The various faces of autoimmune endocrinopathies: non-tumoral hypergastrinemia in a patient with lymphocytic colitis and chronic autoimmune gastritis

Abstract

Serum gastrin levels exceeding 1000pg/ml (normal, <100) usually raise the suspicion for a neuroendocrine tumor (NET) that secretes gastrin. Rarely, such elevated gastrin levels are seen in patients with pernicious anemia which most commonly is associated with autoimmune gastritis (AG). AG can occur concomitantly with other autoimmune disorders including lymphocytic colitis (LC). Gastrin stimulates enterochromaffin-like cells which increase histamine secretion. Histamine excess can cause diarrhea as can bacterial overgrowth or LC. We present a 57-year-old woman with diarrhea, sporadic epigastric pain, and bloating. She also had a history of interstitial cystitis and took pentosan polysulfate and cetirizine. She had no history of ulcers, renal impairment or carcinoid syndrome. Fasting serum gastrin was 1846pg/ml. Esophagoduodenal gastroscopy and biopsies revealed chronic gastritis and a pH of 7 with low stomach acid. Serum gastrin and plasma chromogranin A were suggestive of a gastrinoma or NET. Pernicious anemia was unlikely. Imaging studies did not reveal any tumor. Random colonic biopsy was compatible with LC, possibly explaining her diarrhea, although we also considered excessive histamine from elevated gastrin, bacterial overgrowth, and pentosan polysulfate which can cause diarrhea and be misleading in this setting, pointing to the diagnosis of gastrinoma. At 4year follow-up in 2012, fasting serum gastrin was 1097pg/ml and the patient asymptomatic taking only cetirizine for nasal allergies. This case illustrates that diarrhea may be associated with very high serum gastrin levels in the setting of chronic gastritis, LC, and interstitial cystitis (pentosan use), without clear evidence for a gastrinoma or NET. If no history of ulcers or liver metastases is present in such cases, watchful observation rather than an extensive/invasive and costly search for a NET may be justified. Considering the various forms of polyglandular syndrome, this may represent a variant and we here provide an algorithm for working up such patients, while also reviewing literature on the intertwined relationship between the immune and endocrine systems.

Fig. 1

A. Lymphocytic colitis. Low power view (10×) of the normal colonic architecture with intraepithelial lymphocytes infiltrating the crypts and surface epithelium. The lamina propria is expanded by lymphocytes and plasma cells. B. Lymphocytic colitis. High power view (40×) of intraepithelial lymphocytes infiltrating a crypt. C. Lymphocytic colitis. The intraepithelial lymphocytes marked as T lymphocytes on immunoperoxidase staining for CD3.

Fig. 2

Diagnostic algorithm for hypergastrinemia. GAD, glutamic acid decarboxylase; IA2, protein tyrosine phosphatase; 17-OH and 21-OH, 17- and 21-alpha hydroxylase (steroidogenic P450 enzymes); scc, side chain cleavage enzyme (steroidogenic P450 enzyme); Tg, thyroglobulin; TPO, thyroid peroxidase; AMA, anti-mitochondrial antibody; ASMA, anti-smooth muscle antibody; ANA, antinuclear antibody; ALKM-1, anti-liver-kidney microsome-1 antibodies; ALC-1, anti-liver cytosol antibody-1; anti-SLA/LP, anti-soluble liver/liver pancreas antigen; anti-ASGPR, anti-asialoglycoprotein receptor (modified by Murugesan et al., 2009).