In the setting of a prior partial gastrectomy and blood-work indicative of a megaloblastic anemia, this patient is likely suffering from vitamin B12 deficiency. Symptoms and findings of vitamin B12 deficiency include classic symptoms of anemia (fatigue, lightheadedness, pale skin), neurologic symptoms (including numbness/paresthesias, hyporeflexia, decreased vibratory sensation, ataxia, dementia), and glossitis (swollen, smooth, shiny tongue).
In a gastrectomy or partial gastrectomy, the number of parietal cells that secrete intrinsic factor (IF) is reduced. The resulting decreased levels of IF leads to decreased absorption of B12 in the terminal ileum. The neurologic symptoms associated with B12 deficiency are caused by demyelination. B12 deficiency is the most common cause of subacute combined degeneration of the spinal cord, which is the degeneration of the posterior and lateral columns of the spinal cord.
Langan and Zawistoski review vitamin B12 deficiency. Work-up for vitamin B12 deficiency should include complete blood count, vitamin B12 level, homocysteine level, and methylmalonic acid level. The authors state that both monthly IM and high-dose PO vitamin B12 administration leads to similar improvements in B12 levels regardless of etiology, specifically including malabsorption states.
Kim et al. investigated the efficacy of oral B12 replacement in patients who underwent total gastrectomy for gastric cancer. They showed that there was no significant difference between groups receiving IM versus PO vitamin B12, with both groups exhibiting improvement in B12 levels. 28 of 29 total gastrectomy patients who received oral B12 supplementation experienced neurologic symptom relief.
Illustration A shows an example of glossitis; note the shiny, smooth texture of the surface of the tongue.
Answer 1: Hyporeflexia, not hyperreflexia, is expected in vitamin B12 deficiency.
Answer 2: Night blindness is a marker of vitamin A deficiency
Answer 4: Bleeding gums are classic for scurvy, or vitamin C deficiency.
Answer 5: Bruising and petechiae may be seen in a number of platelet and/or coagulation disorders, including vitamin K deficiency.
Langan RC, Zawistoski KJ. Update on vitamin B12 deficiency. Am Fam Physician. 2011 Jun 15;83(12):1425-30.
PMID:21671542 (Link to Abstract)
Kim HI, Hyung WJ, Song KJ, Choi SH, Kim CB, Noh SH. Oral vitamin B12 replacement: an effective treatment for vitamin B12 deficiency after total gastrectomy in gastric cancer patients. Ann Surg Oncol. 2011 Dec;18(13):3711-7.
PMID:21556950 (Link to Abstract)