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Autoimmune Diseases in Autoimmune Atrophic Gastritis Acta Biomed 2018; Vol. 89, Supplement 8: 100-103 DOI: 10.23750/abm.v89i8-S.7919 © Mattioli 1885 Review Autoimmune diseases in autoimmune atrophic gastritis Kryssia Isabel Rodriguez-Castro1, Marilisa Franceschi1, Chiara Miraglia1, Michele Russo1, Antonio Nouvenne1, Gioacchino Leandro3, Tiziana Meschi1, Gian Luigi de’ Angelis1, Francesco Di Mario1 1 Endoscopy Unit, Department of Surgery, ULSS7-Pedemontana, Santorso Hospital, Santorso (VI), Italy; 2 Department of Me- dicine and Surgery, University of Parma, Parma, Italy; 3 National Institute of Gastroenterology “S. De Bellis” Research Hospital, Castellana Grotte, Italy Summary. Autoimmune diseases, characterized by an alteration of the immune system which results in a loss of tolerance to self antigens often coexist in the same patient. Autoimmune atrophic gastritis, characterized by the development of antibodies agains parietal cells and against intrinsic factor, leads to mucosal destruction that affects primarily the corpus and fundus of the stomach. Autoimmune atrophic gastritis is frequently found in association with thyroid disease, including Hashimoto’s thyroiditis, and with type 1 diabetes mellitus, Other autoimmune conditions that have been described in association with autoimmune atrophic gastritis are Ad- dison’s disease, chronic spontaneous urticaria, myasthenia gravis, vitiligo, and perioral cutaneous autoimmune conditions, especially erosive oral lichen planus. Interestingly, however, celiac disease, another frequent auto- immune condition, seems to play a protective role for autoimmune atrophic gastritis. The elevated prevalence of autoimmune disease clustering should prompt the clinicial to exclude concomitant autoimmune conditions upon diagnosis of any autoimmune disease. (www.actabiomedica.it) Key words: autoimmune atrophic gastritis, Hashimoto’s thyroiditis, diabetes mellitus, celiac disease Autoimmune diseases, characterized by dysregu- tric cell destruction and hypochlorhydria increase the lation of the immune system which results in a loss of risk of adenocarcinoma and neuroendocrine tumors; tolerance to self-antigens, tend to cluster, often coex- an early diagnosis and an appropriate follow-up are isting in the same patient. While the exact etiology therefore warranted. AG is usually diagnosed using of the majority of these diseases is unclear, a complex a combination of APCA positivity and histological combination of host and environmental factors seem criteria. However, the latter is an invasive and costly to play a pivotal role. Moreover, sequential or simulta- method, and lacks an evaluation of gastric function. neous development of two or more autoimmune dis- The unraveling of the pathophysiology leading to orders, causing deficiencies in the function of several autoimmune atrophic gastritis is somewhat challeng- endocrine organs, is termed autoimmune polyglandu- ing due to the following reasons: 1) the prevalence of lar syndrome (1). autoimmune atrophic gastritis is relatively low, possi- Autoimmune atrophic gastritis (AAG) is a bly due at least in part to underdiagnosis, 2) in many chronic disease that affects the corpus-fundus of the cases there is a concurrent Helicobacter pylori-induced stomach, and is characterized by the development two gastritis, and 3) early stages of disease lack clinical types of auto-antibodies: anti-parietal cells antibodies manifestations. Alike other autoimmune disorders, and anti-intrinsic factor antibodies. A strong associa- autoimmune atrophic gastritis more commonly affects tion between autoimmune atrophic gastritis and other females than males, with a 3:1 ratio. autoimmune disorders has been well documented. The Although mechanisms of disease development are hypergastrinemia that ensues as a consequence of gas- yet to be established, disease evolution appears to fol- Autoimmune diseases in autoimmune atrophic gastritis 101 low through a sequence that commences with infiltra- series reporting on 8 patients with marked pangastric tion of the oxyntic mucosa by lymphocytes and plasma atrophy, associated systemic autoimmune and/or con- cells. At this initial stage, endoscopic appearance of nective tissue diseases included inflammatory bowel islets is due to the uneven destruction of parietal cells disease, systemic lupus erythematosus, and autoim- with preserved islands of relatively normal oxyntic mu- mune hemolytic anemia (11). cosa. Subsequently, loss of oxyntic mucosa as well as It has long been recognized that AAG, as well as disruption of maturation of parietal cells (2) lead to other autoimmune disorders, tend to cluster in fami- hypochlorydria. Thereafter, loss of negative feedback lies, which could reinforce the genetic component of from parietal cells induces G-cell