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Geriatr Gerontol Int 2016; 16: 686–692
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Factors related to low serum vitamin B12 levels in elderly patients with non-atrophic gastritis in contrast to patients with normal vitamin B12 levels Çag˘das¸ Kalkan,1 Fatih Karakaya,1 Ali Tüzün,1 Zeynep Bıyıklı Gençtürk2 and Irfan Soykan1 Departments of 1Gastroenterology and 2Biostatistics, Ibni Sina Hospital, Ankara University Faculty of Medicine, Ankara, Turkey
Aim: Vitamin B12 deficiency is frequent in older patients, and the main reason is pernicious anemia. However, vitamin B12 deficiency can occur in patients who do not have atrophic gastritis. The aim of the present study was to investigate factors affecting serum vitamin B12 levels in older patients with non-atrophic gastritis. Methods: A total of 1256 out of 1607 patients aged over 60 years who had undergone upper gastrointestinal endoscopy for various reasons, and who had serum vitamin B12 value and were diagnosed as having “non-atrophic gastritis” were analyzed by means of factors affecting low serum vitamin B12 levels. Results: Non-atrophic gastritis patients were divided into two groups: patients with normal serum vitamin B12 (group I, n = 759) and patients with low serum vitamin B12 (group II, n = 497). The median serum vitamin B12 was 339 pg/mL (range 201–987 pg/mL) in group I and 180 pg/mL (range 50–200 pg/mL) in group II. Helicobacter pylori (n = 154 vs 325, P < 0.001), neutrophil activity (n = 176 vs 367, P < 0.001), intestinal metaplasia (n = 35 vs 14, P < 0.001) and inflammation (n = 230 vs 386, P < 0.001) were present significantly more often in group II compared with group I. A total of 785 patients were both negative for Helicobacter pylori and atrophy. Of these 785 patients, neutrophil activity (n = 56, [32.6%] vs 25, [4.4%], P < 0.001) and inflammation (n = 69, [40.1%] vs 82, [13.4%], P < 0.001) scores were present significantly more often in group II compared with group I. Conclusions: Helicobacter pylori was present significantly more often in older patients whose serum vitamin B12 levels were ≤200 pg/mL, and Helicobacter pylori density was inversely correlated with serum B12 level. Upper gastrointestinal endoscopic examination should be suggested for elderly patients with serum vitamin B12 level ≤200 pg/mL. Geriatr Gerontol Int 2016; 16: 686–692. Keywords: Helicobacter pylori, inflammation, intestinal metaplasia, neutrophil activity, mean platelet volume, vitamin B12.
Introduction Vitamin B12 is a water-soluble vitamin, and plays an important role in DNA synthesis and neurological function. Deficiency can lead to a wide spectrum of neuropsychiatric and hematological disorders that can often be reversed by early diagnosis and timely treatment.1 The true prevalence of vitamin B12 deficiency is difficult to predict in the general population, as underdiagnosis and subclinical disease is considered. However, the incidence seems to increase with age, and it has been Accepted for publication 17 April 2015. Correspondence: Professor Irfan Soykan MD, Gastroenterology, Ankara University Medical School, Sihhiye, 06100 Ankara, Turkey. Email: [email protected]
686 |
doi: 10.1111/ggi.12537
reported that 15% of adults older than 65 years had laboratory evidence of vitamin B12 deficiency.2 Causes of vitamin B12 deficiency can be divided into three main groups: nutritional deficiency, malabsorption syndromes and other gastrointestinal causes. Vitamin B12 deficiency rarely occurs as a result of inadequate intake; however, nutritional deficiency can occur in specific populations, such as elderly patients with insufficient diets, and chronic alcoholics are at especially high risk and it can be seen in strict vegans.3 Vitamin B12 deficiency is usually associated with inadequate absorption, such as pernicious anemia or secondary to gastric diseases. Other common causes of vitamin B12 deficiency are malabsorption syndromes, ileal disease/resection or by-pass, blind loop syndrome, infection with Diphyllobothrium latum or intestinal bacterial overgrowth.4 Agents, such as neomycin, biguanides and nitric oxide © 2015 Japan Geriatrics Society
Vitamin B12 in non-atrophic gastritis
anesthetics that block or inhibit vitamin B12 absorption, could also cause deficiency of this vitamin. A very common cause of vitamin B12 deficiency is the widespread use of acid blocking agents, such as proton pump inhibitors and histamine2 receptor antagonists, especially in the elderly population.3 An acidic environment is mandatory in the stomach for vitamin B12 to be released from food protein. The incidence of atrophic gastritis increases with age and is associated with hypochlorhydria. Vitamin B12 deficiency is especially common in older adults, and is more likely because of the high incidence of atrophic gastritis and achlorhydriainduced food-cobalamin malabsorption,5 and many patients with clinically overt vitamin B12 deficiency have pernicious anemia.6 Pernicious anemia is associated with intrinsic factor antibodies or antiparietal cell antibodies, and onset is often after age 60 years, but might be earlier in African Americans and Hispanic women.7 However, there are some reports showing that foodcobalamin malabsorption arises from at least two different gastric conditions; one of which involves neither gastric atrophy, nor achlorhydria. Cohen et al. showed that severe food-cobalamin malabsorption can occur in patients who do not have atrophic gastritis of the oxythintic mucosa or achlorhydria.8 Serin et al. also reported that age was an independent risk factor for vitamin B12 deficiency irrespective of gastric atrophy.9 In a recent study from Turkey, it was reported that vitamin B12 deficiency was found in 62.2% (n = 395), 72.2% (n = 130), and 50% (n = 5) in the 60–74, 75–84 and >85 years-of-age groups, respectively.10 In view of that study and data from the World Health Organization showing that the number of individuals aged 60 years or older was equivalent to 600 million individuals in the year 2000, it is estimated that this number will be double by 2025 and triple by 2050. In this context, elucidation of health problems common among older individuals is becoming important and, vitamin B12, deficiency is frequent in elderly patients, but it is often unrecognized or not investigated because the clinical manifestations are subtle.11 Therefore, the results of these studies have led us to investigate factors affecting serum vitamin B12 levels in elderly patients with non-atrophic gastritis with a special emphasis on Helicobacter pylori-negative nonatrophic gastritis patients.
