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Additional risk factors include: Chronic kidney disease : Reduced renal clearance may impair B12 excretion Liver disease : Hepatic dysfunction can disrupt B12 metabolism and storage Myeloproliferative disorders : Certain blood cancers increase B12-binding proteins Concurrent medication use : Some drugs may interact with B12 metabolism, including metformin, proton pump inhibitors, and H2 antagonists Patients with these conditions should have B12 supplementation carefully monitored by their healthcare team

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Defecation disorders, including dyssynergia (the puborectalis is spastic) and anismus (the anal sphincter does not relax), could reduce emptying of the left colon which leads to abdominal pain or distension [22]