Fluids, Electrolytes & Nutrition: Vitamins

General Physiology

Definition

  • Vitamin Definition: Essential Organic Micronutrients
  • Types:
    • Fat-Soluble Vitamins (4)
    • Water-Soluble Vitamins (9)

Fat-Soluble Vitamins

  • Includes 4 Vitamins:
    • Vitamin A
    • Vitamin D
    • Vitamin E
    • Vitamin K
  • Absorbed Through the Intestinal Lumen in Chylomicrons
    • Exported by Exocytosis into Lymph
    • Bile is Essential for Absorption
  • Stored in Liver & Adipose Tissue

Water-Soluble Vitamins

  • Includes 9 Vitamins:
    • Vitamin B1 (Thiamine)
    • Vitamin B2 (Riboflavin)
    • Vitamin B3 (Niacin)
    • Vitamin B5 (Pantothenic Acid)
    • Vitamin B6 (Pyridoxine)
    • Vitamin B7 (Biotin)
    • Vitamin B9 (Folic Acid)
    • Vitamin B12 (Cobalamin)
    • Vitamin C (Ascorbic Acid)
  • Dual Sources:
    • Dietary Source – Mostly Absorbed in Small Intestine
    • Intestinal Microbial Synthesis – Absorbed in the Large Intestine
  • Not as Readily Stored
    • Require More Consistent Intake
    • Deficiency is More Common

Fat-Soluble Vitamin Deficiency

Vitamin A

  • Effects:
    • Nyctalopia (Night Blindness)
    • Xerophthalmia – Dry Eyes from Insufficient Lacrimal Gland Function with Bitot Spots (Squamous Cell Proliferation & Keratinization)
  • Causes:
    • Malnutrition
    • Fat Malabsorption
      • Cystic Fibrosis
      • Pancreatic Insufficiency
      • Celiac Disease
      • Primary Biliary Cholangitis
      • Crohn’s Disease
      • Short Gut Syndrome
    • Bariatric Surgery & Gastric Bypass

Vitamin D

  • Effects:
  • Causes:
    • Malnutrition or Inadequate Oral Intake
    • Fat Malabsorption
      • Cystic Fibrosis
      • Pancreatic Insufficiency
      • Celiac Disease
      • Primary Biliary Cholangitis
      • Crohn’s Disease
      • Short Gut Syndrome
    • Bariatric Surgery & Gastric Bypass
    • Inadequate Sunlight Exposure
    • Cirrhosis or Renal Failure

Vitamin E

  • Effects:
    • Ataxia & Hyporeflexia
    • Peripheral Neuropathy
    • Myopathy
    • Hemolytic Anemia
    • Thrombocytosis
  • Causes:
    • Malnutrition or Inadequate Oral Intake – Rare in Developed Countries
    • Fat Malabsorption
      • Cystic Fibrosis
      • Pancreatic Insufficiency
      • Celiac Disease
      • Primary Biliary Cholangitis
      • Crohn’s Disease
      • Short Gut Syndrome
    • Bariatric Surgery & Gastric Bypass

Vitamin K

  • Effects:
    • Coagulopathy – Impaired Production of Vitamin K-Dependent Coagulation Factores
      • Easy Bruisability
      • Mucosal Bleeding
      • Melena
      • Hematuria
  • Causes:
    • Malnutrition
    • Fat Malabsorption
      • Cystic Fibrosis
      • Pancreatic Insufficiency
      • Celiac Disease
      • Primary Biliary Cholangitis
      • Crohn’s Disease
      • Short Gut Syndrome
    • Bariatric Surgery & Gastric Bypass
    • Antibiotics

Water-Soluble Vitamin Deficiency

Vitamin B1 (Thiamine)

