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Oral folate
6%
9/141
Oral iron
4%
6/141
Oral pyridoxine
3%
4/141
Parenteral folate
5/141
Parenteral vitamin B12
72%
101/141
Select Answer to see Preferred Response
This patient has vitamin B12 deficiency (e.g., paresthesia with decreased vibration and pinprick sensation and hypersegmented neutrophils) secondary to her gastric bypass surgery. The most appropriate treatment is to administer parenteral vitamin B12. Vitamin B12 deficiency can result from a wide range of etiologies such as insufficient intake (e.g., veganism), malabsorption (e.g., Crohn disease), pernicious anemia, Diphyllobothrium latum infection, and gastrectomy. Gastrectomy results in vitamin B12 deficiency because it removes a large portion of the gastric parietal cells that produce intrinsic factor, a substance vital to the absorption of vitamin B12 at the ileum. Laboratory studies will demonstrate macrocytic anemia (e.g., increased mean corpuscular volume), increased homocysteine, and increased methylmalonic acid (which differentiates it from folate deficiency). In addition, patients may present with neurologic symptoms (e.g., reversible dementia and subacute combined degeneration) in addition to signs and symptoms of anemia. Management includes treating the underlying disease and replenishing vitamin B12 stores via parenteral or oral routes. The parenteral route is often preferred in patients with impaired absorption of vitamin B12 though very high oral doses are effective as well. Figure/Illustration A is a peripheral blood smear demonstrating hypersegmented neutrophils (arrow) characteristic of folate or vitamin B12 deficiency. Incorrect Answers: Answer 1: Oral folate is inappropriate in this patient as she is displaying signs and symptoms of vitamin B12 deficiency (e.g., neurologic symptoms). Replacing folate is not going to correct her symptoms. Answer 2: Oral iron is inappropriate in this patient as her anemia is megaloblastic (e.g., suggested by the hypersegmented neutrophils) and not due to iron deficiency. Answer 3: Oral pyridoxine is inappropriate as this patient likely has vitamin B12 deficiency. Although vitamin B6 deficiency can result in peripheral neuropathy, it is often associated with medications such as isoniazid and oral contraceptives. This patient's medical history makes vitamin B12 deficiency more likely. Answer 4: Parenteral folate is inappropriate in this patient as she is displaying signs and symptoms of vitamin B12 deficiency (e.g., neurologic symptoms). Replacing folate is not going to correct her symptoms. Bullet Summary: Vitamin B12 deficiency can be managed and treated with regular parenteral vitamin B12 doses.
3.2
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