Role of autoimmune gastritis, Helicobacter pylori and celiac disease in refractory or unexplained iron deficiency anemia.
OBJECTIVE
Conventional endoscopic and radiographic methods fail to identify a probable source of gastrointestinal blood loss in about one third of males and post-menopausal females and in most women of reproductive age with iron deficiency anemia (IDA). Such patients, as well as subjects refractory to oral iron treatment, are often referred for hematologic evaluation.


METHODS
Patient clinic, screened for non-bleeding gastrointestinal conditions including celiac disease (antiendomysial antibodies), autoimmune atrophic gastritis (hypergastrinemia with strongly positive antiparietal cell antibodies) and H. pylori infection (IgG antibodies confirmed by urease breath test).


RESULTS
The mean age of all subjects was 39+/-18 years, and 119 of 150 were females. We identified 8 new cases of adult celiac disease (5%). Forty IDA patients (27%) had autoimmune atrophic gastritis of whom 22 had low serum vitamin B12 levels. H. pylori infection was the only finding in 29 patients (19%), but was a common co-existing finding in 77 (51%) of the entire group. Refractoriness to oral iron treatment was found in 100% of patients with celiac disease, 71% with autoimmune atrophic gastritis, 68% with H. pylori infection, but only 11% of subjects with no detected underlying abnormality. H. pylori eradication in previously refractory IDA patients in combination with continued oral iron therapy resulted in a significant increase in hemoglobin from 9.4+/-1.5 (mean +/- 1SD) before, to 13.5+/-1.2 g/ dL (p<0.001 by paired t test) within 3 to 6 months.


CONCLUSIONS
The recognition that autoimmune atrophic gastritis and H. pylori infection may have a significant role in the development of unexplained or refractory IDA in a high proportion of patients should have a strong impact on our daily practice of diagnosing and managing IDA.
Hershko
Chaim
C
Department of Hematology, Shaare Zedek Med Center, Jerusalem, Israel. hershko@szmc.org.il
Hoffbrand
A Victor
AV
Keret
Dan
D
Souroujon
Moshe
M
Maschler
Itzhak
I
Monselise
Yehudit
Y
Lahad
Amnon
A
D000293:Adolescent; D000328:Adult; D000368:Aged; D000658:Amoxicillin / Q000627:therapeutic use; D018798:Anemia, Iron-Deficiency / Q000209:etiology*; D000907:Antibodies, Bacterial / Q000097:blood; D001323:Autoantibodies / Q000097:blood; D001327:Autoimmune Diseases / Q000150:complications*; D001426:Bacterial Proteins / Q000032:analysis; D001944:Breath Tests; D002446:Celiac Disease / Q000150:complications*; D002648:Child; D017291:Clarithromycin / Q000627:therapeutic use; D015897:Comorbidity; D004359:Drug Therapy, Combination; D005260:Female; D005296:Ferrous Compounds / Q000627:therapeutic use; D005755:Gastrins / Q000097:blood; D005756:Gastritis / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy / Q000276:immunology / Q000382:microbiology; D005757:Gastritis, Atrophic / Q000150:complications / Q000175:diagnosis / Q000276:immunology; D016481:Helicobacter Infections / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D016480:Helicobacter pylori / Q000276:immunology / Q000472:pathogenicity*; D006801:Humans; D007074:Immunoglobulin G / Q000097:blood; D008297:Male; D008875:Middle Aged; D009853:Omeprazole / Q000627:therapeutic use; D010295:Parietal Cells, Gastric / Q000276:immunology; D011446:Prospective Studies; D014510:Urease / Q000032:analysis; D014806:Vitamin B 12 Deficiency / Q000150:complications
D000907:Antibodies, Bacterial; D001323:Autoantibodies; D001426:Bacterial Proteins; D005296:Ferrous Compounds; D005755:Gastrins; D007074:Immunoglobulin G; C020748:ferrous sulfate; D000658:Amoxicillin; D014510:Urease; D017291:Clarithromycin; D009853:Omeprazole