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Abstract: This 50-year-old female patient recently always felt dizziness, palpitations, general weakness, inactivity, and inability to do things, went to the local clinic, and after a period of oral drug treatment according to the cold, felt no effect, so came to our hospital, after examination, the preliminary diagnosis of the patient is autoimmune gastritis combined with severe anemia, after intramuscular injections and oral drug treatment, the symptoms After treatment with intramuscular injections and oral medication, the symptoms improved and the patient gradually recovered.
Basic information】Female, 50 years old
Disease Type】Autoimmune gastritis combined with severe anemia
Hospital】Liaocheng Second People’s Hospital
Date of Consultation】March 2021
Treatment plan】Intramuscular injection (vitamin B12 injection) + oral medication (pantoprazole sodium enteric capsule)
Treatment period】1 month of drug treatment
Treatment effect】Anemia was corrected and anemia symptoms were relieved
I. Initial consultation
The patient’s symptoms of dizziness, palpitations, general weakness, lack of concentration, and forgetfulness have lasted for more than half a year, seriously affecting her daily work and life. The patient and his family felt very distressed, especially the patient himself was in a state of anxiety.
The patient’s face was pale, her eyelid conjunctiva and nail bed were pale, she showed signs of significant anemia, and her anemic symptoms such as dizziness, palpitations, weakness and forgetfulness were obvious. To exclude hematopoietic system diseases, bone marrow aspiration examination was required. After explaining to the patient and his family, they said they would start with non-invasive examination first, so they started with the most common causes of anemia and prescribed preliminary examinations such as routine blood, three types of anemia, stool routine + occult blood, gastroscopy, etc. The examination results showed routine blood: erythrocytes 1.96×10^12/L, hemoglobin 59g/L, average volume of erythrocytes 113fL, stool routine + occult blood showed yellow soft stool, occult blood (-), gastroscopy showed chronic atrophic gastritis (type O-3), pathology showed chronic atrophic gastritis. The patient was considered to have autoimmune gastritis combined with severe anemia.
II. Treatment history
The treatment of chronic atrophic gastritis can be treated with glucocorticoids, but the patient is in the perimenopausal period and is at the peak of calcium loss. After communicating the side effects of glucocorticoids to her, in order to avoid adverse consequences such as gastric ulcer, osteoporosis, and femoral necrosis, she was given pantoprazole sodium enteric capsules to protect the gastric mucosa, and was given intramuscular vitamin B12 injection to correct anemia. The patient was advised to have regular blood tests, and to have electronic gastroscopy and pathological examinations according to medical advice.
Treatment effect
After one month of treatment with oral medication and intramuscular injection of vitamin B12, the patient’s routine blood tests showed 4.28×10^12/L erythrocytes, 108g/L hemoglobin, 86fL average volume of erythrocytes, and 1034pg/ml of vitamin B12 in the anemia triad, which showed improvement in all indicators. The patient’s symptoms of dizziness, palpitations and weakness gradually improved, and no more inattention and forgetfulness occurred.
IV. Precautions
I am glad that the patient’s condition has improved, but I also need to advise the patient to pay attention to good living habits, avoid overexertion, avoid smoking and drinking alcohol, avoid eating spicy and stimulating food, and pay attention to balanced nutrition, ensure the diversity of food, eat more fresh food, and supplement rich nutrients. The patient’s family members are also advised to be more understanding and patient with the patient, and to be attentive to the patient when the patient is in a bad mood and anxious during the long-term treatment.
V. Personal insights
Autoimmune gastritis is a chronic gastritis caused by atrophic changes in the gastric mucosa due to autoimmune mechanisms, with atrophy mainly in the gastric body. In this case, the patient did not have dyspeptic symptoms such as poor appetite, abdominal distension, abdominal pain, etc. This time, he came to the clinic mainly because of obvious symptoms of anemia, so autoimmune gastritis needs to be considered when encountering a patient with anemia.
In addition, the treatment process of this disease is long and not easily curable, and the patient needs to return to the hospital regularly for a series of follow-up examinations, so it is necessary to explain to the patient and his family the necessity of follow-up examinations, to obtain the understanding and support of the patient and his family, and to reduce the psychological burden of the patient to avoid anxiety, irritability and depression.