A patient developed pernicious anemia after total gastrectomy surgery. Which of the following medicine would be prescribed to prevent complication in this patient?

1. A

   Daily iron Supplements

2. B

   Folic acid

3. C

   Lifelong administration of Oral intrinsic factor

4. D

   Lifelong administration of Vita. B12 injection for every month

Appeared in: NORCET 3 - 2022 (Shift-2)

Explanation

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• Total gastrectomy removes the stomach's parietal cells, which are the only source of intrinsic factor (IF).
• Intrinsic factor is essential for the absorption of Vitamin B12 from the gastrointestinal tract.
• Without IF, oral Vitamin B12 cannot be absorbed, leading to pernicious anemia.
• Therefore, Vitamin B12 must be administered parenterally (via injection) to bypass the digestive system.
• This is a lifelong requirement because the stomach cannot regenerate, and the inability to produce IF is permanent.

Why Other Options Were Wrong

• Option A: Iron supplements are used to treat iron-deficiency anemia, which is characterized by small, pale red blood cells (microcytic anemia). Pernicious anemia is a type of macrocytic anemia (large red blood cells) caused by B12 deficiency.
• Option B: Administering folic acid alone is dangerous in a patient with Vitamin B12 deficiency. It can correct the anemia visible on a blood test but does not address the neurological damage, allowing it to progress irreversibly. It effectively 'masks' the full extent of the deficiency.
• Option C: Oral intrinsic factor is not a viable treatment. Being a protein, it would be digested by proteases in the small intestine before it could perform its function of binding to Vitamin B12.

Related Visual

• Visual 1: Diagram - A flowchart showing the normal pathway of Vitamin B12 absorption (requiring intrinsic factor from the stomach to be absorbed in the ileum) contrasted with the pathway after a total gastrectomy (showing the block in absorption).
• Visual 2: Infographic - A comparison table highlighting the key differences in symptoms and lab findings between Vitamin B12 deficiency and Folic Acid deficiency, emphasizing the presence of neurological symptoms in B12 deficiency.

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Management of pernicious anemia following total gastrectomy in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Patient education is a critical nursing responsibility. The nurse must ensure the patient understands that Vitamin B12 injections are a lifelong necessity to prevent severe anemia and permanent nerve damage.
• Nurses must monitor for both hematologic improvement (resolution of anemia) and neurologic status (improvement or stabilization of symptoms like tingling, numbness, or gait disturbance).
• What if? If the patient was a strict vegan but had not undergone a gastrectomy, the cause of B12 deficiency would be dietary. In this case, high-dose oral B12 supplements might be effective because the intrinsic factor mechanism is still intact. However, after a gastrectomy, injections are non-negotiable.

How to Approach the Question

• First, identify the key terms in the question: 'pernicious anemia' and 'total gastrectomy'.
• Connect the procedure (total gastrectomy) to its physiological consequence: the complete removal of the stomach means no more production of intrinsic factor.
• Recall the function of intrinsic factor: it is essential for the absorption of Vitamin B12.
• Deduce the problem: The patient cannot absorb Vitamin B12 from food or oral supplements.
• Evaluate the options based on this deduction. The only logical solution is to provide Vitamin B12 in a form that bypasses the gastrointestinal absorption pathway, which is an injection.
• Eliminate other options: Iron is for a different type of anemia. Folic acid is dangerous as it masks the problem. Oral intrinsic factor is ineffective.

Concept Tested & Keywords

• Concept Tested: Management of pernicious anemia following total gastrectomy.
• Stem keywords: pernicious anemia, total gastrectomy, prevent complication
• Lead-in keywords: Which of the following
• Clinical cues: The patient's history of 'total gastrectomy' is the critical clue, as it directly points to the cause of pernicious anemia: the inability to produce intrinsic factor.

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