Materials and methods In the present study, patients who had undergone upper gastrointestinal endoscopy for various reasons, and who had a low serum vitamin B12 value and histological examination of gastric biopsy specimens were analyzed. All data including history of drug or alcohol intake, clinical status, relevant biochemical data, evidence of H. pylori infection, and histological examination of © 2015 Japan Geriatrics Society
gastric biopsy specimens were obtained retrospectively from medical records. Mean platelet volume (MPV; fl), and platelet and lymphocyte counts (×109/L) were extracted from medical records. The platelet-tolymphocyte ratio (PLR) was calculated using the results of these parameters. For the purpose of the present study, we defined “elderly” patients as aged older than 60 years.12 Cobalamin deficiency was defined according to the criteria of Snow and Klee: a serum cobalamin level less than 200 pg/mL was accepted as a vitamin B12 deficiency.13,14 Histological examination of biopsy specimens was evaluated for chronic inflammation (based on lymphocyte and plasma cell infiltration of the lamina propria), neutrophil activity, atrophy, and H. pylori density and intestinal metaplasia were scored by using the updated Sydney classification and assessed in a semiquantitative scale, as follows: 0 = none, l = mild, 2 = moderate and 3 = marked.15 Patients were accepted as having non-atrophic gastritis if their atrophy score was zero. Patients with non-atrophic gastritis were stratified into two groups: group I, serum vitamin B12 levels were in the normal range (>200 pg/mL); and group II, patients with low (≤200 pg/mL) serum vitamin B12 levels. These two groups were compared by means of possible factors that might affect serum vitamin B12 level, such as age, sex, H. pylori, activity, inflammation and metaplasia. As the main determinants of vitamin B12 deficiency are atrophic corpus gastritis and ongoing H. pylori infection in elderly patients, a third group was also created from patients in whom both H. pylori and atrophy scores were negative in order to identify factors other than H. pylori and gastric atrophy that might affect serum vitamin B12 levels.16 Other parameters analyzed included simple inflammation markers, such as mean platelet volume and PLR, that might be helpful in predicting serum vitamin B12 levels. Patients who had a previous history of gastrointestinal tract surgery; organic and metabolic diseases, such as diabetes mellitus, chronic liver diseases, renal failure, inflammatory bowel diseases and autoimmune gastritis; known vegetarians; and intake of antibiotics, proton pump inhibitors, H2 receptor blockers or nonsteroidal anti-inflammatory drugs for two months before the study were excluded from the study. The present study was approved by the institutional review board of Ankara University Faculty of Medicine (Decision date: 24 December 2014, no: 21-890-14), and this study conformed to the provisions of the Declaration of Helsinki.
Statistics Statistical analysis was carried out with SPSS 16.0 (SPSS, Chicago, IL, USA) for Windows. The Shapiro–Wilk test was used to test of normality. According to the results, | 687
Ç Kalkan et al.
Table 1 Demographic characteristics, laboratory and histological parameters of patients with non-atrophic gastritis (n = 1256) according to the serum vitamin B12 levels
Age, years (range) Sex (female/male) Vitamin B12 (pg/mL) MPV, fl (range) PLT/L Hp+ Activity+ Inflammation+ Metaplasia+
Group I, n = 759 (B12 >200)
Group II, n = 497 (B12 < 200)
67 (60–97) 499/260 339 (201–987) 8.7 (5.7–14.1) 124.64 (18.4–602) 154 (20.3%) 176 (23.2%) 230 (30.3%) 14 (1.8%)
67 (60–92) 287/210 180 (50–200) 8.55 (5.8–13.1) 122.35 (11.02–872.86) 325 (65.4%) 367 (73.8%) 386 (77.7%) 35 (7%)
P 0.707 0.004 0.034 0.825 200 pg/mL (n = 69, [40.1%] vs 82, [13.4%], P < 0.001). The relationship between H. pylori density and neutrophil activity was also investigated in the present study. When H. pylori density was absent, 89.6% of patients were negative for neutrophil activity. However, when H. pylori density was 1, 2 and 3, 99.4%, 99.2% and 100% of patients had a varying degree of neutrophil activity, respectively (P < 0.001, kappa = 0.76; Fig. 3). We also investigated some simple systemic inflammatory response markers, such as PLR and mean platelet volume in peripheral blood of patients, to discover whether these biomarkers have a role in the differentiation of patients with low and normal serum vitamin B12 levels. As for MPV, there were significant differences between groups I and II, showing that MPV was significantly higher in group I compared with group II (8.7 fl [5.7–14.1] vs 8.55 [5.8–13.1], P = 0.034). receiver operating characteristic curve analysis suggested that the optimum MPV cut-off point was 8.05 fl with a specificity and sensitivity of 0.75 and 0.30, respectively (Fig. 4). However, there was no statistically significant difference between groups I and II by means of PLR (124.64 [18.4– 602] vs 122.35, P = 0.825).11–29
Discussion The present retrospective study showed the various factors that might affect serum vitamin B12 level in a group of unselected elderly patients. According to the results of this study, ongoing H. pylori infection was | 689
Ç Kalkan et al.
