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Because a healthy liver is able to store several years' worth of vitamin B12, signs of deficiency may not be obvious for a long time. Vitamin B12 can not be absorbed on its own: it must first combine with another substance called 'intrinsic factor' which is produced by your stomach lining. B12 is stored in the liver after it is absorbed, and any excess is excreted in the urine. Another cause is the bowel failing to absorb vitamin B12 because it has been damaged by disease (e.g. Crohn's disease) or shortened by surgery (usually to treat bowel disease).
B12 is absorbed by the part of the bowel called the ileum, so surgery to remove the ileum (an ileostomy) is quite likely to cause B12 deficiency. A test for low stomach acid (achlorhydria) is an important part of the investigation, and a blood test that shows the typical changes in the red blood cells is also essential.
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