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. 2000 Nov;47(5):638–645. doi: 10.1136/gut.47.5.638

Heterogeneity of gastric histology and function in food cobalamin malabsorption: absence of atrophic gastritis and achlorhydria in some patients with severe malabsorption

H Cohen 1, W Weinstein 1, R Carmel 1
PMCID: PMC1728117  PMID: 11034579

Abstract

BACKGROUND—The common but incompletely understood entity of malabsorption of food bound cobalamin is generally presumed to arise from gastritis and/or achlorhydria.
AIM—To conduct a systematic comparative examination of gastric histology and function.
SUBJECTS—Nineteen volunteers, either healthy or with low cobalamin levels, were prospectively studied without prior knowledge of their absorption or gastric status.
METHODS—All subjects underwent prospective assessment of food cobalamin absorption by the egg yolk cobalamin absorption test, endoscopy, histological grading of biopsies from six gastric sites, measurement of gastric secretory function, assay for serum gastrin and antiparietal cell antibodies, and direct tests for Helicobacter pylori infection.
RESULTS—The six subjects with severe malabsorption (group I) had worse histological scores overall and lower acid and pepsin secretion than the eight subjects with normal absorption (group III) or the five subjects with mild malabsorption (group II). However, histological findings, and acid and pepsin secretion overlapped considerably between individual subjects in group I and group III. Two distinct subgroups of three subjects each emerged within group I. One subgroup (IA) had severe gastric atrophy and achlorhydria. The other subgroup (IB) had little atrophy and only mild hypochlorhydria; the gastric findings were indistinguishable from those in many subjects with normal absorption. Absorption improved in the two subjects in subgroup IB and in one subject in group II who received antibiotics, along with evidence of clearing of H pylori. None of the subjects in group IA responded to antibiotics.
CONCLUSIONS—Food cobalamin malabsorption arises in at least two different gastric settings, one of which involves neither gastric atrophy nor achlorhydria. Malabsorption can respond to antibiotics, but only in some patients. Food cobalamin malabsorption is not always synonymous with atrophic gastritis and achlorhydria, and hypochlorhydria does not always guarantee food cobalamin malabsorption.


Keywords: cobalamin; cobalamin malabsorption; atrophic gastritis; achlorhydria; pepsin; gastrin; Helicobacter pylori

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Figure 1  .

Figure 1  

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Diagrammatic representation of the gastric biopsy sites.

Figure 2  .

Figure 2  

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Low power view of a normal appearing oxyntic biopsy from the mid body greater curvature from subject No 14 in group III. Note that the pits (P) are close together (arrow), not separated as in figure 4 by inflammatory cells. The band of predominantly red staining cells below the pits is where parietal cells are concentrated. The predominantly blue staining gland zone beneath that band is where chief cells are concentrated.

Figure 3  .

Figure 3  

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Severe atrophic gastritis of the mid body greater curvature in subject No 2 in subgroup IA with severe food cobalamin malabsorption. Most of the section shows full thickness intestinal metaplasia with villi lined by enterocytes and goblet cells. The centre is lined by gastric surface epithelium and, beneath it, a small group of residual glands. The clear staining glands (thin arrow) are metaplastic mucous glands (pseudopyloric metaplasia). The blue and red cells in the centre are chief and parietal cells (thick arrow).

Figure 4  .

Figure 4  

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Mid body biopsy from subject No 6 in subgroup IB. A dense infiltrate separates the gastric pits (contrast with fig 2). There is encroachment of inflammatory cells beneath the pits into the uppermost part of the gland zone. This was graded as mild atrophic gastritis. It could be argued, however, that this is the severe end of the superficial gastritis spectrum, which would only strengthen the concept that severe malabsorption occurs in the absence of atrophy.

Figure 5  .

Figure 5  

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Biopsy from the mid body in subject No 10 from group II with mild food cobalamin malabsorption. Inflammatory cells separate the pits, similar to fig 4. A plug of oxyntic glands sits atop a lymphoid aggregate. To the left is pink staining oedema fluid.

Selected References

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