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Heterogeneity of Gastric Histology and Function in Food Cobalamin Malabsorption: Absence of Atrophic Gastritis and Achlorhydria

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Heterogeneity of Gastric Histology and Function in Food Cobalamin Malabsorption: Absence of Atrophic Gastritis and Achlorhydria 638 Gut 2000;47:638–645 Heterogeneity of gastric histology and function in food cobalamin malabsorption: absence of Gut: first published as 10.1136/gut.47.5.638 on 1 November 2000. Downloaded from atrophic gastritis and achlorhydria in some patients with severe malabsorption H Cohen, W M Weinstein, R Carmel Abstract Keywords: cobalamin; cobalamin malabsorption; Background—The common but incom- atrophic gastritis; achlorhydria; pepsin; gastrin; pletely understood entity of malabsorp- Helicobacter pylori tion of food bound cobalamin is generally presumed to arise from gastritis and/or Food cobalamin malabsorption, defined as the achlorhydria. inability to absorb food bound or protein bound Aim—To conduct a systematic compara- cobalamin while absorption of free cobalamin is tive examination of gastric histology and intact, may be the most common form of function. cobalamin malabsorption. Evidence suggests Subjects—Nineteen volunteers, either that its frequency exceeds that of classical disor- healthy or with low cobalamin levels, were ders of free cobalamin absorption such as perni- prospectively studied without prior cious anaemia.1 Nevertheless, the mechanisms knowledge of their absorption or gastric responsible for food cobalamin malabsorption status. are incompletely understood. Methods—All subjects underwent pro- Much clinical and laboratory evidence spective assessment of food cobalamin points to gastric dysfunction, especially loss of absorption by the egg yolk cobalamin acid secretion, as a key factor.1–6 Although the absorption test, endoscopy, histological stomach’s role is undoubted, selection may grading of biopsies from six gastric sites, have influenced the strength of that measurement of gastric secretory func- association7 because most of the initial studies tion, assay for serum gastrin and antipari- identified gastric surgery, gastric atrophy, or etal cell antibodies, and direct tests for use of acid suppressing drugs as predisposing Helicobacter pylori infection. conditions and selected their study subjects Results—The six subjects with severe from such populations.23 There has been no http://gut.bmj.com/ malabsorption (group I) had worse histo- prospective systematic assessment of all the logical scores overall and lower acid and gastric correlates of food cobalamin malab- pepsin secretion than the eight subjects sorption. with normal absorption (group III) or the The present study was designed to address five subjects with mild malabsorption this gap in our understanding by examining (group II). However, histological findings, gastric histology and gastric function in a and acid and pepsin secretion overlapped blinded prospective fashion and comparing on September 27, 2021 by guest. Protected copyright. Department of considerably between individual subjects Medicine, University these characteristics with absorption results. in group I and group III. Two distinct sub- The aim was to develop a profile of the of Southern California groups of three subjects each emerged School of Medicine, stomach in food cobalamin malabsorption that and the Los Angeles within group I. One subgroup (IA) had could be compared concurrently with findings County-USC Medical severe gastric atrophy and achlorhydria. in subjects without malabsorption. Center, Los Angeles, The other subgroup (IB) had little atrophy California, USA, and only mild hypochlorhydria; the gas- Department of tric findings were indistinguishable from Methods Medicine, UCLA those in many subjects with normal SUBJECTS Health Sciences Most of the subjects were recruited during a Center, Los Angeles, absorption. Absorption improved in the two subjects in subgroup IB and in one community survey of cobalamin status in appar- California, USA, and 8 Department of subject in group II who received antibiot- ently healthy elderly subjects. Proportionately Medicine, New York ics, along with evidence of clearing of H more subjects found to have low rather than Methodist Hospital, pylori. None of the subjects in group IA normal cobalamin levels during the survey Brooklyn, New York, responded to antibiotics. volunteered for the study, but their absorption USA Conclusions—Food cobalamin malab- status was not known beforehand. All partici- H Cohen pants were community dwellers and had no W M Weinstein sorption arises in at least two diVerent R Carmel gastric settings, one of which involves contraindications for the test procedures. Sub- neither gastric atrophy nor achlorhydria. jects with a history of gastrointestinal surgery Correspondence to: Malabsorption can respond to antibiotics, (other than remote appendicectomy or chole- Dr R Carmel, New York cystectomy) or receiving acid suppressive medi- Methodist Hospital, 506 but only in some patients. Food cobalamin Sixth St, Brooklyn, New York malabsorption is not always synonymous cations were excluded. Although our initial 11215, USA. with atrophic gastritis and achlorhydria, [email protected] and hypochlorhydria