Elevated H/H, very low Folic Acid/B12

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One year s/p bariatric surgery. Hemoglobin 19 and Hematocrit 56 (high) all other indices completely normal. Folate 300 ng/mL. (very low) and Vitamin B12 180 (very low)!

Anyone else make sense of this? I'm personally redrawing everything in two months but I referred to hematology.

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I would wait for hematology, meanwhile, refer back to bariatric surgeon. But we can't give advice on the board.

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Specializes in Medical and general practice now LTC.

Is this personal request for information or for a patient?

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Specializes in Nephrology, Cardiology, ER, ICU.

Moved to NP forum

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Specializes in ICU, LTACH, Internal Medicine.

Vitamin B12 has a great reserve in liver. It is a cofactor, so it is not actually "spent" and it particitates in rather limited amoung of reactions, intencity of which decreases as one ages. Assuming you stop absorbing it completely for some reason in adulthood and were well fed before it, it will take you 10 years or so to manifest as clinical deficiency even with low serum level.

Folic acid pathodynamic is estimated in months under similar circumstances.

Make sure the patient is not dehydrated, which will artificially bump H&H up (common thing for AM fasting labs). He also might have COPD or still be morbidly obese or smoke or have overlap syndrome/OSA, all that causing elevated Hb through hypoxia mechanism.

A little supplement probably won't hurt anybody but I personally hate to treat numbers. Make sure the patient eats what he is supposed to and follows with bariatric RD and not going into sny fad diets.

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I agree with KatieMI

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Definitely remember smokers can have an elevated hematocrit.

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Also if they are living above sea level like on a mountain.

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Specializes in Family.

EPO?

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Specializes in ICU, LTACH, Internal Medicine.
On 6/24/2019 at 12:47 AM, Kahalaukane said:

EPO?

That would be either CKD at least IV (in which case he likely wouldn't go bariatric and wouldn't be so high) or use for doping in sports (in which case bariatric also unlikely). Too much a zebra to even considering as a possibility.

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Specializes in Emergency medicine.

Need an assessment. Who is this patient? What symptoms are they having? Why were the labs ordered? Consider age, personal, family and social history. Specifically, what bariatric surgery was done?

What’s your differential for polycythemia?

What’s your ddx for folate and b12 deficiency? Consider ingestion and absorption. What would interfere with that? Consider use/elimination- what could increase those processes?

In deciding whether to treat the deficiency, do the presence or absence of symptoms or related findings (e.g. macrocytosis) dictate treatment? Does the etiology of the deficiency help you decide if you should give PO, IM or IV treatment?

Much more to think about here, and it’s within the scope of primary care.

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Specializes in Emergency medicine.
On 6/25/2019 at 9:42 AM, KatieMI said:

That would be either CKD at least IV (in which case he likely wouldn't go bariatric and wouldn't be so high) or use for doping in sports (in which case bariatric also unlikely). Too much a zebra to even considering as a possibility.

...or cancer.

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