I posted a poll on Twitter on 2/19/24 asking whether one should refer a patient with pernicous anemia (PA) to a gastroenterologist for consideration of upper endoscopy.
Most respondents answered YES.
- There is no evidence that initial or surveillance endoscopy affects the outcome of patients with PA.
- That being said, most GI practice guidelines recommend endoscopy, whereas the sole hematology guideline (BSH) does not.
- All recommendations are consensus based. The justification for endoscopy is that PA is a manifestation of chronic autoimmune gastritis and that the latter is associated with an increased risk of carcinoid tumors and gastric adenocarcinoma.
- This risk is further increased in males, smokers, those > 50 years old or with a family history of gastric cancer.
- British Society for Haematology:
- 1) Endoscopy if patient develops Fe deficiency (ID)
- 2) Surveillance endoscopy not needed
- … these are not graded recommendations and run counter to those of UpToDate which claims that ID precedes B12 deficiency in autoimmune gastritis.
- American Gastroenterological Association:
- 1. Endoscopy at time of PA diagnosis
- 2. Optimal surveillance interval unclear
- … these are called BEST PRACTICE POINTS… the second recommendation suggests that some form of surveillance should be considered.
- American Society for Gastrointestinal Endoscopy (ASGE):
- 1. Endoscopy within 6 months of diagnosis of PA
- 2. Surveillance if other risk factors present, optimal interval unclear
- British Society of Gastroenterology (BSG):
- 1. Endoscopy at baseline (at diagnosis)
- 2. Surveillance if other risk factors present, interval not mentioned
- … both recommendations are low-grade based on low-quality evidence
- European Society of Gastrointestinal Endoscopy (ESGE):
- 1. No mention of initial endoscopy at diagnosis
- 2. Surveillance endoscopy every 3-5 years
- … low-grade recommendation based on low-quality evidence
UpToDate
- There are 2 cards/topics that address the question of endoscopy for patients with PA in UpToDate. One is a topic on PA written by hematologists, the other is focused on chronic atrophic gastritis, written by gastroenterologists.
- Interestingly, the recommendations differ between topics, somewhat reflecting the difference between the British Society of Haematology (which takes a minimalistic approach) and GI-centric guidelines (largely pro-endoscopy).
- While both PA and chronic atrophic gastritis topics advocate for initial endoscopy in a patient with PA (which is more than the BSH recommends), the PA topic recommends surveillance endoscopy only if GI symptoms develop rather than every 3-5 yrs.
