.[tropicalgastro.com]
    • Autoimmune gastropathy in type 1 diabetic patients with parietal cell antibodies: histological and clinical findings .[nature.com]
    Loss of Appetite
    • Alcoholic gastritis’ symptoms include pain in the upper abdomen area, loss of appetite, vomiting, or bloating.[plushcare.com]
    • However, if an H. pylori infection is present, common symptoms include: stomach pain nausea and vomiting loss of appetite unexpected weight loss stomach ulcers iron deficiency anemia (a low level of healthy red blood cells) Autoimmune AG may lead to a[healthline.com]
    • They can include: Desire to eat ice or other non-food things ( pica ) Diarrhea or constipation Fatigue , lack of energy, or lightheadedness when standing up or with exertion Loss of appetite Pale skin Problems concentrating Shortness of breath , mostly[medlineplus.gov]
    • Most patients do not have any clinical symptoms or only manifestations of abdominal pain, bloating, nausea, acid reflux, loss of appetite and other symptoms of indigestion.[healthfrom.com]
    • The outstanding symptom is abdominal pain, and there is also a feeling of distention, with loss of appetite and nausea.[medical-dictionary.thefreedictionary.com]
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  • Workup

    Upper GI endoscopy and biopsy of the gastric samples is the definitive test to confirm atrophic gastritis. One requires at least two samples taken from the antrum, two samples from the corpus and one from the incisure and submit separately for histopathologic evaluation.

    Determination of serum pepsinogen levels with the ratio of serum pepsinogen I to pepsinogen II have high specificity and sensitivity in diagnosing gastric atrophy.

    Although, there are a number of laboratory investigations to further confirm the type of atrophic gastritis, biopsy remains the gold standard. However, because in late stages of H. pylori-associated atrophic gastritis, the concentration of the organism is markedly reduced because of the unfavorable environment created by the malignant change [4], other investigations to detect H. pylori like urea breath test should be employed. Culture and rapid urease test of gastric biopsy samples, and serology for anti-H. pylori antibodies are alternative investigations in confirming H. pylori-associated atrophic gastritis.

    Histologic findings in H. pylori-associated atrophic gastritis includes the presence of the bacteria within the gastric mucosa, usually more numerous in the antral region in early stages of the disease. PMNs are found in the lamina propria and the glands while lymphoid follicles can be observed within the lamina propria causing its expansion. Significant glandular atrophy is observed with disease progression. In advanced stages of the disease also, there is the extensive replacement of gastric architecture with intestinal metaplasia.

    Autoimmune atrophic gastritis can be confirmed via the following laboratory investigations; serologic detection of serum anti-IF and anti-parietal cell antibodies, serum cobalamin levels , serum gastrin levels and schilling test. Serum gastrin levels are usually high and cobalamin levels are low in autoimmune gastritis. Achlorhydria, either basal or stimulated, also suggests autoimmune atrophic gastritis.

    The histologic findings in autoimmune atrophic gastritis vary with the phase of the disease. During the early phase, there is diffuse distortion in the architecture of gastric structures due to infiltration of the lamina propria by eosinophils and mononuclear cells and of the oxyntic glands by T-lymphocytes. Hypertrophy of parietal cells is also found. Over time, there is increased lymphocytic inflammatory changes with atrophy of the oxyntic glands, and intestinal metaplasia. Intestinal metaplasia with widespread involvement of the fundus and corpus marks the end stage of the disease. The antrum is usually spared in autoimmune gastritis. Autoimmune gastritis may also present with gastric polyps which are non-neoplastic hyperplasia of spared oxyntic glands.

