Perplexed over lab work

[aybaylay]

Hello,

I am a 32 y/o white female.

Some history about me that may be applicable:

Surgeries: Gallbladder removed (2011), Gastric Sleeve (2017)

Weight loss surgery: Started at 332lbs, currently fluctuate between 178-185.

Diagnoses: Major Depressive Disorder, GERD (resulting from WLS), ADHD, Anemia

I have one child and had a high-risk pregnancy with him due to an elevated AFP level. He developed IUGR and stopped growing at 36 weeks. Delivered via induction at 37w3d. He weighed 5 1/2 pounds with no health issues.

I should have received a blood transfusion after giving birth based on my extremely low hemoglobin after birth but didn't (I didn't see those results until I happened upon them over a year later). I've struggled with anemia, low iron, low b-12, low ferritin and low folate since then. I had an iron transfusion in July 2022 but it did not make much of a difference in my levels. I've used various supplements that also have not made much of a difference, if any. I also developed hypothyroidism after giving birth and took Armour thyroid for 2 years. My levels returned to normal and my doctor took me off the medication. Until now, my levels remained normal.

I have extreme fatigue, low stamina, intolerance to exercise, brain fog, migraines, insomnia and trouble staying asleep, restlessness.

Below are some of my recent lab work results. I've included those that measured outside normal parameters and those that were borderline as well. I'm looking for some insight if any of these have a correlation to something that may explain my symptoms/history and any recommendations for additional tests.

FERRITIN 12.4 Low (Normal Range: 23.9-336.2 (ng/mL))

IRON 93 (Normal Range: 50-212 (ug/dL))

TOTAL IRON BINDING CAPACITY 329 (Normal Range: 274-476 (ug/dL))

PERCENT SAT TIBC 28 (Normal Range: 20-50 (%))

VITAMIN B12 201 (Normal Range: 180-914 (pg/mL))

FOLATE > 20.00 (Normal Range: 5.90-22.00 (ng/mL))

CALCIUM 8.4 Low (Normal Range: 8.6-10.3 (mg/dL))

VITAMIN D 29.4 Low (Normal Range: 30-100 (ng/mL))

AST 13 (Normal Range: 13-39 ([iU]/L))

ALT 9 (Normal Range: 7-52 ([iU]/L))

GLOBULIN 2.3 (Normal Range: 1.9-3.8 (g/L))

ALK PHOS 58 (Normal Range: 41-126 (U/L))

PROLACTIN 31.43 High (Normal Range: 3.34-26.72 (ng/mL))

ESTRONE MAYO 34 (Normal Range: 17-200 (pg/mL))

ESTRADIOL MASS SPEC MAYO 81 (Normal Range: 15-350 (pg/mL))

PROGESTERONE 4.04 - Blood was drawn two days before period started. I have a very short luteal phase and my cycles range from 23-28 days. My doctor said it was high and "pregnancy level" but based on my period it appears low, not high). I am NOT pregnant.

TESTOSTERONE TOTAL MAYO 14 (Normal Range: 8-60 (ng/dL))

My doctor is rechecking hormones and also adding a cortisol test and sending me for an MRI to check for issues with my pituitary gland.

Any insight you may have would be helpful.

[wedgewood]

Having had a gastric sleeve operation , I am surprised that you are not on B 12 injections FOR LIFE Often enough to keep your symptoms at bay . You should get these injections ASAP . See your GP about this as soon as you are able , please . Very best wishes . VERY IMPORTANT!!!

[Nackapan]

Of what I understand your ferritin is low .Are ypu prescribed iron?

Low ferritin causes several of the symptoms you have.

Do you take daily vitamin D ?

Are you on B12oral supplements ?

If so ask for b12 injections now .

Have you had an IfAB trst?

[wedgewood]

Download the latest NICE ( National Institute for Health and Care Excellence). guidance on B12 management. ( published in March 2024 )

nice.org.uk/guidance/ng239

On page 18 you will read that bariatric surgery ( gastric sleeve op is one such surgery , which you had in 2017 ) should be treated with LIFELONG INTRAMUSCULAR B12 REPLACEMENT. PLEASE show this to your GP. .Im so concerned about you . I woke in the night and kept thinking of you . It fits that after your bariatric surgery in 2017, you are now experiencing B12 deficiency, because you have now used up your liver stores of b12 which has kept you going up till now . You should have received B12 injections straight after surgery .

The fundus section of your stomach is removed during the gastric sleeve operation. This is where the Parietal cells are found . These cells produce the intrinsic Factor and stomach acid . Both are needed to absorb Vitamin B12 . Stomach acid is needed to break down and absorb other vitamins , minerals and trace elements .So you are likely to be deficient in other vitamins and minerals . Enzymes in saliva do a bit of the work in breaking down food , but not enough . Chew your food well and eat small meals more often .

