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  1. 1. Vit.b12 Eman youssif
  2. 2. Usually seated in an atrophic gastritis, the autoimmune destruction of gastric parietal cells (and autoantibody inactivation of intrinsic factor) leads to a lack of intrinsic factor.[1] Since the absorption from the gut of normal dietary amounts of vitamin B12[2] is dependent on intrinsic factor, the loss of intrinsic factor leads to vitamin B12 deficiency. While the term 'pernicious anemia' is sometimes also incorrectly used to indicate megaloblastic anemia due to any cause of B12 deficiency, its proper usage refers to that caused by atrophic gastritis, parietal cell loss, and lack of intrinsic factor only.
  3. 3. The loss of ability to absorb vitamin B12 (B12) is the most common cause of adult B12 deficiency.[3] Impaired absorption of vitamin B12 may be due to a loss of intrinsic factor or to a number of other conditions that decrease production of gastric acid, which also plays a part in the absorption of B12 from foods.
  4. 4. Replacement of vitamin stores does not correct the defect in absorption from loss of intrinsic factor. Since the defect defines the disease, a person without the ability to absorb B12 in this way will have pernicious anemia for the remainder of their life. However, unless the patient has sustained permanent peripheral nerve damage before treatment, regular B12 replacement will keep PA in check, with no anemia and no further symptoms. Although initial treatment of the disease usually involves injections of B12 to rapidly replace body stores, a number of studies have shown long-term vitamin replacement treatment may be maintained with high-dose oral B12 supplements, since sufficient B12 is absorbed from these by a normal intestine, even without any intrinsic factor. In this regard, nasal and sublingual forms of B12 have not been found to have any special value over simple swallowed tablets
  5. 5. causes
  6. 6. Vitamin B12 cannot be produced by the human body, and must be obtained from the diet. When foods containing B12 are eaten, the vitamin is usually bound to protein and is released by stomach acid. Following its release, most B12 is absorbed by the body in the small bowel (ileum) after binding to a protein known as intrinsic factor. Intrinsic factor is produced by parietal cells of the gastric mucosa (stomach lining) and the intrinsic factor-B12 complex is absorbed by cubilin receptors on the ileum epithelial cells.[13][14] PA is characterised by vitamin B12 deficiency caused by the absence of intrinsic factor.
  7. 7. PA may be considered as an end stage of immune gastritis, a disease characterised by stomach atrophy and the presence of antibodies to parietal cells and intrinsic factor.[16] A specific form of chronic gastritis, Type A Gastritis or Atrophic Body Gastritis is highly associated with PA. This autoimmune disorder is localised to the body of the stomach, where parietal cells are located.[15] Antibodies to intrinsic factor and parietal cells cause the destruction of the oxyntic gastric mucosa, in which the parietal cells are located, leading to the subsequent loss of intrinsic factor synthesis. Without intrinsic factor, the ileum can no longer absorb the B12.[17]
  8. 8. Pernicious Anemia is an autoimmune disease that attacks the intrinsic factor. This is a type of protein that helps your body absorb the B12 in your stomach. The body needs the B12 to make red blood cells. If you have a B12 deficiency it does not mean you have Pernicious Anemia. There are tests done to diagnose you. Some people just don’t eat the proper foods to get the B12 in their system. These people can take B12 supplements. For people with Pernicious Anemia we need to by-pass the stomach and make sure the B12 goes right into our blood steam. I give myself shots to keep my B12 levels up.
  9. 9. In patients with pernicious anemia, malabsorption of vitamin B12 is caused by intrinsic factor deficiency. This is due to two mechanisms: 1) the progressive destruction of parietal cells from the gastric mucosa leading to intrinsic factor destruction and 2) the binding of blocking autoantibodies to the vitamin B12binding site of intrinsic factor, preventing the formation of the vitamin B12intrinsic factor complex [3]. If confirmation of malabsorption due to intrinsic factor deficiency is needed, the Schilling test can be performed. However, parietal cell antibodies and intrinsic factor antibodies are now being used to diagnose autoimmune gastritis and pernicious anemia, respectively [4].
  10. 10. (1) Dietary vitamin B12 is normally bound to proteins in food and is provided by food products of animal origin. (2) Pepsin and acid pH in the stomach will degrade these food proteins and release vitamin B12. (3) The vitamin B12 that is now free then binds to one of the three vitamin B12 binding proteins, called haptocorrin, which is produced by the salivary glands and the parietal cells in the stomach. In the duodenum the pH is now less acidic and this allows pancreatic proteases to degrade the haptocorrin, and vitamin B12 (both newly ingested and from the bile duct) is released again and binds tightly to Intrinsic Factor produced by parietal cells. (4) In the mucosal cells of the distal ileum the vitamin B12-Intrinsic Factor complex is recognised by special receptors.