Figure 4 Receiver operating characteristic (ROC) curve analysis of mean platelet volume for the identification of low and normal serum vitamin B12 levels. ROC analysis suggested that the optimum mean platelet volume cut-off point was 8.05 fl, with a specificity and sensitivity of 0.75 and 0.30, respectively.
significantly more prevalent in patients whose serum vitamin B12 levels were ≤200 pg/mL than in patients with serum vitamin B12 levels >200 pg/mL (n = 325 vs 154, P < 0.001). Kaptan et al. investigated the H. pylori incidence in patients with vitamin B12 deficiency prospectively, and assessed whether treatment for H. pylori infection could correct this deficiency in a group of patients with anemia and vitamin B12 deficiency.17 H. pylori was detected in 77 (56%) of 138 patients with vitamin B12 deficiency, and eradication of H. pylori infection successfully improved anemia and serum vitamin B12 levels in 31 (40%) of 77 infected patients. They concluded that H. pylori could be a causative agent in the development of adult vitamin B12 deficiency, and suggested that eradication of H. pylori infection alone might correct vitamin B12 levels and improve anemia. In a similar study, Sarari et al. investigated the possible association between H. pylori infection and vitamin B12 deficiency in 60 patients suffering from gastric disease as a result of H. pylori infection.18 They found H. pylori in 71.7% (43/60) of the patients investigated. The level of vitamin B12 was lower than 200 pg/mL in 67.4% (29/43) of patients who tested positive for H. pylori, and they concluded that H. pylori appears to be implicated in causing vitamin B12 deficiency. We also tested whether H. pylori density affects serum vitamin B12 levels in elderly patients with non-atrophic gastritis. We found 690 |
that as the density of H. pylori infection increased, the serum vitamin B12 level decreased; H. pylori density is inversely correlated with serum B12 level. When patients were evaluated by means of neutrophil activity, inflammation and intestinal metaplasia, all these parameters were inversely correlated with serum vitamin B12 level irrespective of histological score. Serin et al. investigated the impact of H. pylori infection on the development of vitamin B12 deficiency in 145 patients with non-atrophic gastritis.9 They found that the histopathological scores for H. pylori density, inflammation and neutrophil activity were all inversely correlated with serum vitamin B12 level, and only H. pylori density was significantly correlated with serum B12 level, and concluded that either H. pylori itself or the effects of inflammation caused by the bacterium somehow caused food-cobalamin malabsorption in their patients. In order to find an answer to this question, we selected H. pylori-negative patients with non-atrophic gastritis. What we found was, both neutrophil activity and inflammation were significantly more prevalent in patients whose serum vitamin B12 levels were ≤200 pg/mL than in patients whose serum vitamin B12 levels were >200 pg/mL. In this context, although we do not know whether H. pylori-negative patients received prior anti-H. pylori therapy, it can be speculated that inflammation of the gastric mucosa could reduce acid secretion by several mechanisms, such as decreased gastrin response to reduced acid levels and blockage of parietal cell function by certain cytokines.19 In another study, Gümürdülü et al. studied 310 patients with non-atrophic gastritis by means of chronic inflammation, neutrophil activity and H. pylori load as variables that might affect serum vitamin B12 level.20 They found that patient age and all three histological parameters were inversely related to vitamin B12 levels, and factors independently associated with serum vitamin B12 deficiency were age and antral H. pylori load, and concluded that the higher frequency of vitamin B12 deficiency might be a reflection of the effect of H. pylori infection on serum vitamin B12 level, and age was shown to be an independent risk factor for vitamin B12 deficiency irrespective of gastric atrophy. It has been reported that some simple systemic inflammatory response markers, such as PLR in peripheral blood, might have diagnostic importance in some clinical conditions. In some malignant conditions, endogenous anticancer pre-inflammatory and precoagulative response arise, and the PLR is used as a marker in order to evaluate this response. In malignant diseases, such as breast cancer, ovarian and colorectal cancers, PLR is assumed as a sensitive marker for prognostic evaluation.21 In clinical practice, there are some easily measurable parameters in complete blood count, such as MPV, and MPV projects the average size of platelets and platelet production rate.22 There is abundant evidence that MPV levels increase in malignant, © 2015 Japan Geriatrics Society
Vitamin B12 in non-atrophic gastritis
