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6 Multiple microbes in both the small and large intestines can convert dietary L-carnitine into GBB, but relatively few can transform GBB into TMA.13 The GBB-to-TMA conversion is much higher in omnivores than in vegans and vegetarians, likely because of differences in the gut microbiota, although this aspect of the L-carnitine-to-TMAO pathway is not fully understood

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On reviewing literature, it became apparent that chronic paracetamol ingestion in nontoxic doses was being increasingly reported as a cause for HAGMA [2]

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