Red Cell Disorders • Research Paper Role of autoimmune gastritis, Helicobacter pylori and celiac disease in refractory or unexplained iron deficiency anemia Chaim Hershko Background and Objectives. Conventional endoscopic and radiographic methods fail to A. Victor Hoffbrand identify a probable source of gastrointestinal blood loss in about one third of males Dan Keret and post-menopausal females and in most women of reproductive age with iron defi- Moshe Souroujon ciency anemia (IDA). Such patients, as well as subjects refractory to oral iron treat- Itzhak Maschler ment, are often referred for hematologic evaluation. Yehudit Monselise Amnon Lahad Design and Methods. We prospectively studied 150 consecutive IDA patients referred to a hematology outpatient clinic, screened for non-bleeding gastrointestinal conditions including celiac disease (antiendomysial antibodies), autoimmune atrophic gastritis (hypergastrinemia with strongly positive antiparietal cell antibodies) and H. pylori infec- tion (IgG antibodies confirmed by urease breath test). Results. The mean age of all subjects was 39±18 years and 119 of the 150 patients were female. We identified 8 new cases of adult celiac disease (5%). Forty IDA patients (27%) had autoimmune atrophic gastritis of whom 22 had low serum vita- min B12 levels. H. pylori infection was the only finding in 29 patients (19%), but was a common co-existing finding in 77 (51%) of the entire group. Refractoriness to oral iron treatment was found in 100% of patients with celiac disease, 71% with autoimmune atrophic gastritis, 68% with H. pylori infection, but only 11% of subjects with no detect- ed underlying abnormality. H. pylori eradication in previously refractory IDA patients in combination with continued oral iron therapy resulted in a significant increase in hemo- globin from 9.4±1.5 (mean ± 1SD) before treatment to 13.5±1.2 g/ dL (p<0.001 by paired t test) within 3 to 6 months of treatment. Interpretation and Conclusions. The recognition that autoimmune atrophic gastritis and H. pylori infection may have a significant role in the development of unexplained or refractory IDA in a high proportion of patients should have a strong impact on our daily practice of diagnosing and managing IDA. Key words: iron deficiency, celiac disease, Helicobacter pylori, atrophic gastritis, vitamin B12 deficiency. Haematologica 2005; 90:585-595 ©2005 Ferrata Storti Foundation From the Department of pontaneous iron excretion in adult treatment are often referred for hemato- Hematology, Shaare Zedek Medical Center (CH), Department of subjects is minimal and iron deficien- logic evaluation. In recent years, there has Gastroenterology (DK), Central cy anemia (IDA) is generally attrib- been an increasing awareness of subtle, S 1 Clinical Laboratories (MS, IM), uted to abnormal blood loss. This may be non-bleeding gastrointestinal conditions Clinical Immunology Laboratories caused by gastrointestinal bleeding or, in that may result in abnormal iron absorp- Rabin Medical Center (YM), young females of reproductive age, by tion leading to IDA in the absence of gas- Department of Family Medicine, Clalit Health Services, Jerusalem, increased menstrual flow and the trointestinal symptoms. Thus, the impor- and Hebrew University Hadassah increased requirements of pregnancy. tance of celiac disease as a possible cause Med. School, Jerusalem, Israel (AL), However, in adult males and post- of IDA refractory to oral iron treatment, Department of Hematology, Royal menopausal females, major studies evalu- without other apparent manifestations of Free Hospital, London, UK (AVH), ating the gastrointestinal tract for IDA malabsorption syndrome4-10 is increasingly Correspondence: employing endoscopic and radiographic being recognized. In addition, Helicobacter Chaim Hershko M.D., methodologies have only been able to pylori infection has been implicated in sev- Department of Hematology, identify a probable source of upper or eral recent studies as a cause of IDA refrac- Shaare Zedek Med Center, lower gastrointestinal bleeding in about 62 tory to oral iron treatment with a favor- Jerusalem, Israel, PO Box 3235. to 64% of patients.2,3 Similarly, no evi- able response to H. pylori eradication.11-17 E-mail: [email protected] dence of gastrointestinal blood loss can be Likewise, achlorhydric gastric atrophy or found in the vast majority of young, fertile autoimmune atrophic gastritis, a condition females with IDA. Such patients with a associated with chronic idiopathic iron low likelihood of gastrointestinal blood deficiency, has been shown to be respon- loss, and patients refractory to oral iron sible for refractory IDA in over 20% of haematologica/the hematology journal | 2005; 90(5) | 585 | C. Hershko et al. patients with