Vitamin B12 deficiency

Last reviewed: 28 Aug 2022
Last updated: 06 May 2022

Summary

Definition

History and exam

Key diagnostic factors

  • old age
  • history of gastric surgery (gastrectomy, or bypass for obesity)
More key diagnostic factors

Other diagnostic factors

  • paresthesias
  • vegan and strict vegetarian diet
  • chronic gastrointestinal disease (e.g., Crohn disease or celiac disease)
  • medication (proton-pump inhibitors, H2 receptor antagonists, metformin, anticonvulsants)
  • ataxia
  • decreased vibration sense
  • positive Romberg test
  • pallor
  • petechiae
  • glossitis
  • angular cheilitis
  • cognitive impairment
Other diagnostic factors

Risk factors

  • age >65 years
  • gastric surgery (bypass or resection)
  • chronic gastrointestinal (GI) disease
  • vegan diet
  • metformin use
  • H2 receptor antagonist or proton-pump inhibitor use
  • Helicobacter pylori infection
  • anticonvulsant use
  • diabetes mellitus
  • pregnancy
More risk factors

Diagnostic investigations

1st investigations to order

  • CBC
  • peripheral blood smear
  • serum vitamin B12
  • reticulocyte count
More 1st investigations to order

Investigations to consider

  • methylmalonic acid (MMA)
  • homocysteine
  • holotranscobalamin
  • anti-intrinsic factor antibody (anti-IFAB)
  • antiparietal cell (APC) antibody
  • serum gastrin (fasting)
More investigations to consider

Treatment algorithm

ACUTE

symptomatic

asymptomatic or borderline deficiency

Contributors

Authors

Robert C. Oh, MD, MPH, CAQSM
Robert C. Oh

Associate Chief of Staff, Education

VA Puget Sound Health Care System

Seattle

WA

Disclosures

RCO declares that he has no competing interests.

Peer reviewers

Thein Hlaing Oo, MD, FRCP Edin, FACP

Professor of Internal Medicine

Consultant Hematologist

The University of Texas MD Anderson Cancer Center

Houston

TX

Disclosures

THO declares that he has no competing interests.

Rebecca Connor, MD

Chief Fellow

Section of Hematology and Oncology

Department of Internal Medicine

Wake Forest University Baptist Medical Center

Winston-Salem

NC

Disclosures

RC declares that she has no competing interests.

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