An obese patient undergoes a gastric bypass procedure in order to lose weight but never returns for follow-up or continuing care. Three years later, he presents to an emergency room with fatigue, a glossy tongue, and a macrocytic and hyperchromic anemia. Which one of the following is deficient or malfunctioning in this patient, leading to this anemia?
**Core Concept**
The patient's presentation of fatigue, glossy tongue, and macrocytic and hyperchromic anemia following a gastric bypass procedure suggests a deficiency of a crucial nutrient essential for erythropoiesis and overall health. This condition is often overlooked in patients with malabsorptive surgeries due to altered gut anatomy and decreased nutrient absorption.
**Why the Correct Answer is Right**
The patient's symptoms are characteristic of vitamin B12 deficiency, which is a common complication of gastric bypass surgery. Vitamin B12 plays a vital role in the synthesis of DNA and the maintenance of the nervous system. The gastric bypass procedure leads to malabsorption of vitamin B12 due to reduced secretion of intrinsic factor, a protein required for the absorption of vitamin B12 in the ileum. Without adequate intrinsic factor, vitamin B12 is not absorbed, leading to a deficiency. This deficiency impairs DNA synthesis in red blood cell precursors, resulting in macrocytic anemia. The neurological manifestations of vitamin B12 deficiency, such as fatigue and a glossy tongue, are also evident in this patient.
**Why Each Wrong Option is Incorrect**
**Option A:** Folic acid deficiency can also cause macrocytic anemia, but the presentation of a glossy tongue and neurological symptoms is not typical of folic acid deficiency. Folic acid is primarily involved in the synthesis of DNA and is not as closely linked to the nervous system as vitamin B12.
**Option B:** Iron deficiency is a common cause of microcytic anemia, which is characterized by small, pale red blood cells. This option is incorrect because the patient presents with macrocytic anemia, not microcytic anemia.
**Option C:** Vitamin C deficiency can cause scurvy, which is characterized by fatigue, malaise, and connective tissue weakness. While vitamin C is essential for overall health, it is not directly related to the patient's presentation of macrocytic anemia.
**Clinical Pearl / High-Yield Fact**
Gastric bypass surgery can lead to malabsorption of multiple nutrients, including vitamin B12, iron, and calcium. It is essential for surgeons and physicians to carefully monitor patients post-operatively for signs of nutritional deficiencies and to provide appropriate supplementation to prevent complications.
**Correct Answer:** C. Vitamin B12 deficiency.