anemia 2

ok, l read it superficialy and threw the answer upon neurologic and lab results.

lets take it with details:
we have macrocytic aneamia.
causes r:
b12/b9 difeciency.
alcohol (toxic effects).
liver disease
drugs.
---------

we should rule them out one by one.
folate def doesn't contain nuerological sxs.

now which one can cause dirrhea (or associated with)?

B12 deficiency is associated with diarrhea and smooth tongue
increased LDH is another clue

here is the right answer ( good job guys )

Critique (Correct Answer = B)

The patient most likely has vitamin B12 deficiency, based on the degree of macrocytosis and neurologic findings. An elevated serum lactate dehydrogenase level, due to intramarrow cell death from ineffective erythropoiesis, is consistent with this diagnosis.

Severe macrocytosis (mean corpuscular volume > 120 fL) is often associated with vitamin B12 deficiency or folate deficiency (megaloblastic anemia), usually seen in conjunction with “oval” macrocytes. The presence of frequent hypersegmented neutrophils (> 5 segments) is strongly suggestive of vitamin B12 or folate deficiency.

Bone marrow morphology in patients with vitamin B12 or folate deficiency is referred to as “megaloblastic” and is characterized by the presence of large cells with immature nuclear chromatin but maturing erythrocyte cytoplasm (nuclear-cytoplasmic dissociation). Anemia accompanies this process; hence the term “ineffective erythropoiesis.” The intramarrow death of megaloblastic cells causes the serum lactate dehydrogenase level to rise. If a patient has a low serum vitamin B12 or folate level, a bone marrow examination is probably unnecessary. However, the physician should determine the cause of the deficiency. If a patient has a normal serum vitamin B12 or folate level, a bone marrow examination is frequently helpful to exclude myelodysplastic syndromes or other infiltrative marrow disorders.

Folate deficiency can induce megaloblastosis within weeks to months, whereas vitamin B12 deficiency requires years to cause megaloblastosis since stores of vitamin B12 persist for years in the liver and other tissues. In patients with vitamin B12 or folate deficiency, parenteral or oral repletion of vitamin B12 or folate reverses some morphologic abnormalities within hours. Serum folate levels fluctuate quickly with changes in dietary consumption. Low erythrocyte folate levels often reflect prior nutritional depletion. In patients who are hospitalized and are begun on regular diets, the erythrocyte folate test may provide a better assessment of tissue folate levels than determination of the serum folate level. The erythrocyte folate test often requires a special laboratory, and results often are not quickly available.

In patients with megaloblastic anemias, erythrocyte production is diminished and a “corrected” reticulocyte count is inappropriately low for the degree of anemia. This patient had a corrected reticulocyte count of 1% (inappropriately low for a hemoglobin level of 9.4 g/dL).

In addition to changes in the blood, the epithelial cells in patients with megaloblastic anemias may become atrophic and cause a smooth tongue and cheilosis. Posterior column dysfunction, particularly in patients with vitamin B12 deficiency, may lead to changes in vibratory or position sense, causing ataxia. Signs of dementia may appear. However, neurologic dysfunction is very uncommon in adults with folate deficiency.

Alcoholic cerebellar degeneration results in ataxia but not position loss. Although liver metastases are possible in a patient with a history of colon cancer, their presence would not account for the neurological findings in this patient. Brain metastases would most likely produce focal neurological findings and also would not account for the blood findings

yah vit B12 deficiency in which this vit absorbed from the terminal of ilum through the intrinsic factor which secreted form the chief cells in the stomach

SO for this patient : besides giving Vit B 12 you should (choose one or more)
A- Recommend upper endoscopy to look for the possibility of proximal gastric cancer (since these people are at higher risk of developing this malignancy)
B- Perform the Benteromide test to assess the cause of B12 deficiency
C- Perfom imaging as well as functional testing for the pancreas to look for features of
chronic pancreatitis which is likely in this (ex- alcoholic patient)
D- Consider Antibiotic trial for the possibility of bacterial overgrowth (related to previous surgery) as a cause of B12 deficiency
E- Recommend colonoscopy for his previous history of colon cancer and present diarrhea

Please explain your answers

Why would diarrhea happen in B 12 deficiency?

Remember that in B 12 deficiecy the affected nurve bundle is in the posterior column of the spinal cord (transmitting the sensation of posture)not the splanchnic viseral innervation. SO you answer is not correct!!