Longitudinal study of Chinese patients with pernicious anaemia

Incidence of Gastric Neoplasms Arising from Autoimmune Metaplastic Atrophic Gastritis: A Systematic Review and Case Reports

Autoimmune metaplastic atrophic gastritis (AMAG) is associated with an increased risk of gastric neoplasms. This study aimed to systematically analyze the incidence rate of gastric cancer (GC), low-grade dysplasia (LGD) and type-1 gastric neuroendocrine tumor (gNETs) development in AMAG adults. Studies on AMAG patients reporting the incidence of gastric neoplasms was identified through a systematic search in PUBMED and EMBASE. Study quality was assessed using the Joanna Briggs Institute quality assessment tool. Incidence rates of GC, LGD and type-1 gNETs were examined by meta-analysis. Thirteen studies met eligibility criteria. Incidence rate of gastric cancer calculated from the pooled data was 0.14% per person-year in both single-center studies and national registration studies. Meta-analysis showed a relative risk of 11.05 (95% CI: 6.39-19.11) for gastric cancer development in AMAG patients. The calculated pooled gastric LGD and type-1 gNETs incidence rates were 0.52% and 0.83% per person-year, respectively. As for experience from our center, we presented three distinctive cases of gastric neoplasm arising from the background of AMAG. This study underscores the potential for malignant transformation of precancerous lesions and reiterates the importance of careful esophagogastroduodenoscopy screening.

Incidence of cancer (other than gastric cancer) in pernicious anaemia: A systematic review with meta-analysis

BACKGROUND

Pernicious anaemia (PA) is associated with increased gastric cancer risk, but the evidence is conflicting regarding the associated risk of other cancers.

AIM

To systematically determine the incidence rates of gastro-intestinal cancers other than gastric cancers (GI-other-than-GC) and non-gastrointestinal cancers (non-GIC) in PA adults, globally and per tumour site, and the risk associated with PA for GI-other than GC and non-GIC.

METHODS

Studies of PA patients reporting the incidence of GI-other-than-GCs and non-GICs were identified with MEDLINE (PubMed)-EMBASE (from first date available to April 2017). A meta-analysis of annual cancer incidence rates was performed. The outcome was the cumulative incidence of GI-other-than-GCs and non-GICs (ratio between the numbers of new cancer cases identified during the follow-up period and the number of PA patients) and the incidence rate expressed as the rate of events-per-time-unit (person-years).

RESULTS

Of 82,257 PA patients, the pooled incidence rates/100 person-years for non-GCs and non-GICs of 0.27 (95% CI:0.16-0.42) and 0.23 (95% CI:0.22-0.25) were calculated by meta-analysis. Compared to the GLOBOCAN data for the general population from the countries of the included studies, the meta-analysis showed an overall relative risk (RR) of cancer in PA of 0.68 (95% CI:0.48-0.95). PA patients had a lower RR of colorectal, breast, liver, oesophageal, lung, thyroid, ovary, non-melanoma skin and kidney cancers but had a higher RR of biliary tract cancer (1.81:1.21-2.70), multiple myeloma (2.83:1.76-4.55), Hodgkin's lymphoma (3.0:1.35-6.68), non-Hodgkin's lymphoma (2.08: 1.58-2.75), and leukaemia (1.56:1.16-2.12).

CONCLUSION

An overall lower RR of cancers-other-than-gastric-cancer in PA patients but an increased RR of biliary tract cancers and haematological malignancies was observed.

Pernicious anemia and colorectal cancer risk - A nested case-control study

BACKGROUND

Hypergastrinemia was shown to stimulate colonic epithelial cell proliferation.

AIMS

To evaluate the association between pernicious anemia (PA), a disease with hypergastrinemia, and colorectal cancer (CRC) risk.

METHODS

We conducted a nested case-control study within a large database from the UK. Cases were defined as all individuals in the cohort with at least one medical code for CRC. Controls were selected based on incidence-density sampling. For each case, up to four eligible controls were matched on age at diagnosis, sex, practice-site, and both duration and calendar time of follow-up. Exposure of interest was diagnosis of PA prior to CRC diagnosis date. The primary analysis was a multivariable conditional logistic regression.

