Approach To Anemia: Bisrat D

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Approach to anemia

Bisrat D.
Normal Red Cells

No nucleus, enzyme
packets
Biconcave discs – Haem +
Gl
Center 1/3 pallor
Pink cytoplasm (Hb filled)
Cell size 7- 8 µ - capill. 2 µ
Na less, K more inside
100-120 days life span
The Factory – Bone Marrow

From stem cells (pleuripotent)


75% of marrow for WBC
25% of BM for Red cells
Erythroid / Granulocyte Ratio
1:3
E:G ratio increases in Anemia
Large white areas are marrow
fat
Normal BM
High Power Aplastic Anemia
E:G=1:3
Myelofibrosis
Definition of Anemia
• Decrease in the quantum of circulating RBC mass
and there by ↓ O2 carrying capacity
• Serum hemoglobin level or hematocrit less than
the expected value for age- and sex-matched
normal persons
• WHO criteria
 Adult men
• hemoglobin concentration <140 g/L (<14 g/dL) or
Adult women
• hemoglobin concentration <120 g/L (<12 g/dL) or
What is Anemia ?

Important to remember
• Anemia is a clinical sign of disease
• Most common hematological disorder
by far
• Almost always a secondary disorder
• It is not a single disease by itself
• Its diagnosis is not that simple !! We’ll
make it
Mechanism
• 3 major physiologic mechanisms cause anemia

1. Marrow production defects: Hypoproliferative


anemias (75% of cases)
2. Erythrocyte maturation defects: ineffective
erythropoiesis
3. Decreased erythrocyte survival: blood loss or
hemolysis
Mechanism
First Question

• The onset of Anemia


• Acute versus chronic
• Clues
• Hemodynamic stability
• Previous CBC
• Overt blood loss
Screening Tests – Anemia

• Clinical Signs and symptoms of Anemia


• Look for bleeding – all possible sites
• Look for the causes for anemia
• Routine Hemoglobin examination
Symptoms & Signs
• Most often recognized by abnormal results on
screening laboratory tests
• Degree of symptomatology depends on
• magnitude and rapidity of fall,
• adequacy of physiologic corrective
mechanisms and
• presence of associated diseases
Signs and Symptoms
• Fatigue
• Loss of stamina
• Breathlessness
• Dyspnea
• Pallor
• Tachycardia
Diagnostic Approach
• Careful history
• Nutritional history related to drugs or alcohol intake
• Family history of anemia
• geographic backgrounds and ethnic origins
• Exposure to certain toxic agents or drugs
• Physical examination
• May provide clues to the mechanisms of anemia
• Infection
• Blood in the stool
• Splenomegaly and lymphadenopathy
• Petechiae
• Laboratory assessment
• Including review of past laboratory measurements to
determine time of onset
Clinical Signs to be looked for

• Skin / mucosal pallor,


• Skin dryness, palmar creases
• Bald tongue, Glossitis
• Mouth ulcers, Rectal exam
• Jaundice, Purpura
• Lymph adenopathy
• Hepato-splenomegaly
• Breathlessness
• Tachycardia, CHF
• Bleeding, Occult Blood
Anaemia Workup - MCV

