S3560 Who Knows When It All Began? A Case of Autoimmune Gastritis

Abstract

Introduction: Gastritis is a common entity that manifests as erythema of the gastric mucosa seen on EGD. The most common cause of Gastritis is infection, specifically H pylori. Atrophic gastritis is suggested endoscopically by loss of rugal folds and appearance of the submucosal vessels. Autoimmune Metaplastic Atrophic Gastritis (AMAG) is a subtype and is suggested pathologically by full thickness chronic inflammation, oxyntic gland destruction, prominent eosinophils, metaplasia, or parietal cell pseudohypertrophy. Endoscopic surveillance remains controversial. Management strategies include eradication of H pylori infection. We present a case of AMAG assoc with Lupus. Case Description/Methods: A 45-year-old Caucasian female with history of Lupus presented with persistent, dull, aching epigastric pain aggravated by solid food intake and anemia. She had no previous history of H pylori, no previous use of antacids, NSAIDs, or digestive enzymes. When she was younger, she had iron deficiency anemia thought to be solely nutritional or related to heavy menses. Her Mother had Hashimoto's thyoiditis. Laboratory work up showed mild microcytic anemia Ferritin 253 ng/mL, Iron 143 ug/dL while on Iron supplementation. EGD showed loss of rugal folds with edematous change in fundus and body. Biopsy showed chronic gastritis with intestinal metaplasia. Repeat EGD in 1 year showed loss of rugal folds and pallor to the mucosa. Biospies were done according to mapping protocol for intestinal metaplasia of greater and lesser curvature of antrum, incisura and body showed atrophic/autoimmune gastritis. Gastrin level was 1419 pg/mL, Antiparietal cell Antibody 108.1 Units (>24 U being positive), and Intrinsic factor Ab was low 1.0 AU/mL (Cut off is 1.1 AU/mL). She was managed with Iron supplementation, assessment for other vitamin deficiencies (B12 and folate were normal), and with yearly surveillance EGDs with mapping due to presence of intestinal metaplasia (Figure). Discussion: The endoscopic findings in Atrophic Gastritis can be very subtle. It is important that endoscopists are aware of these findings in order to better identify this illness. Additionally regimented biopsies per protocol ensure that this diagnosis is not missed. Beyond eradication of H. pylori further surveillance measures remain controversial. These should be considered on a case by case basis taking family history, region, smoking history, age, comorbidities, obesity, and alcohol consumption into consideration. More research is required to make universal screening guidelines.Figure 1.: Stomach showing atrophic folds.