The anemia of achylia gastrica revisited

[Dr.Vad]

Recommendations for the diagnostic workup of refractory or obscure IDA

In view of the above considerations, initial testing for celiac disease (anti-endomysial antibodies), autoimmune type A atrophic gastritis (gastrin, antiparietal antibodies) and H. pylori (IgG antibodies followed by urease breath test) may provide a high-sensitivity screening and an effective starting point for further investigations. This is particularly recommended in all patients with obscure iron deficiency anemia and in those refractory to oral iron treatment. The implications of diagnosing celiac disease or autoimmune atrophic gastritis for abnormal iron absorption are obvious. Interpretation of positive serology for H. pylori confirmed by positive urease breath test requires clinical judgment as 20–50% of the general and largely healthy population in industrialized countries will have such findings. In such patients, refractoriness to oral iron treatment may justify a “test-and-treat” approach of H. pylori eradication as currently advocated for the management of dyspeptic patients [45]. Cure of previously refractory iron deficiency anemia by H. pylori eradication could then be regarded as evidence supporting a cause-and-effect relation.

Achylia gastrica revisited

With a hindsight of over 100 years, one cannot help admiring the clinical wisdom and logic of past generations of physician-scientists relying almost entirely on empirical medicine. The unique clinical features of iron deficiency anemia associated with autoimmune gastritis including its refractoriness to conventional oral iron treatment, female predominance, relatively young age, increased prevalence of thyroid disease and tendency to progress to typical pernicious anemia have all been accurately described by Faber, Wintrobe and others in relation to the hypochromic anemia associated with achylia gastrica. Autoimmune gastritis is encountered in 20–27% of patients presenting with obscure, or refractory iron deficiency anemia and is 4 to 6 times more common than celiac disease presenting with unexplained iron deficiency. A significant new insight is its probable relation to H. pylori gastritis. H. pylori per se impairs gastric acid secretion and it is quite likely that a proportion of patients described originally as achylia gastrica with hypochromic anemia represented H. pylori and not autoimmune gastritis. The intriguing recent observations of H. pylori antibodies directed against epitopes on gastric mucosal cells imply an autoimmune mechanism triggered byH. pylori and directed against gastric parietal cells by means of antigenic mimicry of H + K + -ATPase, the most common autoantigen in pernicious anemia. These findings introduce a new element into the 100-year-old saga of achylia gastrica and pernicious anemia and open new possibilities for its prevention and management.

From Hershko C, Patz J, Ronson A.
The anemia of achylia gastrica revisited.
Blood Cells Mol Dis. 2007 May 8