no evidence of gastrointestinal blood healthy subjects of comparable age (see below) and loss.18-20 Although achylia gastrica, a condition indis- gender (9 males and 51 females) referred within the tinguishable from autoimmune atrophic gastritis, same period for evaluation of minor problems such was defined by Faber as a distinct clinical entity as suspected thrombophilia without evidence of responsible for IDA as early as 190921 and extensive- thrombosis (n=44), no disease (n=10) or borderline ly studied subsequently by Wintrobe and others,22-25 white blood cell counts (n=6). this entity was almost completely forgotten and largely ignored in major studies of IDA.2,3 Laboratory methods The recent availability of convenient, non-invasive Complete blood counts (CBC) were performed by screening methods for identifying celiac disease, a SysmexSE-9000 automated analyzer (KOBE, Japan) autoimmune atrophic gastritis and H. pylori gastritis, calibrated daily with standards provided by the man- has greatly facilitated the recognition of patients with ufacturer. Routine biochemical measurements these entities, resulting in an increased awareness of including serum iron (normal range 59-158 mg/dL), these conditions and their possible role in the causa- total iron binding capacity (TIBC; normal range 226- 18,19 tion of IDA. Unlike IDA patients referred for eval- 338 mg/dL) and serum ferritin (normal range males uation of possible gastrointestinal bleeding in whom 40-340, females 14-150 mg/L) were performed by a the causes of anemia are well documented, our Hitachi 747 automated analyzer with quality control knowledge of underlying conditions responsible for assurance by UKNEQAS (Birmingham, UK). Fasting IDA in patients referred for hematologic evaluation serum B12 levels were determined by the ADVIA with no apparent gastrointestinal disease is limited. Centaur VB12 assay which is an automated competi- The objective of the present study was to establish, tive immunoassay using direct chemiluminescent in a systematic and prospective manner, the cause of technology. The lower limit of normal was defined as IDA among patients referred for evaluation to a com- <181 ng/L. Fasting serum gastrin levels were deter- munity hematology clinic over a period of two years mined by GammaDab® Gastrin 125I RIA Kit (DiaSorin, with particular emphasis on non-bleeding gastroin- Stillwater Minnesota, USA) and expressed as pg/mL, testinal causes of IDA, employing non-invasive sero- normal limits < 107. For the detection of IgG anti- logical screening tests supplemented by currently bodies to H. pylori in human serum, the IMMULITE® accepted diagnostic methodologies. 2000 H. pylori IgG, a solid-phase chemiluminescent immunometric assay (DPC Diagnostics, Los Angeles, CA, USA) with an analytical sensitivity limit of 0.4 Design and Methods U/mL was used; a value < 0.9 U/mL was considered to be negative. Anti-endomysial IgG and IgA anti- Target population bodies and anti-gastric parietal cell IgG antibodies The population for this prospective study consist- (APCA) were determined by an indirect immunoflu- ed of patients with IDA and a low apparent likeli- orescence antibody test for semi-quantitative detec- hood of gastrointestinal disease referred by family tion of antibodies using the ImmuGloTM Anti- physicians to a community hematology clinic. All the Endomysial Antibody Test System (IMMCO® diag- patients had received oral iron treatment prior to nostics, Buffalo, NY, USA). Results were considered referral and many were described as refractory to positive if equal to or greater than 1:40 dilution. oral iron therapy. All newly referred patients with Intrinsic factor antibodies were assayed by enzyme- IDA were included, starting from September 1, 2001, linked immunoassay (ALPHADIA,® Belgium) detect- for a period of 2 years, if their hemoglobin at refer- ing type I and type II antibodies. Results exceeding ral was 11 g/dL or less, and if they fulfilled the fol- 1.1 were considered positive. Anti-gliadin antibodies lowing criteria for iron deficiency anemia: mean cor- were measured by an indirect assay employing per- puscular volume (MCV) less than 80 fL, transferrin oxidase-labeled rabbit anti-human IgG and IgA anti- saturation less than 15%, and serum ferritin less than bodies employing the BINDAZYMETM Human 12 mg/L (143 patients) or two of the above and an Anti-Gliadin IgG and IgA kits (The Binding Site Ltd., increase in hemoglobin > 1.0 g/dL in response to iron Birmingham, UK). Results were considered positive therapy (7 patients). Although patient recruitment if equal to or more than 10 U/mL for IgG and 5 for was terminated in September 2003, follow-up visits IgA antibodies were continued allowing a follow-up period of at The 13C-urease breath test