    Pathology

    Biopsy
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  • Test Results

    Colonoscopy
    Polyps
    • The optimal endoscopic surveillance strategy is not known but all nodules and polyps should be removed in these patients.[en.wikipedia.org]
    • Management of gastric polyps: an endoscopy based approach .[nature.com]
    • People with pernicious anemia may have gastric polyps.[medlineplus.gov]
    • I was scoped again in April 2012, which endoscopically viewing my stomach showed that I again had a normal, healthy, mucosal lining, but also revealed that I had 3 stomach polyps, the pathology report stated that I still had autoimmune atrophic gastritis[thepaleodiet.com]
    • The condition is associated with an increased risk of pernicious anemia , gastric polyps and gastric adenocarcinoma .[rarediseases.info.nih.gov]
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  • Laboratory

    Serum
    Gastrin Increased
    • "Gastrin increases mcl-1 expression in type I gastric carcinoid tumors and a gastric epithelial cell line that expresses the CCK-2 receptor.".[librepathology.org]
    Hypochlorhydria
    • Hypochlorhydria induces G cell (gastrin-producing) hyperplasia, which leads to hypergastrinemia.[en.wikipedia.org]
    • […] and hypochlorhydria or achlorhydria. 2 This frequent occurrence of anemia and hypochlorhydria or achlorhydria in both hypothyroidism and atrophic gastritis led me to believe that it would be worth while to study a series of hypothyroid or myxedematous[annals.org]
    • CRC Press , 8 mrt. 1993 - 240 pagina's 0 Recensies Chronic Gastritis and Hypochlorhydria in the Elderly provides the most current and comprehensive treatment of atrophic gastritis available.[books.google.com]
    • Hypochlorhydria will increase gastrin levels.[medicowesome.com]
    • Hypochlorhydria leads to G-cell hyperplasia and elevated serum gastrin levels (often 1000 pg/mL).[merckmanuals.com]
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  • Treatment

    Treatment of atrophic gastritis is geared towards treating the cause of gastritis and correcting the complications thereof.

    If H. pylori are detected as the underlying cause of gastritis, its eradication is initiated. Current therapies for H. pylori infection offer 80-95% cure rates. Currently, the most common and effective therapies to eradicate H. pylori are triple therapies, which are considered as first-line treatments and quadruple therapies. Quadruple therapies are recommended as second-line treatments to be used when the first line treatment fails. In both treatment protocols, treatment duration of 10-14 days is associated with best outcomes, although some studies suggest a duration of treatment of 7 days. H. pylori infection is considered cured and the bacteria considered eradicated if there is no trace of the bacterium after at least 4 weeks of treatment.

    Triple therapy consists of two antibiotics and one proton pump inhibitor or bismuth salicylate and includes the following:

    • Twice-a-day (bid) PPI, lansoprazole 30 mg PO bid, omeprazole 20 mg PO bid or Ranitidine bismuth salicylate, RBC (Tritec), 400 mg bid. Antibiotic therapy includes clarithromycin 500 mg PO bid along with amoxicillin 1000 mg PO bid or metronidazole 500 mg PO bid

    Another protocol for triple-therapy includes bismuth subsalicylate 525 mg (two 262.4-mg chewable tabs) qid along with metronidazole 250 mg PO qid and tetracycline HCL 500 mg qid.

    Quadruple therapy consists of one PPI, two antibiotics plus bismuth salicylate. This therapy includes PPI bid, including lansoprazole 30 mg PO bid or omeprazole 20 mg PO bid plus tetracycline HCl 500 mg PO qid, bismuth subsalicylate 120 mg PO qid, and metronidazole 500 mg PO three times per day.

    Prognosis

    Currently, it is not known if treatment of either type of atrophic gastritis alters the course of the disease. However, with the development of gastric cancer open link, the prognosis is generally poor.

