appoach to anemia 07

8/3/2019 Appoach to Anemia 07

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Anemiay Definition: Low Hemoglobin concentration.


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Reference ranges for Hbs at different ages

Age group Hb range (g/dl)

Newborn (< 1 week) 14 22

6 months old 11 14

Children (1 16 years) 11 15

Adults

Men

Women

13 16

12 - 14


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Anaemia

Clinical grading (Adults)

Mild (Hb > 10 g/dl) Asymptomatic

Moderate (Hb 7 10 g/dl) Pallor, lethargyDyspnoea, vertigo

headache

Severe (Hb < 7 g/dl) Tachycardia

hypotension


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Mechanisms of anaemia

1. Decreased productiony Ineffective erythropoiesis

y Deficiency of B12/folate

y Abnormal synthesis of haemoglobin (thalassaemia)

y Decreased effective erythropoiesisy Aplastic anaemia/marrow failure

2. Increased blood lossy Gastrointestinal bleeding

3. Increased destructiony haemolysis


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Classification of anaemia

1. Morphologicaly Based on red cell indices and blood film

y Hypochromic microcytic anaemia (MCVq, MCHq)

y Normochromic normocytic anaemia (MCV N, MCH N)y Normochromic macrocytic anaemia (MCVo, MCH N)

2. Pathophysiological

y Based on causes of anaemiay Iron deficiency anaemia

y Megaloblastic anaemia

y Haemolytic anaemia


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Classification of anaemia

y MCV mean corpuscular volume (fl)

y MCH mean corpuscular Hb (pg)

MCV (80 100 fl) Normocytic

MCV (< 80 fl) Microcytic

MCV (>100 f l) Macrocytic

MCH (27 - 32 pg) Normochromic

MCH (< 27 pg) Hypochromic


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History Takingy Any blood loss

y Melena, epigastric painy Menorrhagiay

Hemoptysisy Per rectal bleed

y Family hx of blood transfusiony Traditional meds/ drugs ingestiony Bleeding tendency, recurrent fever, infectionsy A

utoimmune ds oral ulcer, hair loss, photosensitivityy Dietary intakey Sx of anemia lethargy, reduced effort tolerance, angina,

dyspnea, giddiness, syncope, palpitation, LOW, LOA


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Physical Examinationy Conjunctiva pallory Jaundicey Angular stomatitis

y Glossitisy Gum hypertrophyy Thalassemic facies (frontal bossing, malar prominence)y Bruisingy Lymphadenopathy

y Koilonychiay Leukonychiay Cachexiay Hepatosplenomegalyy Propioceptive loss prenicious anemia


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I

nvestigationsy First step to diagnosis: look at MCV!!!

y Microcytic anemia

y Iron deficiency anemia

y Thalassemia

y Anemia of chronic disease

y

Sideroblastic anemia


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y Macrocytic anemia

y Folate deficiency

y B12 deficiencyy Hypothyroidism

y Chronic liver disease

y Alcohol excess

y Reticulocytosis eg with hemolysisy Myelodysplastic syndrome

y Cytotoxic drugs


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y Normocytic anemia

y Acute blood loss

y Anemia of chronic diseasey Bone marrow failure

y Pregnancy

y Hypothyroidism (can be macrocytic too)

y Hemolysis (can be macrocytic too)


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Microcytic anemiay Serum Iron, TIBC, ferritin

y PBF

y Stool occult bloody Stool ova and cyst

y Endoscopy (if hx, PE suggestive)


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yLow Iron, Low TIBCy Anemia of chronic disease

y Low Iron, High TIBC

y Iron deficiencyy Causes: blood loss, malabsorption (Celiac ds), low

intake, hookworm

y Stool occult blood, ova & cyst, endoscopy

y Normal Iron, TIBC, ferritin

y Hb electrophoresis Thalassemia


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Macrocytic Anemiay PBF

y B12 level

y Folate levely LFT, GGT

y T4, TSH

y Retic count

y Bone marrow biopsy if cause not revealed by abovetests


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y B12 deficiency

y Dietary e.g vegans

y Malabsorptiony Lack of intrinsic factor (pernicious anemia) Schilling test,

anti-parietal cell Ab

y Post gastrectomy

y Ilieum resection

y Chrons disease


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y Folate deficiency

y Dietary poverty

y

Pregnancyy Malabsorption - Celiac disease

y Drugs phenytoin, MTX, sodium valproate

** never treat without folate in low B12 state, amyprecipitate subacute combined degeneration of cord


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Hemolytic Anemiay Causes:

y Acquired

y Immune mediated drug induced,

AIHA

y Isoimmune transfusion reaction

y Infection - malaria

y Hereditary

y Enzyme defect: G6PD deficiency, pyruvate kinase deficiency

y Membrane defect: hereditary spherocytosis, sickle cell disease,Thalassemia


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y Clues

y Anemia normocytic

y

Jaundicey Dark colored urine hemoglobinuria

y Hepatosplenomegaly


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Investigations (as appropriate)y FBC

y Retic count

y LDH

y LFT

y Bilirubins (direct, indirect)

y UFEME

y Coombs test direct

y

BFMPy G6PD level

y Hb electrophoresis

y Plasma haptoglobin

appoach to anemia 07

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