inflammatory and infectious conditions, such as gastric carcinoma, celiac disease and ulcerative colitis.23–25 Mean platelet volume levels were found to be lower in high-grade inflammatory conditions, such as acute attack of familial Mediterranean fever and active rheumatoid arthritis.26,27 In the present study, there were significant differences between patients with serum vitamin B12 levels in normal range (>200 pg/mL) compared with patients with low (≤200 pg/mL) serum vitamin B12 levels, showing that MPV was significantly higher in the vitamin B12 level normal group. Although MPV had limited specificity (0.75) and sensitivity (0.30), receiver operating characteristic curve analysis suggested that the optimum MPV cut-off point was 8.05 fl and can be used in clinical practice in order to discriminate between these two groups of patients. However, there were no statistically significant differences between groups I and II by means of PLR. As for the relationship between H. pylori density and neutrophil activity, there was a close relationship between H. pylori density and neutrophil activity (P < 0.001, kappa = 0.76). As the H. pylori density increases, neutrophil activity increases as well. The association between H. pylori density and neutrophil activity could be related to malabsorption of vitamin B12. However, there was no relationship between H. pylori density and PLR and MPV. In the current study, the optimum serum vitamin B12 cut-off value was found to be 207 pg/mL in order to carry out upper gastrointestinal endoscopy with a specificity and sensitivity of 0.73 and 0.70 respectively. A serum vitamin B12 level ≤200 pg/mL is highly sensitive (97%) for the diagnosis of vitamin B12 deficiency.28 The British Society for Standards in Haematology has developed guidelines and recommended that a serum vitamin B12 cut-off value of 200 pg/mL should be used as vitamin B12 deficiency.29 In the present study, there were several potential limitations due to the retrospective nature of the study. First, we had limited data regarding the previous H. pylori eradication therapies of all patients, especially in the evaluation of H. pylori-negative patients with non-atrophic gastritis. These results created difficulty in drawing a conclusion as to whether they had ever been infected by H. pylori or not. In conclusion, the findings from the present study provide strong evidence that H. pylori infection was significantly more prevalent in elderly patients whose serum vitamin B12 levels were ≤200 pg/mL, and H. pylori density is inversely correlated with serum B12 level in elderly patients. The present study also shows that chronic non-atrophic corpus gastritis is a significant cause of vitamin B12 deficiency in elderly subjects. Considering these issues, it is reasonable to screen all elderly patients with low serum vitamin B12 by means of H. pylori gastritis; however, there are still some patients with H. pylori negative non-atrophic gastritis with some © 2015 Japan Geriatrics Society
degree of inflammation and activity that might be caused by some other agents. Based on findings from the present study and in accordance with current guidelines, we suggest upper gastrointestinal endoscopic examination for elderly patients with a serum vitamin B12 level ≤200 pg/mL. Another finding was that neutrophil activity, inflammation and intestinal metaplasia were inversely correlated with serum vitamin B12 level irrespective of histological score. Simple systemic inflammatory response markers, such as MPV, might be beneficial in clinical practice in the differentiation of patients with low or normal serum vitamin B12 levels.
Disclosure statement No potential conflicts of interest were disclosed.
References 1 Carmel R. Current concepts in cobalamin deficiency. Annu Rev Med 2000; 51: 357–375. 2 Pennypacker LC, Allen RH, Kelly JP et al. High prevalence of cobalamin deficiency in elderly outpatients. J Am Geriatr Soc 1992; 40: 1197–1204. 3 Oh RC, Brown DL. Vitamin B12 deficiency. Am Fam Physician 2003; 67: 979–986. 4 Jennifer Brescoll J, Daveluy S. A review of vitamin B12 in dermatology. Am J Clin Dermatol 2015; 16: 27–33. 5 Andres E, Affenberger S, Vinzio S et al. Food-cobalamin malabsorption in elderly patients: clinical manifestations and treatment. Am J Med 2005; 118: 1154–1159. 6 Toh B-H. Pernicious anemia. NEJM 1997; 337: 1441– 1448. 7 Kumar N. Neurologic aspects of cobalamin (B12) deficiency. Handb Clin Neurol 2014; 120: 915–926. 8 Cohen H, Weinstein WM, Carmel R. Heterogeneity of gastric histology and function in food cobalamin malabsorption: absence of atrophic gastritis and achlorhydria in some patients with severe malabsorption. Gut 2000; 47: 638–645. 9 Serin E, Gümürdülü Y, Özer B, Kayaselçuk F, Yılmaz U, Koçak R. Impact of Helicobacter pylori on the development of vitamin B12 deficiency in the absence of gastric atrophy. Helicobacter 2002; 7: 337–341. 10 Yildirim T, Yalçın A, Atmis V et al. The prevalence of anemia, iron, vitamin B12, and folic acid deficiencies in community dwelling elderly in Ankara, Turkey. Arch Gerontol Geriatr 2015; 60: 344–348. doi: 10.1016/ j.archger.2015.01.001. 11 Matthews JH. Cobalamin and folate deficiency in the elderly. Baillieres Clin Haematol 1995; 54: 245–253. 12 Abraham NS, Hartman C, Richardson P, Castillo D, Street RL, Naik AD. Risk of lower and upper gastrointestinal bleeding, transfusions, and hospitalizations with complex antithrombotic therapy in elderly patients. Circulation 2013; 128: 1869–1877. 13 Snow C. Laboratory diagnosis of vitamin B12 and folate deficiency. A guide for the primary care physician. Arch Intern Med 1999; 159: 1289–1298. 14 Klee GG. Cobalamin and folate evaluation: measurements of methylmalonic acid and homocysteine vs vitamin B12 and folate. Clin Chem 2000; 46: 1277–1283.
