Last reviewed: 11 Apr 2021
Last updated: 21 Mar 2018



History and exam

Other diagnostic factors

  • age >60 years
  • female sex
  • autoimmune disorders
  • weakness
  • lethargy
  • decreased exercise tolerance
  • skin and conjunctival pallor
  • paraesthesias and difficulty ambulating
  • nutritional deficiency (cobalamin, iron, calcium, vitamin D)
  • enteric infection
  • memory loss, irritability, depression, and dementia
  • ataxia, shuffling gait, decreased position sense, decreased vibration sense
  • pale, smooth, and glossy tongue
  • koilonychia

Risk factors

  • autoimmune disorders
  • age >60 years
  • Helicobacter pylori infection
  • prior gastric surgery
  • hypergastrinaemia
  • gastric carcinoid

Diagnostic investigations

1st investigations to order

  • haemoglobin
  • biopsy of corpus and/or fundus of stomach
  • intragastric pH

Investigations to consider

  • serum gastrin
  • gastric acid secretory test (gastric analysis)
  • parietal cell antibodies
  • intrinsic factor antibodies
  • urea breath test: Helicobacter pylori infection
  • histology: Helicobacter pylori infection
  • rapid urease test on biopsy samples: Helicobacter pylori infection
  • stool antigen test: Helicobacter pylori infection
  • serology: Helicobacter pylori infection
  • polymerase chain reaction (PCR): Helicobacter pylori infection
  • fluorescence in situ hybridisation: Helicobacter pylori infection

Emerging tests

  • serum pepsinogen I and II (PGI and PGII)
  • serum ghrelin

Treatment algorithm


Mitchell L. Schubert

Professor of Medicine and Physiology

Virginia Commonwealth University Health System

Chief of Gastroenterology

McGuire VAMC




MLS is an author of several studies referenced in this monograph.

Dr Mitchell L. Schubert would like to gratefully acknowledge Dr Juan Diego Baltodano, a previous contributor to this monograph. JDB declares that he has no competing interests.

Peer reviewersVIEW ALL

Professor of Medicine

David Geffen School of Medicine at UCLA

Los Angeles



JP declares that he has no competing interests.

Associate Professor of Gastroenterology and Internal Medicine

Medical University of Graz

Attending Gastroenterologist

University Hospitals Graz



HFH has been reimbursed by Astra Zeneca, Nycomed, and Janssen, the manufacturers of proton-pump inhibitors, for attending several conferences and speaking, and has been paid by Astra Zeneca for running educational programs.

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