    Complications

    Achlorhydria
    • […] and hypochlorhydria or achlorhydria. 2 This frequent occurrence of anemia and hypochlorhydria or achlorhydria in both hypothyroidism and atrophic gastritis led me to believe that it would be worth while to study a series of hypothyroid or myxedematous[annals.org]
    • Those with the autoimmune version of atrophic gastritis are statistically more likely to develop gastric carcinoma, Hashimoto's thyroiditis, and achlorhydria.[en.wikipedia.org]
    • Treatment and Prevention A significant number of elderly people have atrophic gastritis with hypo- or achlorhydria , predisposing them to bacterial overgrowth.[diagnose-me.com]
    • Types A involves fundus-body and is associated with histamine fast achlorhydria, hypergastrinemia and severe vitamin B12 malabsorption.[tropicalgastro.com]
    • […] the atrophic body mucosa of autoimmune gastritis Endocrine cell hyperplasia is not typical of Helicobacter Clinicopathologic correlation with knowledge of the location of the biopsy is necessary for the distinction Clinical Rare Frequently results in Achlorhydria[surgpathcriteria.stanford.edu]
    Autoimmune Disease
    • There are thousands of versions of HLA molecules, but only a few are associated with autoimmune diseases.[thepaleodiet.com]
    • Le test ne doit pas être effectué chez les patients ayant eu ou soupçonnés d'avoir une infection gastrique ou gastrite atrophique qui pourrait interférer avec le test respiratoire à l'urée. methods and products for diagnosing autoimmune diseases and gastric[dictionary.reverso.net]
    • Autoimmune metaplastic atrophic gastritis is an inherited autoimmune disease that attacks parietal cells, resulting in hypochlorhydria and decreased production of intrinsic factor.[merckmanuals.com]
    • Vitamin B12 deficiency is the most serious of these problems and can cause neurological problems in those with pernicious anemia or autoimmune disease.[verywell.com]
    Gastric Adenocarcinoma
    • Risk of gastric adenocarcinoma increases 3-fold.[merckmanuals.com]
    • Patients with atrophic gastritis are also at increased risk for the development of gastric adenocarcinoma.[en.wikipedia.org]
    • Those who develop atrophy are at risk of gastric ulcers, mainly located on the lesser curvature around the incisura angularis, and they may develop intestinal metaplasia, dysplasia, and intestinal-type gastric adenocarcinoma .[humpath.com]
    • The condition is associated with an increased risk of pernicious anemia , gastric polyps and gastric adenocarcinoma .[rarediseases.info.nih.gov]
    • Helicobacter pylori-induced atrophic gastritis predisposes to gastric adenocarcinoma, autoimmune atrophic gastritis is a precursor of type I gastric neuroendocrine tumours, whereas proton pump inhibitor (PPI) use does not affect stomach cancer risk.[biorxiv.org]
    Gastric Polyp
    • People with pernicious anemia may have gastric polyps.[medlineplus.gov]
    • Management of gastric polyps: an endoscopy based approach .[nature.com]
    • The condition is associated with an increased risk of pernicious anemia , gastric polyps and gastric adenocarcinoma .[rarediseases.info.nih.gov]
    Gastritis
    • Autoimmune metaplastic atrophic gastritis (AMAG) is an inherited form of atrophic gastritis characterized by an immune response directed toward parietal cells and intrinsic factor.[en.wikipedia.org]
    • Atrophic Gastritis Atrophic gastritis, also known as Type A or B gastritis, is a subtype of chronic gastritis.[plushcare.com]
    • AG, atrophic gastritis; NAG, not atrophic gastritis.[scirp.org]
    • Simply prepared solid foods in small quantities can then be added. atrophic gastritis chronic gastritis with atrophy of the mucous membranes and glands. chronic gastritis gastritis that occurs repeatedly or continues over a period of time.[medical-dictionary.thefreedictionary.com]
    • Gastritis may occur suddenly (acute gastritis), or appear slowly over time (chronic gastritis).[mayoclinic.org]
    Hashimoto's Thyroiditis
    • Those with the autoimmune version of atrophic gastritis are statistically more likely to develop gastric carcinoma, Hashimoto's thyroiditis, and achlorhydria.[en.wikipedia.org]
    • Some patients also develop Hashimoto thyroiditis and 50% have thyroid antibodies; conversely, parietal cell antibodies are found in 30% of patients with thyroiditis.[merckmanuals.com]
    • ., Hashimoto's thyroiditis ) Additionally in EMAG Asymptomatic progression is common Symptoms often a consequence of gastric or duodenal ulcer bleeding References: [1] [3] Diagnostics Helicobacter pylori diagnostics Collection of biopsies Applied methods[amboss.com]
    • Myasthenia Gravis, Hashimoto's Thyroiditis, and Pernicious Anaemia .[nature.com]
    Iron Deficiency
    • The most common are vitamin B12 deficiency which results in a megaloblastic anemia and malabsorbtion of iron, leading to iron deficiency anaemia.[en.wikipedia.org]
    • Light headedness, shortness of breath and lethargy due to iron deficiency anemia.[allhealthsite.com]
    • Atrophic gastritis can cause serious health complications like Vitamin B12 and iron deficiencies.[plushcare.com]
    • deficiency Loss of pepsin Associated with development of intestinal type gastric adenocarcinoma Risk is very low in USA Risk significantly increased only in regions with a high endemic risk of gastric carcinoma Classification/Lists Gastritis / Gastropathy[surgpathcriteria.stanford.edu]
    Iron Deficiency Anemia
    • Light headedness, shortness of breath and lethargy due to iron deficiency anemia.[allhealthsite.com]
    • I had an endoscopy to find the reason for my iron deficiency anemia.[cancercompass.com]