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15 Dixon MF, Genta RM, Yardley JH et al. Classification and grading of gastritis. The updated Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994. Am J Surg Pathol 1996; 20: 1161– 1181. 16 Sipponen P, Laxen F, Huotari K, Harkonen M. Prevalence of low vitamin B12 and high homocysteine in serum in an elderly male population: association with atrophic gastritis and Helicobacter pylori infection. Scand J Gastroenterol 2003; 38: 1209–1216. 17 Kaptan K, Beyan C, Ural AU et al. Helicobacter pylori – is it a novel causative agent in vitamin B12 deficiency? Arch Intern Med 2000; 160: 1349–1353. 18 Sarari AS, Farraj MA, Hamoudi W, Essawi TA. Helicobacter pylori, a causative agent of vitamin B12 deficiency. J Infect Dev Ctries 2008; 2: 346–349. 19 Kuipers EJ, Klinkenberg EC. Helicobacter pylori, acid, and omeprazole revisited: bacterial eradication and rebound hypersecretion. Gastroenterology 1999; 116: 479–483. 20 Gümürdülü Y, Serin E, Ozer B et al. Predictors of vitamin B12 deficiency: age and Helicobacter pylori load of antral mucosa. Turk J Gastroenterol 2003; 14: 44–49. 21 Proctor MJ, Morrison DS, Talwar D et al. A comparison of inflammation-based prognostic scores in patients with cancer. A Glasgow Inflammation Outcome Study. Eur J Cancer 2011; 47: 2633–2641.
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22 Ifran A, Hasimi A, Kaptan K et al. Evaluation of platelet parameters in healthy apheresis donors using the ADVIA 120. Transfus Apher Sci 2005; 33: 87–90. 23 Purnak T, Efe C, Yuksel O et al. Mean platelet volume could be a promising biomarker to monitor dietary compliance in celiac disease. Ups J Med Sci 2011; 116: 208–211. 24 Yüksel O, Helvaci K, Basar O et al. An overlooked indicator of disease activity in ulcerative colitis: mean platelet volume. Platelets 2009; 20: 277–281. 25 Kilincalp S, Ekiz F, Basar O et al. Mean platelet volume could be possible biomarker in early diagnosis and monitoring of gastric cancer. Platelets 2014; 25: 592–594. 26 Gasparyan AY, Ayvazyan L, Mikhailidis DP et al. Mean platelet volume: a link between thrombosis and inflammation? Curr Pharm Des 2011; 17: 47–58. 27 Ulasli SS, Ozyurek BA, Yilmaz EB et al. Mean platelet volume as an inflammatory marker in acute exacerbation of chronic obstructive pulmonary disease. Pol Arch Med Wewn 2012; 122: 284–290. 28 Carmel R, Sarrai M. Diagnosis and management of clinical and subclinical cobalamin deficiency: advances and controversies. Curr Hematol Rep 2006; 5: 23–33. 29 Devalia V, Hamilton MS, Molloy AM, The British Committee for Standards in Haematology. Guidelines for the diagnosis and treatment of cobalamin and folate disorders. Br J Haematol 2014; 166: 496–513.
© 2015 Japan Geriatrics Society
Geriatr Gerontol Int 2016; 16: 686–692
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Factors related to low serum vitamin B12 levels in elderly patients with non-atrophic gastritis in contrast to patients with normal vitamin B12 levels Çag˘das¸ Kalkan,1 Fatih Karakaya,1 Ali Tüzün,1 Zeynep Bıyıklı Gençtürk2 and Irfan Soykan1 Departments of 1Gastroenterology and 2Biostatistics, Ibni Sina Hospital, Ankara University Faculty of Medicine, Ankara, Turkey
Aim: Vitamin B12 deficiency is frequent in older patients, and the main reason is pernicious anemia. However, vitamin B12 deficiency can occur in patients who do not have atrophic gastritis. The aim of the present study was to investigate factors affecting serum vitamin B12 levels in older patients with non-atrophic gastritis. Methods: A total of 1256 out of 1607 patients aged over 60 years who had undergone upper gastrointestinal endoscopy for various reasons, and who had serum vitamin B12 value and were diagnosed as having “non-atrophic gastritis” were analyzed by means of factors affecting low serum vitamin B12 levels. Results: Non-atrophic gastritis patients were divided into two groups: patients with normal serum vitamin B12 (group I, n = 759) and patients with low serum vitamin B12 (group II, n = 497). The median serum vitamin B12 was 339 pg/mL (range 201–987 pg/mL) in group I and 180 pg/mL (range 50–200 pg/mL) in group II. Helicobacter pylori (n = 154 vs 325, P < 0.001), neutrophil activity (n = 176 vs 367, P < 0.001), intestinal metaplasia (n = 35 vs 14, P < 0.001) and inflammation (n = 230 vs 386, P < 0.001) were present significantly more often in group II compared with group I. A total of 785 patients were both negative for Helicobacter pylori and atrophy. Of these 785 patients, neutrophil activity (n = 56, [32.6%] vs 25, [4.4%], P < 0.001) and inflammation (n = 69, [40.1%] vs 82, [13.4%], P < 0.001) scores were present significantly more often in group II compared with group I. Conclusions: Helicobacter pylori was present significantly more often in older patients whose serum vitamin B12 levels were ≤200 pg/mL, and Helicobacter pylori density was inversely correlated with serum B12 level. Upper gastrointestinal endoscopic examination should be suggested for elderly patients with serum vitamin B12 level ≤200 pg/mL. Geriatr Gerontol Int 2016; 16: 686–692. Keywords: Helicobacter pylori, inflammation, intestinal metaplasia, neutrophil activity, mean platelet volume, vitamin B12.
