Last reviewed:December 2019
Last updated:September  2017



History and exam

Other diagnostic factors

  • age >60 years
  • female gender
  • autoimmune disorders
  • weakness
  • lethargy
  • decreased exercise tolerance
  • skin and conjunctival pallor
  • paresthesias and difficulty ambulating
  • nutritional deficiency (cobalamin, iron, calcium, vitamin D)
  • enteric infection
  • memory loss, irritability, depression, and dementia
  • ataxia, shuffling gait, decreased position sense, decreased vibration sense
  • pale, smooth, and glossy tongue
  • koilonychia

Risk factors

  • autoimmune disorders
  • age >60 years
  • Helicobacter pylori infection
  • prior gastric surgery
  • hypergastrinemia
  • gastric carcinoid

Diagnostic investigations

Treatment algorithm


Mitchell L. Schubert

Professor of Medicine and Physiology

Virginia Commonwealth University Health System

Chief of Gastroenterology

McGuire VAMC




MLS is an author of several studies referenced in this monograph.

Dr Mitchell L. Schubert would like to gratefully acknowledge Dr Juan Diego Baltodano, a previous contributor to this monograph. JDB declares that he has no competing interests.

Peer reviewersVIEW ALL

Professor of Medicine

David Geffen School of Medicine at UCLA

Los Angeles



JP declares that he has no competing interests.

Associate Professor of Gastroenterology and Internal Medicine

Medical University of Graz

Attending Gastroenterologist

University Hospitals Graz



HFH has been reimbursed by Astra Zeneca, Nycomed, and Janssen, the manufacturers of proton-pump inhibitors, for attending several conferences and speaking, and has been paid by Astra Zeneca for running educational programs.

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