vitamin b12 deficiency

A practical guide to management in primary care

Science bitClinical presentation and complicationsInvestigationsManagementDiscussion of guidelinesMini audit of our patients

Derived from the diet found in meat, fish, eggs, milk but not in plantsUp to 2yrs worth are stored in the liver.

Impaired absorptionPernicious anaemiaGastrectomyIleal disease or resectionMalabsorption syndromes Low dietary intakeVegans

Autoimmune disease antibodies are formed against the parietal cells. This produces atrophic gastritis and reduced IF production.1:8000 of over 60sF>MAll races but more common in fair skin, blue eyed peopleAssociated with other AA diseases particularly thyroid diseases, addisons and vitiligo

Slow onset symptoms of anaemiaLemon yellow colour due to pallor and mild jaundice (due to ineffective erythropoiesis)Glossitis and angular stomatitisNeurological changes (B12

FBC Megaloblastic anaemia with hypersegmented neutrophils.B12 levels lowParietal cell antibodies - +ve in 90%Bilirubin may be raised Serum Folate may be normal or highShilling testEndoscopy shows atrophic gastric mucosa

B12 Deficiency without neurological involvement:1mg Hydroxocobalamin 3 times a week for 2 weeks then every 3 months.B12 Deficiency with neurological involvement:1mg Hydroxocobalamin very other day until no further improvement then every 2months.

Prodigy (CKS) guidelines

60 patients with Hydroxocobalamin prescribed.Ave age 70yrs (34-95)58% female 42% male

Do we routinely monitor patients on B12 injections?Do we consistently give B12 every 3months?Do we document (or investigate) the cause of the B12 deficiency?

Chart1

24

36

Sheet1

Number of inj in last 2 yrsNumber of pat.

Zero12

One3

Two1

Three6

Four5

Five1

Six10

Severn3

Eight7

Nine5

Ten3

Eleven2

Twelve2

Mean4.6153846154

Monitoring24

No monitoring36

Cause of B12 deff

Nil recorded28

Pernicious anaemia18

Gastrectomy5

Crohns5

Small bowel resection2

?Diet2

Sheet1

0

0

0

0

0

0

0

0

0

0

0

0

0

B12

0

0

0

0

0

0

0

0

NHS numberTitleFirst NameSurnameSexDate of birthAgeAddressHow many inj in last 2 yearsBlood monitoring in last 1yrComplications?Under specialist?cause Identified?

4068804303MrRonaldAllenMale17-Nov-287920 Crown Hill,Rayleigh, Essex9(sep 07)yesNeuropathy, MCVNoNo

6123458973MrsMargaretAveryFemale14-Nov-307740 Louis Drive East, Rayleigh, Essex0(1999)NoMCV anaemiaGastroPernicious Anaemia, Crohns

6042924737MrRonaldBramleyMale7-Dec-307777 Love Lane,Rayleigh, Essex9 (2002)YesNilGAstroGastrectomy/ 'iron def anaemia'

4526144657MrsJanetBrownFemale12-Mar-5454615 Rayleigh Road, Eastwood, Leigh-On-Sea, Essex4 (1990)yesAnaemia,Gastrocrohns

6042707256MsJeanBuckFemale9-Nov-347321 Pearsons Avenue,Rayleigh, Essex8 (1994)yesno

6206077594MrSantalinaBuckleyMale20-Dec-26813 Pargat Drive, Eastwood, Leigh-On-Sea, Essex4 ( jul07)NoAnaemic MCVNoNo

4525513640MrsTeresaCappFemale3-Aug-5156221 Green Lane, Eastwood, Leigh-On-Sea, Essex9 (1999)YesNo

4167385163MrsMaryCarterFemale8-Jun-30788 Mount Avenue,Rayleigh, Essex1 (2006)NoNo

4143406152MrLeslieCawkwellMale8-Apr-23859 Britton Court Finchfield,Rayleigh, Essex6 (2002)YesAnaemia MCVNoPernicious Anaemia

4128282782MrDonaldChristieMale1-Jan-278151 Queens Road,Rayleigh, Essex10(1994) DNNoNoPartial gastrectomy

4924135100MrsDorisClareFemale3-Aug-287934 Nelson Road,Rayleigh, Essex0(2001)No (but normal FBC'08)No

