Background
Pernicious Anemia (PA) is a chronic illness that is caused by impaired absorption of vitamin B-12 due to lack of (IF) intrinsic factor in gastric secretions. It is a condition in which the body lacks a sufficient number of red blood cells (hemoglobin). Present within red blood cells, hemoglobin is important for carrying oxygen in all body tissues. Pernicious anemia is therefore a decrease in red blood cells which occurs when one’s intestines cannot absorb vitamin B12 properly. The body needs vitamin B12 to make red blood cells. Pernicious anemia is most prevalent in Caucasian people of northern European lineage than in other racial groups. Precisely, in this particular population, 11-20 persons per 100, 000 persons every year are diagnosed with pernicious anemia (Swanson, 2013, p. 79). This disorder can cause other problems such as digestive tract problems, nerve damage and neurological problems such as loss of memory.
Causes/Disease Process
Pernicious anemia is caused by a lack of vitamin B12 which is required for regular production of red blood cells. Often hereditary, its risk factors include; a family history of pernicious, a history of autoimmune disorders and Northern Europe or Scandinavian descent. The dairy products and meat we consume are the primary sources of vitamin B12 therefore; anemia is not only caused by not consuming these foods. It is mainly caused by a failure in the complex process which the digestive tract goes through to absorb vitamin B12. Secondly, the body needs folic acid, vitamin B12 and iron to produce more red blood cells, therefore if there is a lack of any of these nutrients, anemia will then develop.
Common causes of pernicious anemia include:
- Not consuming enough foods that contain vitamin B12
- Weakened stomach lining (atrophic gastritis)
- An autoimmune condition in which the immune system of the body attacks the cells that make it or the intrinsic factor (U, S. G. P. O., 2012, p. 213).
Symptoms
Some people do not have symptoms while in others, symptoms are mild which can include:
- Diarrhea
- Fatigue – lack of energy or light-headedness with exertion or when standing up.
- Loss of appetite
- Problems concentrating
- Pale skin
- Swollen, bleeding gums or red tongue
Untreated pernicious anemia could lead to other disorders and neurological complications while serious cases could result in death (Friedman, 2011, p. 114).
Pathophysiology
In order for vitamin B12 to be fully absorbed by the small intestines, a substance called intrinsic factor (IF) must be produced by the cells that line a part of the stomach. Lack of the intrinsic factor could also be present at birth (congenital). In some rare cases, pernicious anemia is passed down through families (congenital pernicious anemia). Seemingly, babies with this type of disorder cannot properly absorb vitamin B12 in the small intestines and do not make a sufficient intrinsic factor. Among adults, symptoms of pernicious anemia normally are not seen until after like 30 years. Notably, the average age of diagnosing pernicious anemia is age 60 (Hooper, 2012, p. 79).
Diagnosis/Evidence Based Practice
A doctor diagnoses pernicious anemia based on; one’s family and medical histories, test results and a physical exam. The doctor finds out whether the condition is due to deficiency of intrinsic factor or probably another cause. Secondly, the doctor would want to know the severity of the condition to determine its treatment.
- Medical and Family Histories
The doctor could ask about the symptoms and signs, diet and any medicines taken, whether one has any digestive disorders such as Crohn’s disease or celiac disease. Whether the patient has a history of pernicious anemia or whether the patient’s family has a history of autoimmune disorders such as; 1 diabetes or Addison’s disease.
- Physical exam
During the physical exam, the doctor could check for yellowish or pale skin and enlarged liver. She or he could also listen to the patient’s heart for a heart murmur or rapid or irregular heartbeats. The doctor could also check for signs of damaged nerves and how well the patient’s eyes, muscles, senses or reflexes work. He or she could also ask questions or probably do tests to check their coordination, mental status and ability to walk.
- Diagnostic Tests and Procedures
Procedures and blood tests can help diagnose pernicious and also establish its cause.