Introduction Vitamin B12 is a water-soluble vitamin, and plays an important role in DNA synthesis and neurological function. Deficiency can lead to a wide spectrum of neuropsychiatric and hematological disorders that can often be reversed by early diagnosis and timely treatment.1 The true prevalence of vitamin B12 deficiency is difficult to predict in the general population, as underdiagnosis and subclinical disease is considered. However, the incidence seems to increase with age, and it has been Accepted for publication 17 April 2015. Correspondence: Professor Irfan Soykan MD, Gastroenterology, Ankara University Medical School, Sihhiye, 06100 Ankara, Turkey. Email: [email protected]
686 |
doi: 10.1111/ggi.12537
reported that 15% of adults older than 65 years had laboratory evidence of vitamin B12 deficiency.2 Causes of vitamin B12 deficiency can be divided into three main groups: nutritional deficiency, malabsorption syndromes and other gastrointestinal causes. Vitamin B12 deficiency rarely occurs as a result of inadequate intake; however, nutritional deficiency can occur in specific populations, such as elderly patients with insufficient diets, and chronic alcoholics are at especially high risk and it can be seen in strict vegans.3 Vitamin B12 deficiency is usually associated with inadequate absorption, such as pernicious anemia or secondary to gastric diseases. Other common causes of vitamin B12 deficiency are malabsorption syndromes, ileal disease/resection or by-pass, blind loop syndrome, infection with Diphyllobothrium latum or intestinal bacterial overgrowth.4 Agents, such as neomycin, biguanides and nitric oxide © 2015 Japan Geriatrics Society
Vitamin B12 in non-atrophic gastritis
anesthetics that block or inhibit vitamin B12 absorption, could also cause deficiency of this vitamin. A very common cause of vitamin B12 deficiency is the widespread use of acid blocking agents, such as proton pump inhibitors and histamine2 receptor antagonists, especially in the elderly population.3 An acidic environment is mandatory in the stomach for vitamin B12 to be released from food protein. The incidence of atrophic gastritis increases with age and is associated with hypochlorhydria. Vitamin B12 deficiency is especially common in older adults, and is more likely because of the high incidence of atrophic gastritis and achlorhydriainduced food-cobalamin malabsorption,5 and many patients with clinically overt vitamin B12 deficiency have pernicious anemia.6 Pernicious anemia is associated with intrinsic factor antibodies or antiparietal cell antibodies, and onset is often after age 60 years, but might be earlier in African Americans and Hispanic women.7 However, there are some reports showing that foodcobalamin malabsorption arises from at least two different gastric conditions; one of which involves neither gastric atrophy, nor achlorhydria. Cohen et al. showed that severe food-cobalamin malabsorption can occur in patients who do not have atrophic gastritis of the oxythintic mucosa or achlorhydria.8 Serin et al. also reported that age was an independent risk factor for vitamin B12 deficiency irrespective of gastric atrophy.9 In a recent study from Turkey, it was reported that vitamin B12 deficiency was found in 62.2% (n = 395), 72.2% (n = 130), and 50% (n = 5) in the 60–74, 75–84 and >85 years-of-age groups, respectively.10 In view of that study and data from the World Health Organization showing that the number of individuals aged 60 years or older was equivalent to 600 million individuals in the year 2000, it is estimated that this number will be double by 2025 and triple by 2050. In this context, elucidation of health problems common among older individuals is becoming important and, vitamin B12, deficiency is frequent in elderly patients, but it is often unrecognized or not investigated because the clinical manifestations are subtle.11 Therefore, the results of these studies have led us to investigate factors affecting serum vitamin B12 levels in elderly patients with non-atrophic gastritis with a special emphasis on Helicobacter pylori-negative nonatrophic gastritis patients.
Materials and methods In the present study, patients who had undergone upper gastrointestinal endoscopy for various reasons, and who had a low serum vitamin B12 value and histological examination of gastric biopsy specimens were analyzed. All data including history of drug or alcohol intake, clinical status, relevant biochemical data, evidence of H. pylori infection, and histological examination of © 2015 Japan Geriatrics Society
gastric biopsy specimens were obtained retrospectively from medical records. Mean platelet volume (MPV; fl), and platelet and lymphocyte counts (×109/L) were extracted from medical records. The platelet-tolymphocyte ratio (PLR) was calculated using the results of these parameters. For the purpose of the present study, we defined “elderly” patients as aged older than 60 years.12 Cobalamin deficiency was defined according to the criteria of Snow and Klee: a serum cobalamin level less than 200 pg/mL was accepted as a vitamin B12 deficiency.13,14 Histological examination of biopsy specimens was evaluated for chronic inflammation (based on lymphocyte and plasma cell infiltration of the lamina propria), neutrophil activity, atrophy, and H. pylori density and intestinal metaplasia were scored by using the updated Sydney classification and assessed in a semiquantitative scale, as follows: 0 = none, l = mild, 2 = moderate and 3 = marked.15 Patients were accepted as having non-atrophic gastritis if their atrophy score was zero. Patients with non-atrophic gastritis were stratified into two groups: group I, serum vitamin B12 levels were in the normal range (>200 pg/mL); and group II, patients with low (≤200 pg/mL) serum vitamin B12 levels. These two groups were compared by means of possible factors that might affect serum vitamin B12 level, such as age, sex, H. pylori, activity, inflammation and metaplasia. As the main determinants of vitamin B12 deficiency are atrophic corpus gastritis and ongoing H. pylori infection in elderly patients, a third group was also created from patients in whom both H. pylori and atrophy scores were negative in order to identify factors other than H. pylori and gastric atrophy that might affect serum vitamin B12 levels.16 Other parameters analyzed included simple inflammation markers, such as mean platelet volume and PLR, that might be helpful in predicting serum vitamin B12 levels. Patients who had a previous history of gastrointestinal tract surgery; organic and metabolic diseases, such as diabetes mellitus, chronic liver diseases, renal failure, inflammatory bowel diseases and autoimmune gastritis; known vegetarians; and intake of antibiotics, proton pump inhibitors, H2 receptor blockers or nonsteroidal anti-inflammatory drugs for two months before the study were excluded from the study. The present study was approved by the institutional review board of Ankara University Faculty of Medicine (Decision date: 24 December 2014, no: 21-890-14), and this study conformed to the provisions of the Declaration of Helsinki.