    • However, if an H. pylori infection is present, common symptoms include: stomach pain nausea and vomiting loss of appetite unexpected weight loss stomach ulcers iron deficiency anemia (a low level of healthy red blood cells) Autoimmune AG may lead to a[healthline.com]
    • Lymphocytic gastritis Etiology : obscure Clinical signs : epigastric pain , bleeding from the upper gastrointestinal tract, iron deficiency anemia Diagnostics : gastroscopy including biopsy samples from gastric corpus , gastric antrum, and duodenum H.[amboss.com]
    • When diagnosing a patient with iron deficiency anemia and a lack of vitamin B12 in the body, parenterally prescribe drugs B12.[en.medicine-worlds.com]
    Malignant Neoplasm
    • Malignant neoplasm of the stomach - Chronic atrophic gastritis Factor Last reviewed for CCPS 16 July 2003.[clik.dva.gov.au]
    • High Quality Pathology Images of Benign and Malignant Neoplasms and Related Entities 7958 Images : Last Website Update : September 23, 2017 Follow us: Home About Us Acknowledgements Feedback Contact Us Site Map Advertisement Home Gastrointestinal Stomach[webpathology.com]
    Megaloblastic Anemia
    • The most common are vitamin B12 deficiency which results in a megaloblastic anemia and malabsorbtion of iron, leading to iron deficiency anaemia.[en.wikipedia.org]
    • Autoimmune atrophic gastritis is characterized by megaloblastic anemia, anorexia with weight loss, neurologic changes such as numbness and paresthesias.[patientslikeme.com]
    • The lack of intrinsic factor leads to vitamin B12 deficiency that can result in a megaloblastic anemia (pernicious anemia) or neurologic symptoms ( subacute combined degeneration ).[merckmanuals.com]
    Neoplasm
    • Atrophy Adenoma Gastritis Metaplasia Gastritis, Atrophic Gastrointestinal Neoplasms Digestive System Neoplasms Neoplasms by Site Neoplasms Digestive System Diseases Gastrointestinal Diseases Stomach Diseases Pathological Conditions, Anatomical Neoplasms[clinicaltrials.gov]
    • Malignant neoplasm of the stomach - Chronic atrophic gastritis Factor Last reviewed for CCPS 16 July 2003.[clik.dva.gov.au]
    • High Quality Pathology Images of Benign and Malignant Neoplasms and Related Entities 7958 Images : Last Website Update : September 23, 2017 Follow us: Home About Us Acknowledgements Feedback Contact Us Site Map Advertisement Home Gastrointestinal Stomach[webpathology.com]
    • […] and the puerperium ( O00-O9A ) congenital malformations, deformations and chromosomal abnormalities ( Q00-Q99 ) endocrine, nutritional and metabolic diseases ( E00 - E88 ) injury, poisoning and certain other consequences of external causes ( S00-T88 ) neoplasms[icd10data.com]
    • ENETS Consensus Guidelines for the management of patients with gastroduodenal neoplasms.[tgc.amegroups.com]
    Pernicious Anemia
    Vitamin A Deficiency
    • Two types of atrophic gastritis have been described 1-3 : type A: autoimmune gastric body and fundus atrophy secondary to antiparietal cell antibodies decreased secretion of acid and intrinsic factor, with the latter leading to vitamin B12 deficiency[radiopaedia.org]
    • Call your provider if you have symptoms of vitamin B12 deficiency.[medlineplus.gov]
    • The clinical goal of managing AMAG is to identify dysplastic or malignant lesions of the stomach as well as to ensure the proper management of vitamin B12 deficiency to prevent the hematologic and neurologic adverse events of pernicious anemia.[mayoclinic.pure.elsevier.com]
    • The most common are vitamin B12 deficiency which results in a megaloblastic anemia and malabsorbtion of iron, leading to iron deficiency anaemia.[en.wikipedia.org]
    • The lack of intrinsic factor leads to vitamin B12 deficiency that can result in a megaloblastic anemia (pernicious anemia) or neurologic symptoms ( subacute combined degeneration ).[merckmanuals.com]
    Vitamin B12 Deficiency
    • Two types of atrophic gastritis have been described 1-3 : type A: autoimmune gastric body and fundus atrophy secondary to antiparietal cell antibodies decreased secretion of acid and intrinsic factor, with the latter leading to vitamin B12 deficiency[radiopaedia.org]
    • Call your provider if you have symptoms of vitamin B12 deficiency.[medlineplus.gov]
    • B12 deficiency to prevent the hematologic and neurologic adverse events of pernicious anemia.[mayoclinic.pure.elsevier.com]
    • The most common are vitamin B12 deficiency which results in a megaloblastic anemia and malabsorbtion of iron, leading to iron deficiency anaemia.[en.wikipedia.org]
    • The lack of intrinsic factor leads to vitamin B12 deficiency that can result in a megaloblastic anemia (pernicious anemia) or neurologic symptoms ( subacute combined degeneration ).[merckmanuals.com]
    Vitamin Deficiency
    • Type A is caused by dying stomach cells and can increase the risk of cancer, anemia, and vitamin deficiencies.[plushcare.com]
    • It is often associated with impaired absorption of vitamin B 12 and possibly other vitamin deficiencies (such as folate and iron).[rarediseases.info.nih.gov]
    • Among its possible causes are Helicobacter pylori , vitamin deficiencies, abnormalities of the gastric juice, ulcers, hiatus hernia, excessive use of alcohol, or a combination of any of these.[medical-dictionary.thefreedictionary.com]
    • Due to damage to the gastric mucosa, enzymes and nutrients can not be fully absorbed, and this leads to disruption of metabolic processes, the development of vitamin deficiency and iron deficiency anemia.[en.medicine-worlds.com]
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  • Etiology

