A 55-year-old male underwent total gastrectomy due to peptic ulcer disease. Several months later, he presents with complaints of severe fatigue, dizziness, numbness in the hands and feet, and difficulty walking. On physical examination, he has pale skin, ataxia (unsteady gait), and a smooth, swollen tongue. Laboratory tests reveal macrocytic anemia and low vitamin levels. Which nutritional deficiency is the most likely cause of this condition

1. A

   Vitamin-C

2. B

   Vitamin-D

3. C

   Vitamin-B12

4. D

   Vitamin-H

Appeared in: NORCET-7 Mains-2024

Explanation

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• Total gastrectomy removes the stomach's parietal cells, which are the sole source of intrinsic factor (IF).
• Intrinsic factor is essential for the absorption of Vitamin B12 in the terminal ileum.
• Without intrinsic factor, dietary Vitamin B12 cannot be absorbed, leading to a deficiency state known as pernicious anemia.
• This deficiency manifests as macrocytic anemia (due to impaired red blood cell DNA synthesis) and neurological damage (due to demyelination).
• The patient's symptoms of fatigue, pallor, glossitis, ataxia, and numbness are all classic signs of severe Vitamin B12 deficiency.

Why Other Options Were Wrong

• Option A: Vitamin C deficiency (scurvy) presents with symptoms related to defective collagen synthesis, such as bleeding gums, petechiae, and poor wound healing. It does not cause macrocytic anemia or the specific neurological deficits seen in the patient.
• Option B: Vitamin D deficiency affects calcium homeostasis and bone health, leading to osteomalacia in adults (bone pain, fractures, muscle weakness). It is not associated with anemia or the neurological symptoms described.
• Option D: Vitamin H (Biotin) deficiency is extremely rare and typically causes dermatologic symptoms like hair loss (alopecia) and a scaly red rash around the eyes, nose, and mouth. While it can cause some neurologic symptoms, it does not lead to macrocytic anemia.

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Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Nutritional Deficiencies Following Gastrectomy in acute care settings.
• Patients who have undergone a total gastrectomy require lifelong parenteral (injection) Vitamin B12 replacement therapy because they can no longer absorb it orally.
• Nurses must educate the patient and family about the importance of adhering to the lifelong B12 injection schedule to prevent irreversible neurological damage.
• Monitoring for symptoms of dumping syndrome (e.g., cramping, diarrhea, dizziness after meals) is another crucial nursing responsibility for post-gastrectomy patients.

How to Approach the Question

• First, identify the key elements in the clinical scenario: the patient's surgical history (total gastrectomy), hematological findings (macrocytic anemia), and neurological symptoms (numbness, ataxia).
• Connect the surgical history to its physiological consequence. A total gastrectomy means the entire stomach is removed.
• Recall the primary functions of the stomach beyond digestion, specifically the production of intrinsic factor by parietal cells.
• Link intrinsic factor to its role in nutrition. Intrinsic factor is necessary for the absorption of Vitamin B12.
• Evaluate the patient's symptoms in the context of vitamin deficiencies. Macrocytic anemia plus neurological dysfunction is the classic presentation of Vitamin B12 deficiency.
• Eliminate the other options by recalling their primary deficiency syndromes, which do not match the patient's presentation.

Concept Tested & Keywords

• Concept Tested: Nutritional Deficiencies Following Gastrectomy
• Stem keywords: total gastrectomy, macrocytic anemia, numbness, ataxia, smooth, swollen tongue
• Lead-in keywords: most likely cause
• Clinical cues: The patient's history of a total gastrectomy is the most critical piece of information, as it directly points to a specific malabsorption issue.
• Clinical cues: The combination of macrocytic anemia and significant neurological symptoms (paresthesia, ataxia) is a hallmark of Vitamin B12 deficiency.

Question ID

QM3pPu7B2yI9ST6CxiRCoi

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Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 3 p. 138-140

E6 PATHOLOGY QUICK REVIEWBased on Harsh Mohan Textbook of PATHOLOGY p. 104-106

E6 Pharmacology Katzung 16e p. 934-936