Case history
Case history #1
A 60-year-old white man, with past medical history significant for Graves disease, presents with a 2-month history of 4.5-kg (10-lb) weight loss, bilateral lower extremity paresthesias with weakness, and an unsteady gait. Physical exam reveals conjunctival pallor, smooth and glossy tongue, impaired sense of vibration, and ataxia. Laboratory findings are significant for macrocytic anemia, low serum cobalamin (vitamin B12), and positive serum antiparietal cell antibodies. An esophagogastroduodenoscopy (EGD or upper endoscopy) reveals flattened rugal folds in the fundus and corpus of the stomach (oxyntic mucosa) with easily visualized fine submucosal vessels. An aliquot of aspirated gastric juice has a pH >6.0. Biopsy shows atrophic gastritis with focal intestinal metaplasia and absence of Helicobacter pylori.
Case history #2
An active 79-year-old woman presents with a 6-month history of progressive weakness and exercise intolerance. Physical exam is unremarkable except for pallor of the nail beds. Laboratory findings show hypochromic microcytic red blood cells, hemoglobin 8 g/dL, low iron (10 micrograms/dL), low transferrin saturation (4%), and low ferritin (10 nanograms/mL). Colonoscopy is negative except for diverticulae. EGD shows absence of rugal folds and 3 sessile polyps in the body of the stomach, each <1 cm with overlying normal-appearing mucosa. Biopsy of the gastric body shows complete loss of oxyntic glands. Biopsy of the nodules reveals homogeneous well-differentiated oval cells with round nuclei. The cells are argyrophilic with both Grimelius and Sevier-Munger staining methods; additionally, immunostaining is positive for chromogranin A and histamine. Subsequently a serum gastrin was obtained and was elevated, at 1000 picograms/mL.
Other presentations
Patients with achlorhydria are usually asymptomatic. Because gastric acid facilitates the absorption of nonheme iron (and perhaps heme iron), cobalamin (vitamin B12), and calcium, patients may present with signs and symptoms due to a deficiency in these nutrients.[14] In addition, patients with atrophic gastritis lack intrinsic factor, a protein secreted mainly from parietal cells that is necessary for absorption of cobalamin.[15] Gastric acid hyposecretion may be associated with enteric infection.[16]
Several epidemiologic studies have suggested an association between proton-pump inhibitor use and an increased risk of osteoporosis-related hip fracture.[17][18][19] However, one large randomized controlled trial reported no statistically significant difference in fracture risk between pantoprazole and placebo groups over a 3-year period.[16]
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