Donatella Padula

Common Features of Patients With Autoimmune Atrophic Gastritis

BACKGROUND & AIMS Autoimmune atrophic gastritis (AIG) is characterized by immune-mediated chronic inflammation of the gastric body and fundus, leading to hypo-achlorhydria and vitamin B12 deficiency. We analyzed the clinical features of AIG and sought to identify factors that might be used in diagnosis. METHODS We collected and analyzed clinical data from 99 consecutive patients (age, 59 ± 17 y) who were diagnosed with AIG, based on histologic factors and the presence of autoantibodies against gastric parietal cells. RESULTS Clinical factors that led to a diagnosis of AIG included hematologic findings related to vitamin B12 deficiency (n = 37), incidental histologic evidence in gastric biopsy specimens (n = 34), immune disorders (n = 18; 9 were celiac disease), neurologic symptoms (n = 6), and a family history of AIG (n = 4). CONCLUSIONS Based on an analysis of 99 consecutive patients with AIG, this disorder is not solely a condition of the elderly. Other features to look for in making a diagnosis of AIG include vitamin B12 deficiency, histologic factors, and immune disorders.

A laboratory score in the diagnosis of autoimmune atrophic gastritis: a prospective study.

Background: Several biomarkers have been proposed for the diagnosis of autoimmune atrophic gastritis (AAG), but at the present there is no appropriate testing strategy for the disease. Goals: The aim of this study was to develop and validate a laboratory score able to address the diagnosis of AAG in a general practice setting. Study: We prospectively evaluated a number of serum biomarkers (vitamin B12, mean corpuscular volume, hemoglobin, gastrin, and chromogranin A levels) in a case-control population and built 2 biochemical scores, the first with all the parameters [Global Score (GS)], and the second as the best statistical combination of them [Simple Score (SS)]. In the second phase we validated the score that proved to be more efficient on a random population referred to our center (Gastroenterology Outpatient Clinic). Results: Both models turned out to be reliable in detecting patients with suspected AAG, showing excellent accuracy [area under the receiver operating curve (AUC-ROC) 0.94; 95% confidence interval (CI), 0.91-0.97 for GS and AUC-ROC 0.93; 95% CI, 0.89-0.86 for SS]. The SS proved to be more convenient because of its accessibility and availability in a general setting and its low cost. The validation of the SS showed a sensitivity of 85.7% (95% CI, 57.2-98.2) and a specificity of 83.7% (95% CI, 74.2-90.89). Conclusions: Herein, we describe 2 nonexpensive and reliable score models, particularly the SS, that can be applied in daily medical practice for identifying patients potentially affected by AAG.

The challenging diagnosis of autoimmune atrophic gastritis

We read with interest the article by Zhang et al. investigating 320 patients who were diagnosed with autoimmune atrophic gastritis (AAG) within a large cohort of 97,341 Chinese patients referred for an upper gastrointestinal endoscopy, over a 8-year period [1]. The Authors made a comprehensive study, analyzing laboratory tests (cell blood count, vitamin B12 status), serum autoantibodies and endoscopic findings of patients with AAG, with an annual detection rate of 0.9%. This is one of the largest cohorts ever described in an Asiatic population. However, the clinical findings and the inclusion criteria used by the Authors raise a few issues that should be clarified. Over the last two decades, there has been an increasing awareness and attention on AAG pathogenesis [2] and its clinical [3], laboratory [4–6] and histopathological [7] diagnosis. It is known that AAG has a wide clinical spectrum, which encompasses haematological, gastroenterological and neurological manifestations [3]. Furthermore, AAG is surely associated with autoimmune diseases, namely autoimmune thyroid diseases [8] and type I diabetes mellitus [9], but presumably also with celiac disease, connective tissue disorders and others [3]. Zhang et al. reported a rather high prevalence of anti-thyroid (80.6%), anti-nuclear (29.2%) and anti-mitochondrial antibodies (3.5%). These remarkable results warrant a better awareness about these possible associations; however, we wonder how many of those patients might also have a positive serology for celiac disease. The Authors depict variable haematological findings that might also be explained by this latter condition. Moreover, the Authors used potentially misleading diagnostic criteria, also including patients with multifocal atrophic gastritis and with no AAG specific autoantibodies (defining these latter patients as affected by ‘probable’ AAG). Anti-gastric parietal cell antibodies (PCA) marked the turning point in serological diagnosis of AAG and there is evidence that they should be tested through an enzyme-linked immunosorbent assay, which is the most accurate method (81% specificity, 90% sensitivity) [4,6]. Also, it is known that PCA may rise, peak and fall over time in the natural history of AAG [8] and may disappear in the late stages. For these reasons, in case of a clear corpus-restricted atrophic gastritis and no evidence of active H. pylori infection, even in the absence of PCA, we can still diagnose AAG with reasonable assurance. In case of further doubts, the detection of anti-intrinsic factor antibodies could increase PCA diagnostic accuracy [4]. On the contrary, multifocal atrophic gastritis (both corpus and antrum atrophy) in the absence of autoantibodies should be considered as a different disease, possibly with a higher risk of developing gastric cancer according to the OLGA staging [7]. Finally, chromogranin A immunostaining should be an integral part of the pathological assessment as it has been proven to be useful for addressing diagnosis of AAG, especially in its early phase [7,10]. To conclude, AAG is a multifaceted disease whose diagnosis should rely on clinical and laboratory suspicious and histopathological confirmation. Hence, more studies are needed focusing on a better characterization of all these aspects, in order to overcome all the aforementioned limitations.