    Atrophic gastritis, as stated earlier, can be caused by autoimmune causes or H. pylori infection. Both forms of gastritis have unique and different histopathological features as also observed by Yagi et al from results of gastric analysis using magnifying endoscopy [3].

    Autoimmune gastritis affects the gastric body and fundus while the gastric antrum is also affected along with the body and fundus in H. pylori-associated atrophic gastritis.

    Autoimmune atrophic gastritis, the sequel to anti-gastric parietal cell antibodies (APCA), causes marked diffuse destruction and atrophy of parietal cells. The presence of serum anti-intrinsic factor antibodies leads to pernicious anemia from lack of transport/absorption of vitamin B12. Autoimmune atrophic gastritis also has a genetic predisposition with an autosomal dominant mode of inheritance. Research has found that the severity of autoimmune atrophic gastritis is directly proportional to the titers of APCA.

    Epidemiology

    Approximately half of the world's population is infected with H. pylori and the infection is most commonly found in developing countries and in Asia. In the United states, H. pylori affect about 20% of individuals under 40 years and more than half of all persons above 60 years.

    Autoimmune gastritis is relatively rare and it commonly affects Northern Europeans and African Americans. An estimated 127 cases per 100,000 individuals in Sweden, Denmark, and the United kingdom are said to have pernicious anemia/autoimmune gastritis. Concomitant immunological diseases, including Graves disease, Addison's disease, myxedema, and diabetes mellitus raise the risk of autoimmune gastritis.

    Regardless of the cause, atrophic gastritis increases the risk of developing gastric carcinoma and carcinoid tumors. There is a further risk of developing esophageal squamous carcinoma in autoimmune gastritis and pernicious anemia. Autoimmune gastritis also increases the risk of iron deficiency anemia. All these complications of atrophic gastritis greatly increase the morbidity and mortality from the disease.