You really need a good nutritionist to help you with your lack of stomach acid . GPs are often ignorant on nutrition .

If you don’t get immediate treatment , change your doctor .

See to this ASAP . please

Pernicious Anaemia is referred to as Autoimmune Gastritis in this document . It is explained why they do this .

[Parlay]

I’m no expert with with surface area of the stomach made smaller does that not make it way more difficult to absorb a lot of vitamins minerals etc. I know a lot are absorbed in the small bowel but the stomach was designed with a large surface area for a reason. I hope you get it sorted and feel better soon.

[wedgewood in reply to Parlay]

Yes vitamins and minerals are absorbed in the small bowel , but only after they have been broken down by stomach acid and in the case of B12 by stomach acid and the help of the Intrinsic Factor , both of which are produced in the Parietal cells which the Gastric Sleeve operation removes .

[Parlay in reply to wedgewood]

So how does someone that’s had this surgery guarantee getting all the nutrients they need. That’s quite concerning. Even supplements would need breaking down surely? It begs the question if sleeves are good in the long term, yes they do amazing in many ways on weight, joints etc but what then with ongoing health from lack of nutrients?

[Parlay in reply to Parlay]

I would like to add I’m asking from a point of ignorance as I really don’t know!

[wedgewood in reply to Parlay]

Since being diagnosed with P.A.( had to go privately although I couldn’t afford it ) with a positive IFAB test , I’ve read every book and article possible about PA/ B12 deficiency . I’d had a terrible time before hand , ignored by doctors and more or less told I was a hypochondriac. I have huge sympathy with people who are going through simlilar .

Yes , the gastric sleeve op seems wonderful , but there are drawbacks . Doctors are not great whenbi comes to nutrition . I have an acquaintance who had the gastric sleeve op and I knew that B12’injections were given for lifetime after this op .

I looked up information on the operation , and the part of the upper stomach where the parietal cells are , the fundus , is totally removed . That is a huge drawback unless the problem of lack of Intrinsic Factor and Stomach acid is addressed . As a PA patient I have to add some acid drink when I eat protein . Had to find that out myself . My doctors were totally ignorant of this .

Must go now and have a sleep!

Best wishes .

[Sleepybunny]

Hi,

Welcome to the forum.

A few B12 links that might be useful.

PAS (Pernicious Anaemia Society)

Based in Wales, UK. Has overseas members.

pernicious-anaemia-society....

B12info.com

b12info.com/

B12 Awareness (US website)

b12awareness.org/

Stitchting B12 Tekort (Dutch B12 website with English articles)

stichtingb12tekort.nl/english/

B12 Institute - Netherlands

Has useful lists of causes and symptoms.

b12-institute.nl/en/home-2/

Two useful B12 books

Published a few years ago so some bits might need updating.

Could It Be B12?: An Epidemic of Misdiagnoses by Sally Pacholok and J.J. Stuart (US authors).

Very comprehensive. Lots of case histories.

What You need to Know about Pernicious Anaemia and Vitamin B12 deficiency

by Martyn Hooper, former chair of PAS (Pernicious Anaemia Society)

Do you mind me asking which country you are in?

The reason I'm asking is that patterns of treatment/diagnostic process can vary between countries.

Knowing where you are may help people to post relevant info.

If you're in UK, I can pass on a lot more info.

I'm not medically trained.

[bookish]

As well as the likely effect of the gastric sleeve on your parietal cells and therefore stomach acid and intrinsic factor, it is possible that the gallbladder removal would have affected bile processing such that entero-hepatic circulation of B12 has also been compromised. Your folate is quite high in range, which if unsupplemented could be a sign of low cellular B12. The serum B12 is low too of course. Has anyone checked active B12, homocysteine, methylmalonic acid, parietal cell antibodies, intrinsic factor antibodies? If you have tried oral B12 without benefit, you may have to ask for injections on the basis of the two surgeries. Best wishes

[Gambit62 Administrator]

 Hidden ferritin is a protein that binds to iron and as such it tends to be a good indicator of iron status but it does not tell the whole story.

Whilst ferritin is low in the results above they also include some direct measures of iron that imply iron levels are actually okay.

Low ferritin should be a flag to do an iron panel to check for low iron. It should not be used as a single measure to determine iron deficiency. There have been cases of patients who have suffered iron toxicity because their GPs treated them purely on the basis of a ferritin result without doing a full iron panel to check that the patient really is iron deficiency.