4800457726MsCaroleCoffinFemale1-Nov-594899 Lower Lambricks, Rayleigh, Essex0(2005)No(normal FBC '07)NilNo?diet

4641311625MrJohnDelaneyMale29-Dec-317668 Wyburns Ave,Rayleigh, Essex8(2006)Yesanaem. MCVNopernicious

4004600049MsBerylDobsonFemale3-Apr-29798 York Rd,Rayleigh, Essex8(1990)Yes

4701078476MissDawnFullerFemale24-Jun-6642124 Eastwood Road,Rayleigh, Essex6(1980)Yescrohns

4025790688MrsLilianGaulFemale10-May-1791Rosedale Court, Hockley Road, Rayleigh, Essex0(2004)NoNilNo?pernicious anaem

4389007599MrsKellie-AnneGoodyFemale28-Aug-69389 Warwick Road,Rayleigh, Essex1(2004)YesNo

4544074983MrAnthonyGraingerMale12-Apr-476158 Upway,Rayleigh, Essex6(1993)YesnilNoNo

4129971484MsPeggyGreasleyFemale22-Dec-23849 Hanover Court, Barringtons Close,Rayleigh, Essex4(Jan 08)NoAnaemicNoNo

4085035703MrsMarionGreenFemale23-Jul-416720 Southview Close,Rayleigh, Essex0(2003)NoNilYes?diet

4524337687Mr.AlanHallMale2-Jul-47619 Disraeli Road,Rayleigh, Essex7(2002)NoGastro

4083916192MrJamesHallMale15-Jan-13956 Dobsons House, Dobsons Close,Rayleigh, Essex3(2002)YesAnaemicno?pernicious anaem

4270593539MrDavidHarrisMale7-Sep-713639 Avondale Road,Rayleigh, Essex0(1996)NoAnaemiaGastroCrohns

4129969749MrMichaelHarveyMale11-Feb-37717 Bramfield Rd West,Rayleigh, Essex8(2005)NoNoNo

6129289278MrRonaldHaynesMale31-Jul-24846 Nelson Gdns,Rayleigh, Essex7(1990)YesAnaemianopernicious anaem

4084781266Mr.DennisHillMale29-Dec-4661The Hunnypot, 14 Finchfield, Rayleigh, Essex3(joined surgeryjan08)

4402507286MsJoyceHillsonFemale5-Jul-377112 Dene Gardens,Rayleigh, Essex10(1990)YesAnaemiaNoPernicious anaea

4084532363MrPeterHorwoodMale19-Aug-406741 Church Road,Rayleigh, Essex12(1999)YesAnaemia MCV SCDC

4203045207MrCharlesHuntMale2-Feb-357313 Roach Avenue,Rayleigh, Essex4(2003)YesNo

4129630679MrsMavisIlesFemale7-Jun-327632 Willow Drive,Rayleigh, Essex12(2002)YesNoShort bowel syn

4021799648MrsFrancesIlinesFemale20-Jul-22864 Britton Court, Finchfield, Rayleigh, Essex11(2006)Yesanaemia

4208522801MissLisaJacquesFemale8-Oct-773046 Avondale Road,Rayleigh, Essex9(2003)YesAnaemicNo

6166233388MrWilliamJamesMale3-Jan-317716 Gravel Road, Eastwood, Leigh-On-Sea, Essex8(2001)YesNilTotal Gastrec

4128174793MsRubyJephsonFemale12-Nov-258217 Victoria Road,Rayleigh, Essex11(1999)YesGlossitisNo

4642552693MrDouglasKempMale1-Feb-3276Apthorpe, St Johns Drive,Rayleigh, Essex6(2008)NoPerioheral neuropathyNo

4665544573MrsEileenKhanFemale10-Mar-357317 Bracken Dell,Rayleigh, Essex9(1990)YesAnaemiaNoPernicious an

4270480017MrsDianeKiernanFemale26-Mar-654318 Belgrave Close,Rayleigh, Essex3(2008)YesAnaemiaNocrohns

4567451635MrJohnLarnerMale27-Aug-5849135 Eastwood Road,Rayleigh, Essex0(2005)NoAnaemicNoPernicious

4580246241MsMaryLattawayFemale5-Jan-495992 Clarence Road,Rayleigh, Essex8(2006)YesMVCNo