    Atrophic gastritis affects both sexes similarly. There is no gender predilection for contracting H. pylori infection, however, autoimmune gastritis affects females more than males at a ratio of 3:1.

    Atrophic gastritis, being chronic condition presents late in life. H. pylori-associated atrophic gastritis is detected in individuals above 50 years while pernicious anemia secondary to autoimmune atrophic gastritis can be detected from the sixth decade of life.

    The frequency of H. pylori infection is more than is estimated by epidemiological findings, because, in the late stages of H. pylori-associated gastritis, the infection usually clears off [4].

    Sex distribution
    Age distribution

    Pathophysiology

    H. pylori-associated atrophic gastritis

    H. pylorus is a gram-negative bacterium that infects and inhabits the stomach. The bacterium resides within the gastric mucosa. An individual is often infected with H. pylori during childhood and the bacteria remain in the stomach throughout life, if untreated.

    The presence of H. pylori triggers a host response mainly comprising T and B lymphocytes. Subsequently, there is infiltration of the gastric mucosa and lamina propria by polymorphonuclear leukocytes (PMNs) which remove the bacteria by phagocytosis. The release of toxic products which characterize such inflammatory process damages the gastric mucosa, eventually leading to atrophic gastritis. According to a study published by Weck, the association between H. pylori and atrophic gastritis is stronger than that estimated by epidemiological findings because the infection usually clears off in late stages of atrophic gastritis [4]. As reported by another study, the presence of mannan-binding lectin allele (MBL2 codon 54 B) corresponds to a more severe form of atrophic gastritis in Japanese patients infected with H. pylori [5].

    The process of gastric atrophy results in erosion of the glandular structures and replacement with fibrous tissue and intestinal-type tissues expanding the lamina propria [6]. This, consequently, results in parietal cell loss and a reduced gastric acid secretion. Alcohol has been shown to have potentiating effects in the development of H. pylori-associated atrophic gastritis [7].

    There are two main histopathologic forms of H. pylori-associated atrophic gastritis; antral predominant form and the multifocal form. The antral predominant form is limited to the gastric antrum and is most often seen in western countries. It is the form of gastritis mostly associated with peptic ulcers. The multifocal form involves the atrium, fundus, and corpus of the stomach. This form is frequently observed in developing countries and is the form of atrophic gastritis mostly associated with gastric carcinoma.

    Autoimmune atrophic gastritis

    Autoimmune atrophic gastritis is limited to the gastric fundus and corpus and is characterized by diffuse parietal cell loss. Autoimmune gastritis is caused by the effects of serum anti-intrinsic factor and anti-parietal antibodies. As reported by Palladino et al., methylenetetrahydrofolate reductase (MTHFR) polymorphisms may also be associated with autoimmune atrophic gastritis [8]. Generally in autoimmune gastritis, the autoantibodies target at least 3 antigens, including intrinsic factor (IF), cytoplasmic and plasma membrane antigens. There are two types of IF antibodies; types I and II. Type I IF antibodies block the IF-vitamin B12 binding site, preventing the uptake and therefore, transport of vitamin B12.

    Cell-mediated immunity also plays a role in the development of the disease [9]. T lymphocytes infiltrate the gastric mucosa and contribute to the epithelial cell destruction and consequent atrophy. Stummvoll showed that Th17 cells caused the most gastric damage with cellular infiltrates mainly made up of eosinophils associated with high serum IgE levels [10]. Regulatory T cells (Treg) have been noted to inhibit the expansion of the effector T cells. However, effector cells isolated from protected animals were found to proliferate and produce effector cytokines ex vivo [10]. This inhibitory capacity of polyclonal Treg on the proliferation of some effector cells describes its clinical use in the treatment of autoimmune disease. These findings stimulated a study by Huter et al, which showed that antigen-specific-induced Treg suppresses autoimmune gastritis induced by fully differentiated Th17 and Th1 effector cells [11].

    Prevention

    Autoimmune gastritis cannot be prevented mainly because of its strong genetic and immunological predispositions. H. pylori infection, however, can be prevented. This can be achieved by healthy hygiene practices including proper handwashing before and after eating and after using the bathroom. Caregivers should also maintain proper handwashing after handling soiled baby clothing.

