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Nathaniel Alvarez

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Medical Student

Academic Level (Author 2)

Medical Student

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Medical Student

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Internal Medicine

Academic Level (Author 5)

Faculty

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Internal Medicine

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Community/Public Health

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Research/Clinical

Abstract

Background: Vitamin B12 deficiency is a common finding in older adults, which can be attributed to either malnutrition or malabsorption. Despite the commonality of Vitamin B12 deficiency, autoimmune gastritis remains an underrecognized cause of Vitamin B12 deficiency in this population. In autoimmune gastritis, direct parietal cell destruction and loss of intrinsic factor leads to chronic inflammation, which can cause gastric atrophy and intestinal metaplasia. These cellular changes may increase the risk for gastric adenocarcinoma. Recent American Gastroenterological Association (AGA) updates recommend targeted evaluation and endoscopic surveillance for atrophic gastritis or intestinal metaplasia in high-risk patients. This case highlights vitamin B12 deficiency as a clue to atrophic gastritis and reviews evolving recommendations for surveillance in the United States.

Case Presentation: This is a 60 year-old-man with no significant past medical history who presented to the emergency department with right-sided chest pain. The pain was described as sharp, did not radiate, relieved with rest, and was worsened by exertion. Upon questioning, he reported a three-month history of fever, chills, night sweats, fatigue, and 10-15 lbs of unintentional weight loss. Prior to this visit, he had been diagnosed with iron deficiency anemia in Mexico and was started on iron supplementation. He had no history of drug use, alcohol use, and quit smoking four years ago. On exam, he appeared stable with tenderness over the right chest wall and fine crackles on auscultation. Laboratory tests revealed pancytopenia: WBC 2.1x109 /L, HGB of 6.2g/dL, and platelets at 46,000/µL. Further significant findings included macrocytosis with an MCV of 108 fL and a low vitamin B12 level at 129 pg/mL (N=). A CT scan of the abdomen revealed mural thickening of the posterior gastric wall and fluid-filled small bowel loops with air-fluid levels. He was admitted for symptomatic anemia and received supportive care with intramuscular Vitamin B12 shots on a weekly basis.

At hematology follow-up, the patient reported mild fatigue and dyspnea on exertion, but denied abdominal pain, melena, or diarrhea. Repeat labs showed improved Vitamin B12 levels at 426 pg/mL, but pancytopenia (WBC 1.39x109 /L, HGB 8.1g/dL, platelets at 53,000/µL, MCV 101 fL). Peripheral smear revealed severe neutropenia with hypolobated neutrophils, macrocytic anemia, and no blasts. Autoimmune pernicious anemia remained a possibility, but given the patient's presentation, imaging, and lab reports, gastric malignancy was also considered. An esophagogastroduodenoscopy was scheduled for further evaluation.

Conclusion: Our case highlights vitamin B12 deficiency as a potential clue for atrophic gastritis, a premalignant gastric condition requiring risk assessment and surveillance rather than only Vitamin B12 supplementation alone. Updated AGA guidance supports a baseline endoscopic evaluation with biopsies in suspected autoimmune gastritis, with surveillance intervals around three years for advanced atrophy or intestinal metaplasia. Quickly recognizing and managing this condition according to guideline-based practices may improve early detection and outcomes for patients at increased cancer risk in the United States

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Vitamin B12 Deficiency as a Clue for Atrophic Gastritis: A Case Report and Review of Updated Surveillance Guidelines

Background: Vitamin B12 deficiency is a common finding in older adults, which can be attributed to either malnutrition or malabsorption. Despite the commonality of Vitamin B12 deficiency, autoimmune gastritis remains an underrecognized cause of Vitamin B12 deficiency in this population. In autoimmune gastritis, direct parietal cell destruction and loss of intrinsic factor leads to chronic inflammation, which can cause gastric atrophy and intestinal metaplasia. These cellular changes may increase the risk for gastric adenocarcinoma. Recent American Gastroenterological Association (AGA) updates recommend targeted evaluation and endoscopic surveillance for atrophic gastritis or intestinal metaplasia in high-risk patients. This case highlights vitamin B12 deficiency as a clue to atrophic gastritis and reviews evolving recommendations for surveillance in the United States.

Case Presentation: This is a 60 year-old-man with no significant past medical history who presented to the emergency department with right-sided chest pain. The pain was described as sharp, did not radiate, relieved with rest, and was worsened by exertion. Upon questioning, he reported a three-month history of fever, chills, night sweats, fatigue, and 10-15 lbs of unintentional weight loss. Prior to this visit, he had been diagnosed with iron deficiency anemia in Mexico and was started on iron supplementation. He had no history of drug use, alcohol use, and quit smoking four years ago. On exam, he appeared stable with tenderness over the right chest wall and fine crackles on auscultation. Laboratory tests revealed pancytopenia: WBC 2.1x109 /L, HGB of 6.2g/dL, and platelets at 46,000/µL. Further significant findings included macrocytosis with an MCV of 108 fL and a low vitamin B12 level at 129 pg/mL (N=). A CT scan of the abdomen revealed mural thickening of the posterior gastric wall and fluid-filled small bowel loops with air-fluid levels. He was admitted for symptomatic anemia and received supportive care with intramuscular Vitamin B12 shots on a weekly basis.

At hematology follow-up, the patient reported mild fatigue and dyspnea on exertion, but denied abdominal pain, melena, or diarrhea. Repeat labs showed improved Vitamin B12 levels at 426 pg/mL, but pancytopenia (WBC 1.39x109 /L, HGB 8.1g/dL, platelets at 53,000/µL, MCV 101 fL). Peripheral smear revealed severe neutropenia with hypolobated neutrophils, macrocytic anemia, and no blasts. Autoimmune pernicious anemia remained a possibility, but given the patient's presentation, imaging, and lab reports, gastric malignancy was also considered. An esophagogastroduodenoscopy was scheduled for further evaluation.

Conclusion: Our case highlights vitamin B12 deficiency as a potential clue for atrophic gastritis, a premalignant gastric condition requiring risk assessment and surveillance rather than only Vitamin B12 supplementation alone. Updated AGA guidance supports a baseline endoscopic evaluation with biopsies in suspected autoimmune gastritis, with surveillance intervals around three years for advanced atrophy or intestinal metaplasia. Quickly recognizing and managing this condition according to guideline-based practices may improve early detection and outcomes for patients at increased cancer risk in the United States

 

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