Megaloblastic anemia in GI deseases

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Megaloblastic anemia inGI deseases

• Dr Elias MAKHOUL
• Head of Gastro-Enterology department
• H.N.D.Secours Jbeil

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Megaloblastic anemia

• Characterized by large, immature, nucleated
  erythrocytes
• Second most common type of anemia.
• Vitamin B12/Folic acid deficiency
• Pernicious anaemia Biermer
• autoimmune, Gastric atrophy, VitB12 def.

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MEGALOBLASTIC ANEMIA Causes of Vit.B12
deficiency(1)

• 1-Malabsorption
• a) Inadequate production of intrinsic factor
• - pernicious anemia
• - gastrectomy, partial or total
• - Atrophy of gastric mucosa and glands
• b) Inadequate releasing vit. B12 from food
• (partial gastrectomy, abnormality of
  stomach function,
• chronic pancreatic insufficiency)
• c) Terminal ileum disease (sprue, celiac
  disease, ilea resection, Crohn disease,
  Imerslund syndrome)
• d) Competition for intestinal B12
• - bacterial overgrowth jejunal diverticula,
  intestinal stasis and obstruction due to
  strictures.

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MEGALOBLASTIC ANEMIA Causes of Vit.B12
deficiency(1)

• 2. Inadequate intake
• - vegetarians
• 3. Inadequate utylisation
• Drugs PAS, Neomycin, Colchicin, Nitrous oxide

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MEGALOBLASTIC ANEMIAS- Causes of Folic acid
deficiency

• 1. Inadequate intake
• - diet lacking fresh, slightly cook food
  chronic alcoholism, total parenteral nutrition,
• 2. Malabsorption
• - small bowel disease (sprue, celiac disease,)
• - alcoholism
• 3. Increased requirements
• - pregnancy and lactation
• - infancy
• - chronic hemolysis
• - hemodialysis
• 4. Defective utilisation
• Drugsfolate antagonists(methotrexate,
  trimethoprim, triamteren), purine analogs
  (azathioprine), primidine analogs (zidovudine),
  RNA reductase inhibitor (hydroxyurea),
  miscellaneous (phenytoin, N2)

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2.  Maladie de Biermer

•  Mecanisme
• Rarely before 40 years gt 60-70 years.
• Carence in vitamin B12, due to a deficit on
  IF
• Auto-immune pathology, with parietals cells
  and IF anti- body.
• Association with others immunologic
  pathologies thyroïdites, diabetes, vitiligo.

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CLINICS

• Clinics
• Anemic syndrome with variable severity
• Patient pale
• Middle jaundice
• Neurological symptom
• Myelite gt spasmodic paraplegia.
• Pyramidal and posterior cordonal lesions.
• Digestive symptom
• Due to causal affections
• Gastro-intestinal resection
• Glossites
• Dyspepsia
• Diarrhea

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Pre neoplastic conditions

• Biermer
• Atrophic gastritis
• Intestinal metaplasia
• H pylori

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MEGALOBLASTIC ANEMIAGastric cancer

• 1th suggestion by autopsies of patient MA
• 10 of AM? gastric cancer
• Multiple studies demonstrate 1-12 risk of
  cancer
• Hoffman48 patients for 11 years?0 cancer
• Boch123 patient?8.1
• Retrospective study 5161 patients?3.2
• Rq - the risk is well known
• - small risk
• - suggestion the existence of
  pre cancer stage

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MEGALOBLASTIC ANEMIAIntestinal metaplasia

• IM_at_ CAG is a risk factor to develop gastric
  cancer
• Gastric cancer is often associated with
• Diffuse atrophic gastric
• IM
• In chronic atrophic gastritis
• Decrease of normal gastric glands
• Replacement by intestinal metaplasia

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MEGALOBLASTIC ANEMIAIntestinal metaplasia

• Different types of IM
• Type I
• Complete
• (small bowel mucosa)
• Type II
• Incomplete
• Colic mucosa
• a non acid sulfate mucine
• b acide sulfate mucine
• Suggestion
• Generally IM it is not a risk
• Type II b predispose to cancer

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MEGALOBLASTIC ANEMIAHelicobacter-Pylori

• HP play an important role in the developement of
• Chronic gastritis
• Atrophic gastritis
• Intestinal metaplasia
• The intestinale métaplasieis higher in patient
  infected with H. pylori
• The relatif risk to develop cancer with the
  presence of hp
• X4 in atrophic gastritis
• X 5 insuperficiel gastric cancer
• the irradication of hp is important to
  prevent gastric cancer

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MEGALOBLASTIC ANEMIAHelicobacter-Pylori

• !!!! H pylori is usually not found in IM
• 24 patients with 15 patients
• CAG IM normal patients
  dyspepsia
• Detection of Hp
• Histology
• Breath test
• Urease
• Serology
• Non correlation a good correlation
• To prevent false _ in histology
• We have to do others exam
• Copelman and all Gastroenterology 2005

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MEGALOBLASTIC ANEMIA Diagnosis

• Diagnosis megaloblastic anemia
• 2. Establishing a type of deficiency (vit. B12
  and/or folic acid)
• 3. Establishing a cause of deficiency

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MEGALOBLASTIC ANEMIADiagnosis

• 1/ Hemogram
• Anémie macrocytaire (gt 100)
• Rerticulocytes
• Low reticulocites ? ageneratif
• 2/ Myelogram
• megaloblastes
• 3/ Complementary exam
• 4/ Fibroscopy
• 5/ Test de Schilling

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MEGALOBLASTIC ANEMIADiagnosis

• 3/ Complementary exam
• Vit B12 / Folic acid
• Gastrine
• High
• Biermer
• Zollinger Eddison
• Stimulation Pentagastrin test
• Absence of hydrogen ion secretion (achlorhydria)
  with maximal histamine stimulation
• Intrinsic factor, parietal cell and IF-vit.B12
  complex antibodies
• Others anti. Body
• Thyroid

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MEGALOBLASTIC ANEMIA Diagnosis

• SCHILLING TEST
• Deficit absorption of vit B12
• Deficit of IF
• Radiolabeled Vit b12 cobalt 159 absorption
  test (Schilling urinary excretion test) very
  reduced absorption of the B12-isotope,
• 2 groups
• Respond to oral FI
• Not respond

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MEGALOBLASTIC ANEMIADiagnosis

• Endoscopy
• Depistage
• Pre- neoplastic lesions
• Atrophic gastritis
• Intestinal metaplasia
• Biopsies
• To confirm diagnosis
• H Pylori
• Lower endoscopy or Radiology
• If absence of atrophic lesions

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Conclusions

• Megaloblastic anemia is well known
• The risk of gastric cancer is etablished
• But!!!!!!!!!!!

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THE QUESTIONS

• ?
• Frequence of endoscopie?
• Nombre of biopsies?

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Conclusions

• Preconise
• If atrophic gastritis endoscopy every 2 years
• Biopsies
• multiples
• Antral, fundus, corps
• If H pylori breath test
• If intestinal metaplasia
• Type I and II a atrophic gastritis
• Type II b Endoscopy every year