    Summary

    Atrophic gastritis is a chronic inflammatory condition of the gastric mucosa with progressive destruction and loss of the glandular structures of the stomach and replacement of these cells by fibrous tissue and intestinal-type tissues.

    There are two types of atrophic gastritis based on etiological and pathological characteristics. These include type A and type B. Type A atrophic gastritis is also referred to as autoimmune gastritis and type B mostly results from Helicobacter pylori (H. pylori) infection.

    Approximately half of the world's population is infected with H. pylori which are most common in developing countries. Gastritis occurring due to autoimmune causes is relatively rare, and most commonly affects the Northern European and African American population. Generally, atrophic gastritis shows no sex predilections, however, autoimmune gastritis is common among women.

    Both forms of atrophic gastritis have a high risk of malignant transformation. This risk of gastric cancer in H. pylori-associated atrophic gastritis reduces with H. pylori eradication [1]. In addition to the risk of gastric carcinoma, chronic atrophic gastritis is also strongly associated with the development of enterochromaffin-like (ECL) cell hyperplasia and carcinoid tumors [2].

    Endoscopy and biopsy are the definitive tests for confirming a diagnosis of atrophic gastritis. There are several other investigations specific for each type of atrophic gastritis including culture and rapid urease test of gastric biopsy samples for making a diagnosis of H. pylori-associated gastritis and serology for autoimmune gastritis.

    Patient Information

    What is atrophic gastritis?

    Atrophic gastritis is a condition characterized by prolonged inflammation of the stomach's lining. This condition could be caused by a bacterium called Helicobacter pylori, or by the body's antibodies attacking the stomach lining (autoimmunity).

    Causes

    H. pylori infect and lodges in the stomach in the early years of life and results in inflammatory changes by destroying the stomach's protection against its acid contents. H. pylori can be transmitted through contact with feces or saliva of an infected person. It could also be contracted through contaminated food and water. Autoimmune atrophic gastritis usually results in damage to the cells which produce vitamin B12, resulting in anemia.

    Risk factors

    H.pylori infection is the commonest risk factor for developing atrophic gastritis. This infection is commonly found among persons with low socioeconomic status and those who live in overcrowded areas.

    The risk of autoimmune atrophic gastritis is increased in people who have other immune conditions and in African Americans and Northern Europeans.

    The problem with atrophic gastritis is the development of stomach cancer.

    Symptoms

    Atrophic gastritis often presents with no symptoms at all. However, H. pylori-associated atrophic gastritis presents with abdominal pain, loss of appetite, vomiting, and weight loss. Autoimmune atrophic gastritis causes anemia which presents with dizziness, lightheadedness, and palpitations. Vitamin B12 deficiency, also a sequel of autoimmune atrophic gastritis presents with numbness and pain in the arms and feet.

    Diagnosis and workup

    A diagnosis of atrophic gastritis can be made by clinical examination and blood tests. The doctor would examine for features of atrophic gastritis including upper abdominal pain, and signs of complications of autoimmune gastritis including anemia ( pallor, palpitations) and vitamin B12 deficiency.

    Blood tests for pepsinogen (produced by the stomach cells) and gastrin, a substance that stimulates acid production in the stomach, vitamin B12, and antibodies against stomach cells would be necessary.

    Biopsy of the stomach carried out by using a long tube (endoscope) inserted through the mouth into the stomach may also be needed to confirm autoimmune gastritis.

    Treatment

    Treatment of H. pylori-associated gastritis is with antibiotics. Autoimmune gastritis is treated with steroids and vitamin B12. Drugs which lower production or neutralize stomach acid are also prescribed.