Statistics Statistical analysis was carried out with SPSS 16.0 (SPSS, Chicago, IL, USA) for Windows. The Shapiro–Wilk test was used to test of normality. According to the results, | 687
Ç Kalkan et al.
Table 1 Demographic characteristics, laboratory and histological parameters of patients with non-atrophic gastritis (n = 1256) according to the serum vitamin B12 levels
Age, years (range) Sex (female/male) Vitamin B12 (pg/mL) MPV, fl (range) PLT/L Hp+ Activity+ Inflammation+ Metaplasia+
Group I, n = 759 (B12 >200)
Group II, n = 497 (B12 < 200)
67 (60–97) 499/260 339 (201–987) 8.7 (5.7–14.1) 124.64 (18.4–602) 154 (20.3%) 176 (23.2%) 230 (30.3%) 14 (1.8%)
67 (60–92) 287/210 180 (50–200) 8.55 (5.8–13.1) 122.35 (11.02–872.86) 325 (65.4%) 367 (73.8%) 386 (77.7%) 35 (7%)
P 0.707 0.004 0.034 0.825 200 pg/mL (n = 69, [40.1%] vs 82, [13.4%], P < 0.001). The relationship between H. pylori density and neutrophil activity was also investigated in the present study. When H. pylori density was absent, 89.6% of patients were negative for neutrophil activity. However, when H. pylori density was 1, 2 and 3, 99.4%, 99.2% and 100% of patients had a varying degree of neutrophil activity, respectively (P < 0.001, kappa = 0.76; Fig. 3). We also investigated some simple systemic inflammatory response markers, such as PLR and mean platelet volume in peripheral blood of patients, to discover whether these biomarkers have a role in the differentiation of patients with low and normal serum vitamin B12 levels. As for MPV, there were significant differences between groups I and II, showing that MPV was significantly higher in group I compared with group II (8.7 fl [5.7–14.1] vs 8.55 [5.8–13.1], P = 0.034). receiver operating characteristic curve analysis suggested that the optimum MPV cut-off point was 8.05 fl with a specificity and sensitivity of 0.75 and 0.30, respectively (Fig. 4). However, there was no statistically significant difference between groups I and II by means of PLR (124.64 [18.4– 602] vs 122.35, P = 0.825).11–29
Discussion The present retrospective study showed the various factors that might affect serum vitamin B12 level in a group of unselected elderly patients. According to the results of this study, ongoing H. pylori infection was | 689
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Figure 4 Receiver operating characteristic (ROC) curve analysis of mean platelet volume for the identification of low and normal serum vitamin B12 levels. ROC analysis suggested that the optimum mean platelet volume cut-off point was 8.05 fl, with a specificity and sensitivity of 0.75 and 0.30, respectively.
significantly more prevalent in patients whose serum vitamin B12 levels were ≤200 pg/mL than in patients with serum vitamin B12 levels >200 pg/mL (n = 325 vs 154, P < 0.001). Kaptan et al. investigated the H. pylori incidence in patients with vitamin B12 deficiency prospectively, and assessed whether treatment for H. pylori infection could correct this deficiency in a group of patients with anemia and vitamin B12 deficiency.17 H. pylori was detected in 77 (56%) of 138 patients with vitamin B12 deficiency, and eradication of H. pylori infection successfully improved anemia and serum vitamin B12 levels in 31 (40%) of 77 infected patients. They concluded that H. pylori could be a causative agent in the development of adult vitamin B12 deficiency, and suggested that eradication of H. pylori infection alone might correct vitamin B12 levels and improve anemia. In a similar study, Sarari et al. investigated the possible association between H. pylori infection and vitamin B12 deficiency in 60 patients suffering from gastric disease as a result of H. pylori infection.18 They found H. pylori in 71.7% (43/60) of the patients investigated. The level of vitamin B12 was lower than 200 pg/mL in 67.4% (29/43) of patients who tested positive for H. pylori, and they concluded that H. pylori appears to be implicated in causing vitamin B12 deficiency. We also tested whether H. pylori density affects serum vitamin B12 levels in elderly patients with non-atrophic gastritis. We found 690 |
that as the density of H. pylori infection increased, the serum vitamin B12 level decreased; H. pylori density is inversely correlated with serum B12 level. When patients were evaluated by means of neutrophil activity, inflammation and intestinal metaplasia, all these parameters were inversely correlated with serum vitamin B12 level irrespective of histological score. Serin et al. investigated the impact of H. pylori infection on the development of vitamin B12 deficiency in 145 patients with non-atrophic gastritis.9 They found that the histopathological scores for H. pylori density, inflammation and neutrophil activity were all inversely correlated with serum vitamin B12 level, and only H. pylori density was significantly correlated with serum B12 level, and concluded that either H. pylori itself or the effects of inflammation caused by the bacterium somehow caused food-cobalamin malabsorption in their patients. In order to find an answer to this question, we selected H. pylori-negative patients with non-atrophic gastritis. What we found was, both neutrophil activity and inflammation were significantly more prevalent in patients whose serum vitamin B12 levels were ≤200 pg/mL than in patients whose serum vitamin B12 levels were >200 pg/mL. In this context, although we do not know whether H. pylori-negative patients received prior anti-H. pylori therapy, it can be speculated