B12 meat products.
You pick up R-factor.
Next, you’re done in your
acid in your stomach.
You need that acid to properly
convert your pepsinogen into pepsin.
We talked about that.
While you’re there, in your
stomach from your parietal cell,
you pick up intrinsic factor.
This intrinsic factor then binds to B12,
along with this you also have R-factor.
All of this we just did.
You get into duodenum.
From the pancreas, you get your enzyme.
This enzyme from the pancreas
removes the R-factor only.
So now, what are you left with?
Intrinsic factor, B12.
This complex will then move to where?
Terminal ileum for reabsorption.
B12, intrinsic factor.
IF is intrinsic factor.
Goes to terminal ileum and here
comes transcobalamin type II.
I would know that.
I would know transcobalamin.
What’s another name for B12?
Know that as well.
Make sure you know all the different
names of your B vitamins.
That’s important, very.
For example, if you say B1, you’re
going to think about thiamine.
B3, niacin, right?
So on and so forth.
If you’re thinking B6, pyridoxine.
So you wonder
it delivers the B12 from the
terminal ileum to the liver.
So can you have a patient that has --
can you have a patient that has
transcobalamin II deficiency?
Results in B12 deficient.
Okay now, we’re not quite done yet because
you might have heard of Schilling test.
And it’s not that you’re
actually going to perform it.
It’s out of date
and clinical practice, you
don’t want to unnecessarily
expose your patient
Is that clear?
So I’m not going to walk you through the
procedure for Schilling, any of that.
But there is one huge physiologic concept
that you need to take out of Schilling
and then utilize that
with your treatment.
You’ll see what I’m referring to.
Before we move on though,
let me ask you a question.
When you find a substance in
your urine and you've eaten it,
meaning that you ate it first --
Make sure we’re clear.
You’ve eaten something first
and it ends up in your urine,
tell me what happened to
that substance first.
You reabsorbed that substance
first from the intestine,
then you got it into the blood and then you
went to the kidney and you filtered it.
That’s the only way.
The kidney doesn’t filter
the intestine, right?
So meaning to say that if you
find something in your urine,
it had to have been reabsorbed first.
Is that clear?
If it’s not reabsorbed,
where does it end up?
What did you do this morning maybe?
You passed stool?
Yeah, it will end up in your feces.
Is that clear?
Why is that important?
Let me ask you a simple question.
If your patient has megaloblastic anemia
and starts showing signs
of neurologic deficit
and now at this point, there is
absolutely no B12 in the urine.
You give intrinsic factor and you find
B12 in the urine, what’s your diagnosis?
So what we’ll do, ladies and
gentlemen, we’ll go from head to toe.
Is it a vegan?
Or is it an elderly with malnutrition?
Is it a patient with pernicious anemia?
Is it a patient with pancreatitis?
Is it a patient with bacterial overgrowth?
Anytime you then find
cobalamin in your urine
with giving that companion,
whether it be R-factor, intrinsic
factor or whatever enzymes,
then you know that that
is your diagnosis.
So you will see what I’m referring to but
I’m just setting things up here for you.