RESULTS

Our study included 22,098 CRC cases and 85,969 matched controls. We identified 154 (0.70%) cases and 563 (0.65%) controls with past history of PA. The adjusted OR for the association between PA and CRC risk was 1.02 (95% CI 0.85-1.22). There was no difference in the results after stratification according to sex. In a sensitivity analysis only among individuals without chronic use of proton pump inhibitors (PPIs) the adjusted OR was 1.14 (95% CI 0.90-1.45). There was no association between duration of PA and CRC risk.

CONCLUSION

PA is not associated with higher CRC risk.

A retrospective study of 23 cases with subacute combined degeneration

PURPOSE

To study retrospectively the diverse presentations, ancillary tests and neuroimaging in patients with subacute combined degeneration (SCD).

METHODS

Twenty-three Chinese patients with SCD were included in this study. The clinical presentations and laboratory data including comprehensive metabolic panel, serum folic acid, vitamin B12 levels, gastroscopy and images of spinal cord on magnetic resonance imaging (MRI) were evaluated. Rating scales for localizations of lesions and functional disabilities were used to define the severity of neurological impairment.

RESULTS

No difference was found between men and women in the age of disease onset. For most of the patients, sensory symptoms, oftentimes as initial symptoms, occurred earlier than motor symptoms. The signs of the disease were more obvious than the symptoms. Six patients had sensory deficit levels mimicking transverse myelopathy. Anemia was not always detected in our patients with SCD. Normal or even elevated serum levels of vitamin B12 were found in seven patients. Spinal cord lesions on MRI were observed in six patients and the clinical and neuroimaging findings were not necessarily consistent.

CONCLUSIONS

The sensory symptoms occur earlier than the motor symptoms in SCD patients. SCD patients may have sensory deficit level. Normal or even elevated serum levels of vitamin B12 may occur in patients with SCD.

Autoimmune atrophic gastritis--pathogenesis, pathology and management

Autoimmune gastritis is a chronic progressive inflammatory condition that results in the replacement of the parietal cell mass by atrophic and metaplastic mucosa. A complex interaction of autoantibodies against the parietal cell proton pump and sensitized T cells progressively destroy the parietal cells, inducing hypochlorhydria and then achlorhydria, while autoantibodies against the intrinsic factor impair the absorption of vitamin B₁₂. The resulting cobalamin deficiency manifests with megaloblastic anaemia and neurological and systemic signs and symptoms collectively known as pernicious anaemia. Previously believed to be predominantly a disease of elderly women of Northern European ancestry, autoimmune gastritis has now been recognized in all populations and ethnic groups, but because of the complexity of the diagnosis no reliable prevalence data are available. For similar reasons, as well as the frequent and often unknown overlap with Helicobacter pylori infection, the risk of gastric cancer has not been adequately assessed in these patients. This Review summarizes the epidemiology, pathogenesis and pathological aspects of autoimmune metaplastic atrophic gastritis. We also provide practical advice for the diagnosis and management of patients with this disease.

Systematic review: gastric cancer incidence in pernicious anaemia

BACKGROUND

Pernicious anaemia (PA) has an increased risk for gastric cancer (GC). It is not established whether PA patients need to undergo endoscopic/histological follow-up.

AIM

To provide a systematic overview of the literature on PA and the development of gastric cancer, to estimate the gastric cancer incidence-rate.

METHODS

According to PRISMA, we identified studies on PA patients reporting the incidence of gastric cancer. Quality of studies was evaluated using the Newcastle-Ottawa Quality Assessment Scale. Meta-analysis on annual gastric cancer incidence rates was performed.

RESULTS

Twenty-seven studies met eligibility criteria. 7 studies were of high, 6 of medium, 10 of low and 4 of very low quality. Gastric cancer incidence-rates ranged from 0% to 0.2% per person-years in 7 American, from 0% to 0.5% in 2 Asiatic, from 0% to 1.2% in 11 Northern European studies and from 0% to 0.9% in 7 studies from other European countries. The incidence-rates of gastric cancer ranged from 0% to 1.2% per person-years in studies which used gastroscopy, from 0.1% to 0.9% in those based on International Classification of Disease. Heterogeneity between studies was not statistically significant at the 5% level (Chi-squared test = 17.9, P = 0.08). The calculated pooled gastric cancer incidence-rate was 0.27% per person-years. Meta-analysis showed overall gastric cancer relative risk in PA as 6.8 (95% CI: 2.6-18.1).

