Cost of detecting gastric neoplasia by surveillance endoscopy in atrophic gastritis in Italy: A low risk country.

BACKGROUND: Atrophic gastritis (AG) is at increased risk of gastric neoplasia, thus surveillance gastroscopy has been proposed. AIMS: To assess cost of detecting gastric neoplasias by surveillance endoscopy according to identified risk factors in Italy. METHODS: Post-hoc analysis of a cohort study including 200 AG-patients from Italy followed up for a mean of 7.5 (4-23.4) years was done. Considered risk factors were: age >50years, extensive atrophy, pernicious anaemia, OLGA-OLGIM scores 3-4 at diagnosis. The number of 4-year-surveillance endoscopies needed to be performed to detect one gastric neoplasia (NNS) was calculated. RESULTS: In 19 patients neoplasias (4 gastric cancers, 8 type 1 gastric carcinoids, 7 dysplasias) were detected at the 361 surveillance gastroscopies, corresponding to NNS of 19 and a cost per gastric neoplastic lesion of €2945. By restricting surveillance to pernicious anaemia patients, reduction of NNS and cost per neoplasia to 13.8 and €2139 may be obtained still detecting 74% of neoplasias. By limiting the surveillance to pernicious anaemia patients and OLGA 3-4, 5 (26.3%) neoplasias would have been detected with a corresponding NNS of 5.4 and a cost per lesion of €837. CONCLUSION: Risk factors may allow an efficient allocation of financial and medical resources for endoscopic surveillance in AG in a low risk country.

Anemia secondary to combined deficiencies of iron and cobalamin.

The focus of attention on combined-deficiency anemia is often on concurrent deficiencies of cobalamin (vitamin B12) and folate, emphasizing the correction of megaloblastic changes with folate alone and risking neurologic sequelae of uncorrected simultaneous cobalamin deficiency. Simultaneous deficiencies of cobalamin and iron, however, may be a more common cause of combined-deficiency anemia. Variability in red blood cell morphologic characteristics in this setting reflects the relative degree of deficiency of each of these substrates. A patient with combined cobalamin and iron deficiency anemia with microcytic, hypochromic indices and the absence of hypersegmented neutrophils was treated. This case and the literature reviewed emphasize the need to consider combined-deficiency states in all cases of anemia.

Vitamin B12 deficiency. Important new concepts in recognition.

Vitamin B12 deficiency develops over a slowly progressive continuum. Early manifestations may be generalized weakness or fatigue, indigestion, diarrhea, or depression. Pernicious anemia is considered the classic cause, but others include malabsorption because of achlorhydria or other gastric dysfunction, fish tapeworm infection, and strict vegetarianism. Iron deficiency often coexists. Because presentation is often atypical, vitamin B12 deficiency is a diagnostic consideration whenever neuropsychiatric signs or symptoms are unexplained.

Epidemiologic, clinicopathologic, and economic aspects of gastroscopic screening of patients with pernicious anemia.

In a well-defined population with a known prevalence of pernicious anemia (PA), gastroscopic screening was performed in 123 patients with PA, of whom 61 were rescreened after a mean time interval of 32 months. At the primary screening the prevalence of gastric neoplasia was 8.1% and that of gastric malignancy 4.1%. No neoplasias or malignancies were diagnosed at re-screening. The estimated cost per gastric neoplasia diagnosed during primary screening was USD 850 and that per diagnosed malignancy USD 1700. Adenoma, one with early adenocarcinoma, was diagnosed in two patients, primary early adenocarcinoma in two patients, and advanced adenocarcinoma in one patient. Five patients had gastric fundic mucosal carcinoid, of which one was multicentric with a regional metastasis. Gastric carcinoids most probably are underdiagnosed in atrophic gastritis, and, when small and solitary, their clinical relevance is uncertain. Fundic mucosal endocrine cell hyperplasia and hypergastrinemia seem to be important factors in their development.

[A safe alternative for the diagnosis of pernicious anemia--a contribution to medical economics (proceedings)]. / Sichere Alternative für die Perniziosa-Diagnostik--ein Beitrag zur Kostensenkung.

Mucosal biopsies of corpus and antrum were performed in 17 patients with pernicious anemia. In all patients the corpus mucosa showed atrophic gastritis, while in 16 the antrum was normal or showed only superficial gastritis. This combination is conclusive for pernicious anemia. Over 80% of megaloblastic anemias are caused by pernicious anemia. It is therefore proposed that endoscopy and biopsy be performed as the first examination in these patients. In this way the diagnosis is simple, rapid and economical.