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Page: Differential Diagnosis
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* Insufficient dietary vitamin B12 intake, the classic example being the vegan diet. Vegans dispute the association of an animal-product free diet with vitamin B12 deficiency, and emphasize that vitamin B12 is only manufactured by prokaryotic microorganisms, not in food livestock.
* Atrophic Gastritis in the elderly, leading to parietal cell damage in the stomach (reducing intrinsic factor)
* Inadequate absorption of vitamin B12 due to previous stomach surgery, such as was previously undertaken for peptic ulcer disease, or current bariatric surgery for weight loss.
* Fish tapeworm, as in preparers of gefilte fish, who would acquire the tapeworm by sneaking bits of uncooked fish while making the Eastern European delicacy, now eaten by Jews at Pesach. The fish tapeworm competes with the host for absorption of vitamin B12.
* Bacterial overgrowth of the small bowel. The bacteria compete with the host for utilization of vitamin B12
* Proton pump inhibitors reduce the acidity of the stomach, reducing the functionality of proteolytic enzymes that separate vitamin B12 from upper digestive tract R-binders
* Exocrine pancreas insufficiency reduces the efficiency of proteolysis in the small bowel, reducing the efficiency of vitamin B12 absorption from the diet
* Hereditary causes, such as severe MTHFR deficiency, homocystinuria, and transcobalamin deficiency
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