  11. 11. 5) Vitamin B12 then enters the blood bound to another binding protein, transcobalamin, the complex is known as holotranscobalamin (Active B12). The majority of vitamin B12 (70-80%) in blood is bound to haptocorrin and only a minor proportion (20-30%) is bound to transcobalamin. (6) Holotranscobalamin (Active B12) is the biologically active fraction of vitamin B12 in the blood as it is in only this form that vitamin B12 is delivered to all the cells of the body. (7) Vitamin B12 absorbed in the intestine subsequently gets transported to the liver via the portal system. (8) There is extensive enterohepatic circulation of vitamin B12 and B12 is transported from the liver, via the bile duct, to the duodenum.
  12. 12. Cobalamin can be found in meat, milk, and eggs. Once ingested, pepsin and hydrochloric acid in the stomach release cobalamin from the food complex. R protein, which is released from gastric parietal cells, is conjugated with the cobalamin in the stomach. Some of these complexes enter the gallbladder to be stored, and some continue through to the duodenum, where pancreatic enzymes break up the complexes and release cobalamin. Intrinsic factor, released from gastric parietal cells, then conjugates with the free cobalamin in the duodenum, and the complex travels to the distal 80 cm of the ileum, where it is absorbed by the cubilin receptors.6 One study found that a small portion of free cobalamin is also absorbed by a mechanism that is independent of intrinsic factor.7 The plasma half-life of cobalamin is 6 days, and liver stores can persist for 3 to 5 years.8 The overall pathway is - See more at:
  13. 13. Microorganisms, primarily bacteria, are the only organisms known to manufacture B12. These bacteria are thought to live in water, soil, and the digestive tracts of animals. In animals, B12 is normally attached to a protein either for transport or storage. When humans eat animal foods, the B12 is protein-bound. When the proteinB12 complex reaches the stomach, the stomach secretes acids and enzymes that detach the B12 from the protein. Then, in a process unique to B12, another protein, R-protein (aka cobalophilin, haptocorrin, and transcobalamin I (1)) picks up the B12 and transports it through the stomach and into the small intestine. R-protein is found in many fluids in the human body including saliva and stomach secretions. In addition to B12, R-protein can pick up any corrinoid (2). The stomach cells also produce a protein called intrinsic factor (IF), which travels to the small intestine. When the corrinoid-R-protein complex gets to the small intestine, the corrinoid is liberated from the R-protein by enzymes made by the pancreas (3). Of the liberated corrinoids, only the cobalamins attach to intrinsic factor. Intrinsic factor then carries the cobalamins to the last section of the small intestine, the ileum.
  14. 14. The cells lining the ileum contain receptors for the cobalamin-IF complex. The cobalamin-IF complex protects the cobalamin against bacterial and digestive enzyme degradation (4). The IF-receptor also ensures that cobalamins will be given priority for absorption over non-cobalamin corrinoids. In addition to the IF mechanism, passive diffusion normally accounts for 1-3% of B12 absorbed when obtained through normal food sources (3). Some inactive B12 analogues are most likely absorbed through passive diffusion.
  15. 15. In supplements, B12 is not bound to protein, and therefore does not need digestive enzymes or stomach acid to be detached from a protein. Stomach acid is needed to dissolve some B12 tablets, especially if not chewed. When taken in large enough doses, unbound B12 can overcome intrinsic factor defects because so much can be absorbed through passive diffusion. There is some preliminary evidence that unbound B12, especially when combined with an absorption enhancer, can be directly absorbed through the membranes under the tongue at higher rates than through passive diffusion in the digestive tract.
  16. 16. After B12 is absorbed into the intestinal cells, it attaches to transcobalamin II (TC2). Transcobalamin II is made in the intestinal cells (7) where it picks up B12 and transports it to all body tissues through the blood and cerebrospinal fluid (1). Cyanocobalamin appears in the blood no longer than 5 hours after ingestion of B12 (10). While transcobalamin II transports B12 to cells, about 3/4 of the B12 in the blood is stored on haptocorrin (aka transcobalamin I and cobalophilin) (11, 12). Once the B12-TC2 complex arrives at the cell where it is needed, B12 is released from TC2 in the form of hydroxocobalamin. It is then turned into methylcobalamin or adenosylcobalamin (3) and used for their respective enzymes. Transcobalamin II also transports B12 to the liver for storage on transcobalamin III. If the circulating B12 exceeds the binding capacity of the blood, the excess is excreted in the urine. This normally happens only after a B12 injection (5).
  17. 17. References: /dx.html