- Complete Blood Count;
It is usually the first step used to diagnose various types of anemia. It measures many parts of the patient’s blood where a small amount of blood using a needle is drawn from a vein. A CBC device checks the hematocrit and hemoglobin levels. The CBC also checks the number of white blood cells, red blood cells and platelets in the body. Abnormal results could be a sign of anemia, an infection, blood disorders or another condition. Lastly, the CBC looks at mean volume (MCV) corpuscular (kor-pus-kyu-lar). MCV which is a measure of the average size of the patient’s red blood cells can be a clue to the cause of anemia. Precisely, in pernicious anemia, the red blood cells are normally larger than normal (Paulman, 2012, p. 89).
- Bone Marrow Test
This test shows whether the bone marrow is making enough blood cells and if it is healthy. The two bone marrow tests are biopsy and aspiration (as-pi-RA-shun). For a biopsy, the doctor extracts a small amount of bone marrow tissue through a bigger needle and for aspiration; the doctor removes a small amount of fluid bone marrow using a needle. Seemingly, in pernicious anemia the bone marrow cells which turn into blood cells are usually larger than normal.
Treatment
Arguably, there is no permanent cure for pernicious anemia however; certain methods are used to accomplish repletion of B12
- Intramuscular Injections – This method allows the regularity of injections to be tailored to ease to the serum cobalamin levels of the patient. It is a recommended method to administer CN-Cbl in 3 stages; 1000 μg a day for a whole week, 1000 μg/week for a month and 1000 μg/month for life (Case, 2012, p. 114).
- Oral doses - Treatment with OH-Cbl and CN-Cbl provides cells with a good source of cobalamin which can be internalized to create coenzyme forms.
Other treatments include;
- SNAC Complex
- Recombinant Intrinsic Factor
- Sublingual/Intranasal Delivery
- Transdermal Patches
Prevention
Basically, there is no known method to prevent this type of vitamin B12 anemia. Conversely, early detection and treatment of this disorder can greatly help reduce complications. Possible complications could occur if people with pernicious anemia do not have gastric polyps and more likely to develop gastric carcinoid tumors and gastric cancer.
Follow up
- Admit to hospital for severe anemia.
- Continued outpatient visits are very necessary to ensure patients are receiving medication and are responding to treatment well.
- Refer to a neurologist if strange neurological manifestations appear.
Cost
The cost of treating pernicious anemia varies with the type of treatment and medication. For a dose of B12 (10mg thrice a week) for nerve pain runs about $25.00 a month. The normal cost of injections is $450 a month from the pharmacy, while Metafolin costs around $2.50 a day though there are substantial charges at the grass level that amount to $60 a month (Aronson, 2007, p. 115).
Morbidity/Mortality
Seemingly, patients on appropriate therapy have a normal lifespan. In addition to that, patients following the right medication have a high chance of healing gradually. However, untreated pernicious anemia can lead to CHF due to severe anemia and permanent neurological dysfunction. In most cases, incidences of gastric adenocarcinoma are two to three times greater than in the general population. Generally, the rate of complications during the thirty days following surgery normally ranges from 8% for laparoscopic procedures to nearly 15% for open incision operations. Studies show 0% mortality rate out of 400 laparoscopic cases and 0.7% out of open procedures (23 deaths) (Wolters, 2013, p. 450).
References
U, S. G. P. O. (2012). Code of federal regulations title 21: Fodd and drug administration. S.l.: U S Govt Printing Office.
Hooper, M. (2012). Pernicious Anaemia. Hammersmith Health Books.
Swanson, R. W., & Tallia, A. F. (2013). Swanson's family medicine review: A problem-oriented approach. Philadelphia, PA: Mosby/Elsevier.
Friedman, T. C., Friedman, M. D. P. D. T. C., & Scherer, W. Y. (2011). The Everything Guide to Thyroid Disease: From Potential Causes to Treatment Options, All You Need to Know to Manage Your Condition and Improve Your Life. Holbrook, MA: F+W Media.
Paulman, P. M. (2012). Signs and symptoms in family medicine: A literature-based approach. Philadelphia, PA: Elsevier/Mosby.
Aronson, J. K. (2007). Side effects of drugs annual 29: A worldwide yearly survey of new data and trends in adverse drug reactions. Amsterdam: Elsevier.
Wolters Kluwer Health. (2013). Professional guide to diseases. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
