Screening

There are no guidelines recommending that patients with anaemia due to cobalamin or iron deficiency specifically be screened for achlorhydria.

Measurement of anti-parietal cell antibodies and gastrin-17, and the pepsinogen I to pepsinogen II ratio seem to be the most accurate tests for first-line screening of autoimmune gastropathy. Screening for anti-parietal cell antibodies alone would miss those patients who are negative for this antibody, whereas gastrin-17 levels are raised in nearly all patients with autoimmune gastropathy who have developed overt atrophy.

If the aetiology of the deficiency is unexplained, oesophagogastroduodenoscopy with biopsy of the oxyntic mucosa (fundus and corpus) could be considered to rule in or rule out atrophic gastritis as the aetiology.

Gastric atrophy and intestinal metaplasia

The American Gastroenterological Association (AGA) recommends testing for Helicobacter pylori, followed by eradication, in patients with intestinal metaplasia (IM).[67] AGA recommends against the routine use of endoscopic surveillance in patients with IM.[67]

European guidelines and The British Society of Gastroenterology recommend against surveillance endoscopy in patients with gastric atrophy or gastric IM limited to the gastric antrum (in the absence of high risk factors).[120][121]

The international Kyoto guideline recommends that patients be offered endoscopic surveillance based upon the extent and severity of atrophy.​[122]

Patients at high risk for gastric cancer

AGA and the American Society for Gastrointestinal Endoscopy recommend surveillance endoscopy for those with IM who are at high risk for gastric cancer due to their ethnic background, extensive IM, dysplastic IM, or family history of gastric cancer.[67][123]

The British Society of Gastroenterology recommends:[120]

  • Screening endoscopy for those aged over 50 years with risk factors such as male sex, a history of smoking, pernicious anaemia, or a family history of gastric cancer

  • Endoscopic surveillance for patients with:

    • gastric atrophy or IM and additional risk factors (e.g., strong family history)

    • extensive gastric atrophy or IM.

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