A consensus for the development of a vector model to assess clinical complexity

The progressive rise in multimorbidity has made management of complex patients one of the most topical and challenging issues in medicine, both in clinical practice and for healthcare organizations. To make this easier, a score of clinical complexity (CC) would be useful. A vector model to evaluate biological and extra-biological (socio-economic, cultural, behavioural, environmental) domains of CC was proposed a few years ago. However, given that the variables that grade each domain had never been defined, this model has never been used in clinical practice. To overcome these limits, a consensus meeting was organised to grade each domain of CC, and to establish the hierarchy of the domains. A one-day consensus meeting consisting of a multi-professional panel of 25 people was held at our Hospital. In a preliminary phase, the proponents selected seven variables as qualifiers for each of the five above-mentioned domains. In the course of the meeting, the panel voted for five variables considered to be the most representative for each domain. Consensus was established with 2/3 agreement, and all variables were dichotomised. Finally, the various domains were parametrized and ranked within a feasible vector model. A Clinical Complexity Index was set up using the chosen variables. All the domains were graphically represented through a vector model: the biological domain was chosen as the most significant (highest slope), followed by the behavioural and socio-economic domains (intermediate slope), and lastly by the cultural and environmental ones (lowest slope). A feasible and comprehensive tool to evaluate CC in clinical practice is proposed herein.

Diagnosi e trattamento della malattia celiaca refrattaria: presentazione di un caso clinico

Refractory celiac disease (RCD) is defined by persistent symptoms of malabsorption and villous atrophy despite a 8-12 months strictly gluten free diet, in the absence of other causes of unresponsiveness to diet or malignancies. RCD can be classified into two types: intestinal bioptic samples of RCD type 1 show an intraepithelial lymphocytic infiltrate with normal phenotype, in contrast with RCD type 2 where intestinal lymphocytes are aberrant. RCD type 1 is usually characterized by clinical improvement using a treatment strategy that includes nutritional support, gluten free diet and immunosuppressive drugs; RCD type 2 does not benefit from this therapy and shows poor prognosis and elevated risk of developing EATL. The description of this case is due to improve our knowledge on alternative therapeutic strategy for the treatment of RCD in patients with refractory celiac steroid-unresponsive.

Complicanze degli accessi vascolari centrali a lungo termine: presentazione di un caso clinico

Long term central vascular accesses are frequently used in the common clinical practice for drug infusion or sample taking; nevertheless they expose the patient to possible severe complications, mainly infectious and thrombotic ones. This case report summarizes main complications directly or indirectly linked to the long-term permanence of the device, and highlights the importance of an accurate evaluation of risk-benefit ratio of catheter placement and of an adequate knowledge of the patient about the maintenance of the device.

Valutazione del bilancio marziale in pazienti con gastrite atrofica autoimmune

La gastrite atrofica autoimmune (GAA, gastrite di tipo A) e una patologia autoimmune caratterizzata dalla progressiva atrofia della mucosa del corpo e del fondo dello stomaco e dalla scomparsa delle cellule parietali gastriche. La GAA, nel tempo, oltre allo sviluppo di anemia perniciosa conseguente al malassorbimento di vitamina B12, puo portare a sideropenia come conseguenza dell’ipo-acloridria. Abbiamo arruolato 98 pazienti affetti da GAA e per ciascuno di essi abbiamo valutato i seguenti parametri ematochimici: emocromo, ferro, ferritina, vitamina B12. I risultati dimostrano che la sideropenia e frequente nei pazienti affetti da GAA e puo coesistere con il deficit di vitamina B12 con diverse presentazioni ematologiche.

Una giovane donna con disfagia

La sindrome di Plummer-Vinson o Paterson-Kelly si manifesta con la triade disfagia, anemia sideropenica e anelli esofagei. Tipicamente colpisce donne tra la quarta e la settima decade di vita. In questo caso clinico viene descritta una giovane donna vegetariana proveniente dalla Costa d’Avorio che ha manifestato la patologia.

Gastrite atrofica autoimmune: prevalenza, presentazione clinica e clusters diagnostici

La gastrite atrofica autoimmune (GAA) e una patologia organo specifica caratterizzata da un’aggressione autoimmune delle cellule parietali gastriche. La GAA e una malattia considerata rara e puo presentarsi clinicamente in diverse modalita. Abbiamo arruolato 99 pazienti con diagnosi di GAA posta presso il nostro centro e abbiamo valutato: la prevalenza di questa popolazione nell’ambito delle visite ambulatoriali, la presentazione clinica e i clusters diagnostici in base ai motivi che hanno portato alla diagnosi. I clusters comprendono: le alterazioni ematologiche, il riscontro istologico, l’anemia nella malattia celiaca, le associazioni autoimmuni, i sintomi neurologici e la familiarita. La patologia e piu frequente dell’atteso, non e una condizione solo geriatrica e servono ulteriori studi per confermare delle possibili associazioni con altre patologie autoimmuni e per definire meglio la sintomatologia gastroenterologica.

Tipizzazione dell’HLA in pazienti con gastrite atrofica autoimmune e Helicobacter pylori-relata

La gastrite atrofica autoimmune (GAA) e una patologia caratterizzata dall’aggressione autoimmune delle cellule parietali gastriche. La gastrite atrofica Helicobacter pylori-relata invece e il risultato di una patologia infettiva. Alcuni studiosi sostengono che i geni HLA possano avere un ruolo nello scatenare l’aggressione autoimmune nella GAA. Scopo dello studio e stato quello di valutare gli HLA in pazienti con GAA, gastrite atrofica Helicobacter pylori-relata e in donatori di sangue sani. Otto alleli HLA (B*38, Cw*12, Cw*14, Cw*16, Cw*17, DRB1*04, DQA1*0301, DQB1*0302) sono risultati statisticamente associati alla GAA rispetto ai donatori di sangue, mentre nessuna significativita e stata riscontrata tra i pazienti con GAA e i pazienti con gastrite atrofica Helicobacter pylori-relata.