that inflammation of the gastric mucosa could reduce acid secretion by several mechanisms, such as decreased gastrin response to reduced acid levels and blockage of parietal cell function by certain cytokines.19 In another study, Gümürdülü et al. studied 310 patients with non-atrophic gastritis by means of chronic inflammation, neutrophil activity and H. pylori load as variables that might affect serum vitamin B12 level.20 They found that patient age and all three histological parameters were inversely related to vitamin B12 levels, and factors independently associated with serum vitamin B12 deficiency were age and antral H. pylori load, and concluded that the higher frequency of vitamin B12 deficiency might be a reflection of the effect of H. pylori infection on serum vitamin B12 level, and age was shown to be an independent risk factor for vitamin B12 deficiency irrespective of gastric atrophy. It has been reported that some simple systemic inflammatory response markers, such as PLR in peripheral blood, might have diagnostic importance in some clinical conditions. In some malignant conditions, endogenous anticancer pre-inflammatory and precoagulative response arise, and the PLR is used as a marker in order to evaluate this response. In malignant diseases, such as breast cancer, ovarian and colorectal cancers, PLR is assumed as a sensitive marker for prognostic evaluation.21 In clinical practice, there are some easily measurable parameters in complete blood count, such as MPV, and MPV projects the average size of platelets and platelet production rate.22 There is abundant evidence that MPV levels increase in malignant, © 2015 Japan Geriatrics Society
Vitamin B12 in non-atrophic gastritis
inflammatory and infectious conditions, such as gastric carcinoma, celiac disease and ulcerative colitis.23–25 Mean platelet volume levels were found to be lower in high-grade inflammatory conditions, such as acute attack of familial Mediterranean fever and active rheumatoid arthritis.26,27 In the present study, there were significant differences between patients with serum vitamin B12 levels in normal range (>200 pg/mL) compared with patients with low (≤200 pg/mL) serum vitamin B12 levels, showing that MPV was significantly higher in the vitamin B12 level normal group. Although MPV had limited specificity (0.75) and sensitivity (0.30), receiver operating characteristic curve analysis suggested that the optimum MPV cut-off point was 8.05 fl and can be used in clinical practice in order to discriminate between these two groups of patients. However, there were no statistically significant differences between groups I and II by means of PLR. As for the relationship between H. pylori density and neutrophil activity, there was a close relationship between H. pylori density and neutrophil activity (P < 0.001, kappa = 0.76). As the H. pylori density increases, neutrophil activity increases as well. The association between H. pylori density and neutrophil activity could be related to malabsorption of vitamin B12. However, there was no relationship between H. pylori density and PLR and MPV. In the current study, the optimum serum vitamin B12 cut-off value was found to be 207 pg/mL in order to carry out upper gastrointestinal endoscopy with a specificity and sensitivity of 0.73 and 0.70 respectively. A serum vitamin B12 level ≤200 pg/mL is highly sensitive (97%) for the diagnosis of vitamin B12 deficiency.28 The British Society for Standards in Haematology has developed guidelines and recommended that a serum vitamin B12 cut-off value of 200 pg/mL should be used as vitamin B12 deficiency.29 In the present study, there were several potential limitations due to the retrospective nature of the study. First, we had limited data regarding the previous H. pylori eradication therapies of all patients, especially in the evaluation of H. pylori-negative patients with non-atrophic gastritis. These results created difficulty in drawing a conclusion as to whether they had ever been infected by H. pylori or not. In conclusion, the findings from the present study provide strong evidence that H. pylori infection was significantly more prevalent in elderly patients whose serum vitamin B12 levels were ≤200 pg/mL, and H. pylori density is inversely correlated with serum B12 level in elderly patients. The present study also shows that chronic non-atrophic corpus gastritis is a significant cause of vitamin B12 deficiency in elderly subjects. Considering these issues, it is reasonable to screen all elderly patients with low serum vitamin B12 by means of H. pylori gastritis; however, there are still some patients with H. pylori negative non-atrophic gastritis with some © 2015 Japan Geriatrics Society
degree of inflammation and activity that might be caused by some other agents. Based on findings from the present study and in accordance with current guidelines, we suggest upper gastrointestinal endoscopic examination for elderly patients with a serum vitamin B12 level ≤200 pg/mL. Another finding was that neutrophil activity, inflammation and intestinal metaplasia were inversely correlated with serum vitamin B12 level irrespective of histological score. Simple systemic inflammatory response markers, such as MPV, might be beneficial in clinical practice in the differentiation of patients with low or normal serum vitamin B12 levels.
Disclosure statement No potential conflicts of interest were disclosed.
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