  • Effects:
    • Wernicke-Korsakoff Syndrome
      • Wernicke Encephalopathy – Nystagmus, Ataxia & Confusion
      • Korsakoff Syndrome – Impaired Short-Term Memory & Confabulation with Otherwise Grossly Normal Cognition
    • Dry Beriberi – Peripheral Neuropathy
    • Wet Beriberi – Cardiomyopathy & Heart Failure with Peripheral Edema
  • Causes:
    • Chronic Alcoholism
    • Bariatric Surgery & Gastric Bypass
    • Total Parenteral Nutrition (TPN) with Inadequate Supplementation

Vitamin B2 (Riboflavin)

  • Effects:
    • Glossitis – Tongue Swelling
    • Angular Stomatitis/Cheilitis – Inflammation and Crusting of the Corners of the Mouth
    • Sore Throat with Hyperemia of Pharyngeal Mucous Membranes
  • Causes:
    • Malnutrition & Starvation

Vitamin B3 (Niacin)

  • Pellagra – Niacin Deficiency
  • Effects: Mn
    • Dermatitis: Symmetric Hyperpigmented Rash Similar to a Sunburn in Sun-Exposed Areas
    • GI Sequelae: Nausea, Vomiting & Diarrhea
    • Neurologic Sequelae: Anxiety, Encephalopathy & Dementia
  • Causes:
    • Chronic Alcoholism
    • Bariatric Surgery & Gastric Bypass
    • Carcinoid Syndrome
    • Prolonged Use of Isoniazid

Vitamin B5 (Pantothenic Acid)

  • Effects:
    • Burning Feet Syndrome – Paresthesias & Dysesthesias
  • Causes:
    • Malnutrition & Starvation (Rare, Generally During Famine or War)

Vitamin B6 (Pyridoxine)

  • Effects:
    • Microcytic Anemia
    • Peripheral Neuropathy
    • Glossitis/Beefy Tongue
    • Photosensitivity
  • Causes:
    • Medications (Isoniazid, Hydralazine or Levodopa-Carbidopa) – Most Common
    • Chronic Alcoholism

Vitamin B7 (Biotin)

  • Effects:
    • Facial Dermatitis
    • Conjunctivitis
    • Alopecia
    • Lethargy
    • Encephalopathy
  • Causes:
    • Total Parenteral Nutrition (TPN) with Inadequate Supplementation
    • Ingestion of Large Amount of Raw Egg Whites (Contain Adivin Which Prevents Biotin Absorption)

Vitamin B9 (Folate/Folic Acid)

  • Develops Over Weeks-to-Months (Compared to Vitamin B12)
    • Relatively Smaller Amount Stored
  • Effects:
    • Macrocytic Anemia
    • Jaundice
    • Oral Ulcers
    • Elevated Homocysteine but Not Methylmalonic Acid (MMA)
  • Causes:
    • Inadequate Dietary Intake – Rare in Developed Countries with Fortified Foods
    • Chronic Alcoholism
    • Anorexia
    • Goat Milk (Compared to Cow Milk)

Vitamin B12 (Cobalamin)

  • Develops Over Years (Compared to Folate)
  • Effects:
    • Macrocytic Anemia
    • Jaundice
    • Peripheral Neuropathy
    • Glossitis
    • Elevated Homocysteine & Methylmalonic Acid (MMA)
  • Causes:
    • Pernicious Anemia
    • Veganism (Inadequate Dietary Intake from Animal-Based Foods)
    • Bariatric Surgery & Gastric Bypass
    • PPI Use
    • H pylori Infection

Vitamin C (Ascorbic Acid)

  • Effects:
    • Poor Wound Healing
    • Scurvy – Bleeding Gums, Petechiae, Loose Teeth & Arthralgia
  • Causes:
    • Severe Malnutrition
    • Diet without Any Fruits or Vegetables
    • Drug Abuse
    • Chronic Alcoholism

Mnemonic

Vitamin B3 Deficiency

  • 3-D’s of Pellagra
    • Dermatitis
    • Diarrhea
    • Dementia
  • *4-D’s if Including Death