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    References

    1. Yanaoka K, Oka M, Ohata H, et al. Eradication of Helicobacter pylori prevents cancer development in subjects with mild gastric atrophy identified by serum pepsinogen levels. Int J Cancer. 2009;125(11):2697-703.
    2. Vannella L, Lahner E, Annibale B. Risk for gastric neoplasias in patients with chronic atrophic gastritis: a critical reappraisal. World J Gastroenterol. 2012;18(12):1279-85.
    3. Yagi K, Nakamura A, Sekine A, Graham D. Features of the atrophic corpus mucosa in three cases of autoimmune gastritis revealed by magnifying endoscopy. Case Report Med. 2012:368160.
    4. Weck MN, Gao L, Brenner H. Helicobacter pylori infection and chronic atrophic gastritis: associations according to severity of disease. Epidemiology. 2009;20(4):569-74.
    5. Tahara T, Shibata T, Wang FY, et al. Mannan-binding lectin B allele is associated with a risk of developing more severe gastric mucosal atrophy in Helicobacter pylori-infected Japanese patients. Eur J Gastroenterol Hepatol. 2009;21(7):781-6.
    6. Gao L, Weck MN, Nieters A, Brenner H. Inverse association between a pro-inflammatory genetic profile and Helicobacter pylori seropositivity among patients with chronic atrophic gastritis: Enhanced elimination of the infection during disease progression?. Eur J Cancer. 2009 May 7.
    7. Gao L, Weck MN, Stegmaier C, Rothenbacher D, Brenner H. Alcohol consumption and chronic atrophic gastritis: Population-based study among 9,444 older adults from Germany. Int J Cancer. 2009 Jun 2.
    8. Palladino M, Chiusolo P, Reddiconto G, et al. MTHFR polymorphisms involved in vitamin B12 deficiency associated with atrophic gastritis. Biochem Genet. 2009;47(9-10):645-50.
    9. Lahner E, Norman GL, Severi C, et al. Reassessment of intrinsic factor and parietal cell autoantibodies in atrophic gastritis with respect to cobalamin deficiency. Am J Gastroenterol. 2009;104(8):2071-9.
    10. Stummvoll GH, DiPaolo RJ, Huter EN, et al. Th1, Th2, and Th17 effector T cell-induced autoimmune gastritis differs in pathological pattern and in susceptibility to suppression by regulatory T cells. J Immunol. 2008;181(3):1908-16.
    11. Huter EN, Stummvoll GH, DiPaolo RJ, Glass DD, Shevach EM. Pre-differentiated Th1 and Th17 effector T cells in autoimmune gastritis: Ag-specific regulatory T cells are more potent suppressors than polyclonal regulatory T cells. Int Immunopharmacol. 2009;9(5):540-5.
    12. Massironi S, Cavalcoli F, Rossi RE, et al. Chronic autoimmune atrophic gastritis associated with primary hyperparathyroidism: a transversal prospective study. Eur J Endocrinol. 2013;168(5):755-61.

    • A reappraisal of the nature and significance of chronic atrophic gastritis - RG Strickland, IR Mackay - Digestive Diseases and Sciences, 1973 - Springer
    • Pylori infection, glandular atrophy and intestinal metaplasia in superficial gastritis, gastric erosion, erosive gastritis, gastric ulcer and early gastric cancer - C Zhang, N Yamada, YL Wu, M Wen, T Matsuhisa - World J , 2005 - wjgnet.com
    • A biopsy study of chronic gastritis and gastric atrophy - R Motteram - The Journal of pathology and bacteriology, 1951 - Wiley Online Library
    • Atrophic Gastritis as a Possible Precursor of Gastric Carcinoma and Pernicious Anemia Results of follow‐up examinations - M Siurala, K Seppälä - Acta Medica Scandinavica, 1960 - Wiley Online Library
    • BUEVEROV ALEXEY - YT WANG - Journal of Gastroenterology and Hepatology, 2009 - Wiley Online Library
    • A proinflammatory genetic profile increases the risk for chronic atrophic gastritis and gastric carcinoma - JC Machado, C Figueiredo, P Canedo, P Pharoah - Gastroenterology, 2003 - Elsevier
    • Atrophic gastritis in young children and adolescents - O Ricuarte, O Gutierrez, H Cardona, JG Kim - Journal of clinical , 2005 - jcp.bmj.com
    • A clinical and statistical follow-up study of atrophic gastritis - R Cheli, G Ciancamerla, G Canciani - Digestive Diseases and Sciences, 1973 - Springer

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