CONCLUSIONS

This systematic review shows a pooled gastric cancer incidence-rate in pernicious anaemia of 0.27% per person-years and an estimated nearly sevenfold relative risk of gastric cancer in pernicious anaemia patients. Further high quality studies are needed to confirm this higher risk.

Autoimmune pernicious anaemia as a cause of collapse, heart failure and marked panyctopaenia in a young patient

A 35-year-old woman with a history of vitiligo, hypothyroidism and amenorrhoea presented with collapse and clinical features of cardiac failure. Laboratory investigations revealed pancytopaenia, the cause of which was found to be vitamin B12 deficiency due to pernicious anaemia. Treatment with intramuscular hydroxycobalamin was commenced and the patient improved steadily with concomitant improvement in her haematological indices. Clinical features of pernicious anaemia which can include marked pancytopaenia, diagnostic approach, associated conditions and approach to treatment are discussed. The importance of surveillance for gastrointestinal malignancy is emphasised.

Prevalence of autoimmune diseases in in-patients with schizophrenia: nationwide population-based study

BACKGROUND

The association between autoimmune diseases and schizophrenia has rarely been systematically investigated.

AIMS

To investigate the association between schizophrenia and a variety of autoimmune diseases and to explore possible gender variation in any such association.

METHOD

Taiwan's National Health Insurance Research Database was used to identify 10 811 hospital in-patients with schizophrenia and 108 110 age-matched controls. Univariate and multiple logistic regression analyses were performed, separately, to evaluate the association between autoimmune diseases and schizophrenia. We applied the false discovery rate to correct for multiple testing.

RESULTS

When compared with the control group, the in-patients with schizophrenia had an increased risk of Graves' disease (odds ratio (OR) = 1.32, 95% CI 1.04-1.67), psoriasis (OR = 1.48, 95% CI 1.07-2.04), pernicious anaemia (OR = 1.71, 95% CI 1.04-2.80), celiac disease (OR = 2.43, 95% CI 1.12-5.27) and hypersensitivity vasculitis (OR = 5.00, 95% CI 1.64-15.26), whereas a reverse association with rheumatoid arthritis (OR = 0.52, 95% CI 0.35-0.76) was also observed. Gender-specific variation was found for Sjögren syndrome, hereditary haemolytic anaemia, myasthenia gravis, polymyalgia rheumatica and dermatomyositis.

CONCLUSIONS

Schizophrenia was associated with a greater variety of autoimmune diseases than was anticipated. Further investigation is needed to gain a better understanding of the aetiology of schizophrenia and autoimmune diseases.

Corpus predominant gastritis: what does it mean?

PURPOSE OF REVIEW

To summarize this year's relevant literature on the causes and mechanisms of autoimmune gastritis.

RECENT FINDINGS

It is increasingly recognized that parietal cell antibodies, previously assumed exclusive to autoimmune gastritis, are associated with Helicobacter pylori infection. Successful H. pylori eradication with antibiotic treatment decreases antiparietal cell antibodies. Interestingly, vitamin B(12) deficiency, previously associated with autoimmune gastritis, is increasingly described in the elderly, irrespective of H. pylori status. Autoimmune gastritis that mostly affects patients of Scandinavian descent, was reported this year from China, and corpus predominant gastritis (autoimmune associated) was reported from Japan. It is difficult to evaluate the role played by genetics, increased use of proton pump inhibitors, and H. pylori infection, as current patient work-up does not regularly include screening for parietal cell and intrinsic-factor antibodies. As these clinicopathologic changes are seen in both H. pylori-positive patients, and in H. pylori-naïve patients, the debate continues for mechanisms involved in H. pylori-naïve patients.

SUMMARY

The clinical features commonly associated with autoimmune gastritis are increasingly seen in the elderly, irrespective of H. pylori status. Though some patients are genetically predisposed, long-term proton pump inhibitor use increases the prevalence of clinicopathologic features irrespective of genetic tendency.