hyperplasia and in- disease. Using mouse models, it has been possible to creased gastric secretion in the antrum, which, in turn, discover AAG susceptibility genes (Gasa 1, 2, 3, and leads to parietal cell pseudohypertrophy and prolifera- 4) on chromosomes 4 and 6 and H2 region, three of tion of enterochromaffin-like (ECL) cells. Progression which are located on the same locus as non-obese dia- of ECL cell hyperplasia to neoplastic subtype can ulti- betic mouse diabetes mellitus susceptibility genes (12, mately result in carcinoid tumor formation. Metaplasia 13) The prevalence of AAG is increased 3- to 5-fold develops primarily within corpus and fundus, leading in patients with type 1 diabetes mellitus (14), report- to “oxyntic antralization”, with appearance of mucus- edly reaching 5% to 10% and 2.6% to 4%, for auto- secreting cells which phenotypically resemble antral immune atrophic gastritis and for pernicious anemia, mucous cells in oxyntic regions of the stomach (3). respectively (7). In a study conducted at Washington Aside from the fact that most cases of micro- as University Diabetes Center analyzing over 1200 pa- well as macrocytic anemia are treated with iron, fo- tients with type 1 Diabetes Mellitus, incidence and lic acid and vitamin B12 without a complete workup prevalence of concomitant autoimmune disorders in- that excludes the presence of autoimmune atrophic creased with age, and female gender strongly predicted gastritis, anemia might be attributed to concomitant the development of concomitant autoimmune disor- autoimmune disorders. Thus, if unsuspected and not ders. Aside from thyroid disease and collagen vascular specifically sought for, autoimmune atrophic gastritis diseases, pernicious anemia was one of the most fre- easily goes undiagnosed. quent autoimmune comorbidities in patients with type The fact that patients with autoimmune atrophic 1 diabetes (15). gastritis are more prone to developing other concomi- Approximately 10-40% of patients with Hashi- tant autoimmune diseases began to be a consistent moto’s thyroiditis, the most frequent thyroid disease, observation upon initial recognition and description have associated gastric disorders. Similarly, Hashi- of cases of autoimmune atrophic gastritis. In a series moto’s thyroiditis is present in nearly 40% of patients of 34 patients with pernicious anemia, in whom pa- with AAG. In a recently published study analyzing rietal cell antibodies (PCA) were detected in 97% of 320 patients with autoimmune atrophic gastritis, an patients, and intrinsic factor blocking antibody (IFBA) associated autoimmune disorder was present in 53.4%; was found in 52%, 32 patients had concomitant au- the most common concurrent disease was autoimmune toimmune or immunologic diseases (4). Autoimmune thyroiditis, found in 116 (36.2%) patients. Interest- thyroid disease is frequent in patients with autoim- ingly, authors found that serum levels of gastrin, chro- mune atrophic gastritis, and in turn, patients with au- mogranin A, as well as the presence of ECL hyperpla- toimmune thyroid disease are also frequently affected sia, correlated significantly with the coexistence of an by autoimmune atrophic gastritis. Other autoimmune autoimmune disease (16). conditions that have been described in association In a study analyzing (17) 115 patients with with autoimmune atrophic gastritis include Addison’s Hashimoto’s thyroiditis, enterochromafin-like cells disease (5), chronic spontaneous urticaria (6), type 1 were found in 11.3%; nevertheless, normal levels of diabetes mellitus (7), myasthenia gravis (8), vitiligo (9) gastrin and chromogranin were found in a fraction of (10), and perioral cutaneous autoimmune conditions these patients. Conversely, elevated gastrin levels with (especially erosive oral lichen planus). In a small case concomitant low vitamin B12 levels constituted the 102 K.I. Rodriguez-Castro, M. Fransceschi, C. Miraglia, et al. most specific combined parameters associated with a if persistent after adequate L-thyroxine replacement, 96.1% specificity for the presence of enterochromafin- warrant determination of levels of Vitamin B12. Par- like cells. Thus, the authors conclude that elevated esthesis, dysphagia and numbness are more frequently gastrin levels have a high diagnostic accuracy for reported in hypothyroid patients with vitamin B12 de- enterochromafin-like cell hyperplasia identification ficiency with respect to patients with normal vitamin in patients with Hashimoto’s thyroiditis, and that the levels (22). concomitance of low levels of Vitamin B12 are highly It is advisable to screen for Vitamin B12 deficien- specific for the former. The authors acknowledge, how- cy (with or without chronic atrophic gastritis) upon ever, that gastrin levels may be normal in the presence initial
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