6166726384MrsVioletLeeFemale17-Jul-20881 Parkway,Rayleigh, Essex7(2000)NoNOPernicious

4270631368MissJenniferMakepeaceFemale3-Aug-733450 Oakley Avenue,Rayleigh, Essex1(2004)NonilNoSmall bowel resection

4080915543MrsDorisMc AlpineFemale5-Oct-228512 Humber Close,Rayleigh, Essex10(1990)NoNo

6108422564MrThomasMorrisMale22-Oct-367133 Downhall Close,Rayleigh, Essex6(2001)YesnilNoPerinic

6168658173MrsIvyNashFemale8-Oct-37702 Brocksford Avenue,Rayleigh, Essex2(2005)Yes

4069690204MrsPaulineNeasterFemale18-Dec-367124 The Lavers, Hockley Road,Rayleigh, Essex0(2005)Yes

4023232645MrsIrisNicholsonFemale6-Aug-406722 Albany Road,Rayleigh, Essex0(2001)No

4663055443MrChandrakantPatelMale29-Sep-357281A Nelson Road,Rayleigh, Essex6(1998)Yescrohns

6284685920MrsReshmaPatelFemale15-Dec-7136202 Green Lane,Leigh-On-Sea, Essex3(2007)NoAnaemiaNo

4081810281MrsKathleenPimmFemale23-Jan-268267 High Mead,Rayleigh, Essex3(1990)YesPernicious

4007360081MrSydneyPlattMale20-Nov-426514 Leslie Gardens,Rayleigh, Essex4(1994)YesMVCNoPernicious

4005928234MrsHildaPopeFemale9-Jul-14942 Frances Cottee Lodge, Clarence Road,Rayleigh, Essex0(1994)NoAnaemicNoPernicious

4129633333MrsDorothyPrestonFemale24-May-307854 Clarence Road,Rayleigh, Essex6(2006)YesAnaemiaNoPernicious

6045659872MrsVeraPrykeFemale30-Jun-387052 Britton Court, Finchfield, Rayleigh, Essex0(2003)NoPernicious

4023090476MrDanielReganMale18-Nov-268120 Bull Lane,Rayleigh, Essex8(1991)Yesanaemia?gastrectomy

6167531838MrHarrySparrowMale4-Jul-367299 Eastwood Road,Rayleigh, Essex6(1993)YesanaemiaNoPartial gastrectomy

4129756729MrLeslieStensonMale16-Sep-278031 Teignmouth Drive,Rayleigh, Essex6(2005)YesMVCNoPernicious

4162171610MsEileenStoffellFemale12-Oct-268127 Shannon Avenue,Rayleigh, Essex3(2004)YesMCVNo

4106210096MrsLilieTurnerFemale19-Apr-2880217 Bull Lane,Rayleigh, Essex5(feb 07)YesMCVNo

4085276441MrsNormaTurnstillFemale24-Oct-4067168 Grove Road,Rayleigh, Essex0(2000)NoPernicious

4686486963MrNeilWilcockMale3-Jul-31774 The Ramparts, Rayleigh, Essex6(2000)Yes

Ave age69.9534-95

male25

female35

Chart4

12

3

1

6

5

1

10

3

7

5

3

2

2

No. injections

no. patients

Sheet1


Zero12

One3

Two1

Three6

Four5

Five1

Six10

Severn3

Eight7

Nine5

Ten3

Eleven2

Twelve2

Mean4.6153846154

Monitoring24

No monitoring36

Cause of B12 deff

Nil recorded28


Gastrectomy5

Crohns5


?Diet2

Sheet1

No. injections

no. patients

B12






























































Ave age69.9534-95

male25

female35

Chart5

28

18

5

5

2

2

Sheet1


Zero12

One3

Two1

Three6

Four5

Five1

Six10

Severn3

Eight7

Nine5

Ten3

Eleven2

Twelve2

Mean4.6153846154

Monitoring24

No monitoring36

Cause of B12 deff

Nil recorded28


Gastrectomy5

Crohns5


?Diet2

Sheet1

No. injections

no. patients

B12






























































Ave age69.9534-95

male25

female35

Were a bit inconsistent with monitoring.Were a bit inconsistent with dosing.BUT: Does this simply reflect tailoring tests and doses to patients individual needs?We should probably pursue the cause of the B12 deficiency (and document this) more often.

vitamin b12 deficiency

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