Determinants of diagnostic delay in autoimmune atrophic gastritis

Abstract

Background: Autoimmune atrophic gastritis (AAG) is characterised by a wide clinical spectrum that could delay its diagnosis.Aims: To quantify the diagnostic delay in patients suffering from AAG and to explore possible risk factors for longer diagnostic delay. Methods:Consecutive patients with AAG evaluated at our gastroenterological outpatient clinic between 2009 and 2018 were included. Diagnostic delay was estimated as the time lapse occurring between the appearance of the first likely symptoms, laboratory alterations, and other clues indicative of AAG and the final diagnosis.Patient-dependent and physician-dependent diagnostic delays were also assessed.Multivariable regression models were fitted.Results: 291 patients with AAG (mean age at diagnosis 61 ± 15 years; F:M ratio = 2.3:1) were included. The median overall diagnostic delay was 14 months (interquartile range [IQR] 4-41). Factors associated with longer median overall diagnostic delay were female sex (17 months, IQR 5-48), having a previous misdiagnosis (36 months, IQR 17-125) and a history of infertility/miscarriages (33 months, IQR 8-120), whereas a higher level of education was associated with longer patient-dependent diagnostic delay (4 months, IQR 1-12). First evaluation by a gastroenterologist was associated with a median longer diagnostic delay (6 months, IQR 2-15) compared to an internist (3 months, IQR 3-31) and a haematologist (1 month, IQR 0-2). Age, socioeconomic or marital status did not affect the diagnostic delay.Conclusions: AAG is burdened by substantial diagnostic delay, especially in female patients, and due to lack of awareness, particularly among gastroenterologists.Uncommon vitamin B12 deficiency-related manifestations are overlooked and may prolong the diagnostic delay.

Editorial: determinants of diagnostic delay in autoimmune atrophic gastritis—a salutary lesson

“…A delay of ≥10 years occurred in 8.2% and over three quarters of patients (86%) had consulted at least two different specialists prior to diagnosis. The conclusions drawn from this were that a delay in diagnosis may occur due to physicians’ lack of awareness; reasons for patients’ diagnostic delay are less clear . In those with a final diagnosis of AIG, gastrointestinal symptoms were most common with just under half the patients presenting with gastro‐oesophageal reflux disease, dyspepsia, abdominal pain, diarrhoea and weight loss.…”

“…In classical cases, patients present with macrocytic anaemia prompting suspicion of pernicious anaemia and the relevant pathology pathway of serology and endoscopy with biopsy confirms the diagnosis. However, often before reaching this stage, the symptoms of AIG are nonspecific, numerous and nebulous, and diagnostic delay common as shown by the elegant study from Lenti et al…”

“…Haematological abnormalities were present in just over one third, most commonly anisocytosis and macrocytic anaemia, but also microcytic and normocytic anaemia. Other presentations were associated with autoimmune disorders, neurological symptoms (paraesthesia, neuropsychiatric symptoms), hyperhomocysteinaemia, family history of AIG, ischaemic cardiovascular disease and infertility or recurrent miscarriage …”

Editorial: determinants of diagnostic delay in autoimmune atrophic gastritis–a salutary lesson. Authors' reply

“…We thank Prof. Walker for her thoughtful comments on our study . No study had ever previously investigated before the diagnostic delay in autoimmune atrophic gastritis (AAG), a multifaceted disorder characterised by a wide clinical spectrum, especially due to micronutrient deficiencies, such as vitamin B12 and iron deficiency‐related manifestations .…”

“…Many uncertainties and unmet needs still exist in the recognition and clinical care of AAG, which has been somewhat neglected by many specialist physicians including gastroenterologists . This could be partially explained by lack of knowledge of AAG pathogenesis, which still needs to be completely uncovered, and by confusion with the classification of different forms of atrophic gastritis, especially with multifocal atrophic gastritis which includes antrum‐predominant atrophic gastritis and atrophic pangastritis, as a consequence of Helicobacter pylori infection .…”