does not always Abbreviations used in this paper: EYCAT, egg yolk Accepted for publication guarantee food cobalamin malabsorption. cobalamin absorption test; MAO, maximum acid 9 May 2000 (Gut 2000;47:638–645) output. www.gutjnl.com Heterogeneity of gastric histology and function in food cobalamin malabsorption 639 focus was on volunteers >60 years old, six Because a normal EYCAT result is presump- subjects below that age were subsequently tive proof that absorption of free cobalamin is accepted. The only subjects that were not also normal, Schilling tests were rarely done in Gut: first published as 10.1136/gut.47.5.638 on 1 November 2000. Downloaded from recruited from a presumably healthy population patients with normal food cobalamin absorp- were two patients who had been referred for tion. Other markers of pernicious anaemia, testing because of mild cobalamin deficiency. such as gastric intrinsic factor secretion, gastrin The objective of the recruitment was to provide levels, and antibodies to intrinsic factor, were enough subjects with and without malabsorp- also assessed in most patients. As a result, two tion for comparative analyses of gastric status, subjects with findings suspicious of pernicious rather than to determine the prevalence rates of anaemia were excluded from the study and are malabsorption. Median age of the subjects was not presented here. 69 years (range 33–81), 11 were men and eight were women, and there were 12 whites, four ENDOSCOPY AND BIOPSY blacks, two Latin Americans, and one Asian- After absorption testing, each volunteer under- American. The study was approved by the insti- went upper gastrointestinal endoscopic exam- tutional review board at the Los Angeles ination. The procedure was performed by an County-USC Medical Center and each partici- investigator who was blinded to the subject’s pant gave written informed consent. absorption test results. Biopsies were taken from standardised sites as shown in fig 1, using a large ABSORPTION TESTING capacity pinch biopsy forceps with an 8 mm The egg yolk cobalamin absorption test open span. The two biopsies on the greater (EYCAT) method, modified from that of curve of the body (mid body and 3 cm distal to Doscherholmen and colleagues9 by omitting the it) were designed to sample the oxyntic mucosa dual isotope feature, has been previously where the folds are thickest. The biopsy of the described.10 In brief, 57Co-cyanocobalamin and mid body lesser curve was designed to help unlabelled cobalamin were mixed with reconsti- complete the overall picture of the status of the tuted lyophilised egg yolk in a Waring blender. oxyntic mucosa, fully recognising that oxyntic The egg yolk preparation was scrambled in a glands in the lesser curve of the body are often Teflon coated skillet, and 12 or 13, 50 g portions thinner and gastritis, if present, may appear to be were weighed out from this batch and stored at more severe.11 −20°C until use. Each portion contained about All biopsies were mounted mucosal side up 0.8 µg of cobalamin (approximately 0.5 µCi of on a plastic mesh and fixed in Bouin’s solution 57Co). On the day of testing, the fasted subject for 2–6 hours before transfer to 70% alcohol ate the scrambled egg yolk portion that had been and subsequent processing for paraYn embed- reheated in a microwave oven; no other food or ding. Two slides each containing 15 serial sec- liquids were taken for four hours. The rest of the tions at 4 µm were prepared, one for haema- procedure was the same as in the standard toxylin and eosin staining and the second for http://gut.bmj.com/ Schilling test, with an intramuscular injection of staining with haematoxylin and eosin-alcian 1000 µg of cyanocobalamin given two hours blue, pH 2.5, to facilitate detection and grading after the test meal. A 24 hour urine collection of intestinal metaplasia. Four to five additional was done. The radioactivity excreted was sections were stained with the Genta stain for compared witha1geggyolkcobalamin stand- identification of H pylori.12 ard from the original batch preparation. Based on results in 168 normal and abnor- HISTOLOGICAL ASSESSMENT mal subjects, 24 hour excretion values below Biopsy specimens were coded, mixed, and on September 27, 2021 by guest. Protected copyright. 1% indicate severe food cobalamin malabsorp- evaluated by a single observer without knowl- tion and values >2% represent normal absorp- edge of any of the other findings. A similarly tion. Values of 1.00–1.99% represent probable blinded observer examined the specially or mild malabsorption. EYCAT reproduc- stained tissue sections for H pylori. ibility had been shown in the retesting of seven subjects within 1–6 months. Two subjects with severe malabsorption had repeat values of Gastritis index Gastric inflammatory, epithelial, and glandular 0.43%/0.24% and 0.19%/0.17%/0.10%, re- changes were scored separately in a similar spectively. Five subjects with normal absorp- fashion to that described previously.13 For tion had repeat values of 4.06%/4.10%, inflammation, neutrophils and mononuclear 4.66%/5.38%, 2.67%/3.63%, 2.85%/3.21%, cells were each graded separately with scores of and 2.91%/2.25%, respectively. After baseline blood samples were obtained, all fasted volunteers underwent the EYCAT.
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