MCV

Microcytic Normocytic Macrocytic


Iron Deficiency IDA Chronic disease Megaloblastic anemias
Chronic Infections Early IDA Liver disease/alcohol
Thalassemias Hemoglobinopathies Hemoglobinopathies
Hemoglobinopathies Primary marrow disorders Metabolic disorders
Sideroblastic Anemia Combined deficiencies Marrow disorders
Increased destruction Increased destruction
www.drsarma.in
Decreased RBC production
• Anemia will ultimately result if the rate of RBC production is less than
that of RBC destruction.
• The more common causes for reduced (effective) RBC production
include
Lack of nutrients,
Bone marrow disorders
Bone marrow suppression
Low levels of trophic hormones
Increased RBC destruction
•  A RBC life span below 100 days is the operational definition of
hemolysis
• Hemolytic anemia will ensue when the bone marrow is unable to
keep up with the need to replace more than about 5 percent of the
RBC mass per day, corresponding to a RBC survival of about 20 days.
Blood loss
• Is the most common cause of anemia and may take any one of a
number of forms:
• Obvious bleeding (eg, trauma, melena, hematemesis,
menometrorrhagia)
• Occult bleeding (eg, slowly bleeding ulcer or carcinoma).
• Induced bleeding (eg, repeated diagnostic testing , hemodialysis
losses, excessive blood donation)
Morphologic approach
• This according to measurement of RBC size,
• The normal RBC
-has a volume of 80 to 96fl and a
-diameter of approximately 7 to 8 microns,
equal to that of the nucleus of a small lymphocyte.
• RBCs larger than the nucleus of a small lymphocyte on a peripheral
smear are considered large or macrocytic,
• while those that appear smaller are considered small or microcytic
Iron deficiency anemia
Causes:
• inadequate dietary iron intake
• Malabsorption: gastrectomy, chronic diarrhea,
celiac sprue
• increased iron needs: pregnancy and lactation
• chronic occult blood loss: bleeding ulcers, GI
inflammation, hemorrhoids, cancer, chronic
hemoglobinuria
• Menstrual blood loss
Iron Deficiency Anemia
Iron Deficiency Anemia - koilonychia
ANGULAR CHEILITIS AND SMOOTH
TONGUE
EVALUATION OF THE PATIENT
• Anemia is a clinical sign of disease
• Almost always a secondary disorder
• Most often recognized by abnormal results on screening
laboratory tests
• It is never normal and its cause(s) should always be sought.
• The history, physical examination, and simple laboratory testing are
all useful in evaluating the anemic patient.
• The workup should be directed towards answering the following
questions
Is the patient bleeding (now or in the past)?
Is there evidence for increased RBC destruction (hemolysis)?
Is the bone marrow suppressed?
Is the patient iron deficient? If so, why?
Is the patient deficient in folic acid or vitamin B12? If so, why?
History
• Degree of symptomatology depends on
• magnitude and rapidity of fall,
• adequacy of physiologic corrective mechanisms
and
• presence of associated diseases
• Symptoms related to anemia can result from two factors:
-decreased oxygen delivery to tissues, and,
-hypovolemia
• Decreased oxygen delivery to tissues
• Exertional dyspnea
• Dyspnea at rest
• Fatigue
• Signs and symptoms of hyperdynamic state
• Bounding pulses
• Palpitations
• Life threatening: heart failure, angina, myocardial infarction
• Hypovolemia
• Fatiguablitiy, postural dizziness, lethargy, hypotension, shock and death
• A past history of blood transfusions, liver disease, treatment of the
patient (or other family members) with iron or other hematinics,
herbal preparations, and exposure to toxic chemicals in the workplace
or environment should also be obtained.
• An assessment of nutritional status is especially important in the
elderly and alcoholics.
Physical examination
•  The major aim on physical examination is to find signs of organ or
multisystem involvement and to assess the severity of the patient's
condition.
PHYSICAL EXAM
•Stable or Unstable? -
Vitals
•Pallor
•Jaundice
-hemolysis
•Lymphadenopathy
•Hepatosplenomegally
•Bony tenderness
•Petechiae
•Rectal-? Occult blood
Treatment Approach
• Initiate treatment of mild to moderate anemia only when a specific
diagnosis is made.
o Often, the cause of the anemia may be multifactorial.
• In every circumstance, it is important to evaluate the patient's iron
status fully before and during the treatment of any anemia.
• Rarely, in the acute setting, anemia may be so severe that red cell
transfusions are required before a specific diagnosis is made.
Transfusion of packed red blood cells
• Indications
o Acute: significant blood loss resulting in hypovolemic shock
o Chronic: life-threatening symptoms, e.g., unstable angina, transient
ischemic attacks
o Adequate oxygen can be maintained with a hemoglobin content of
70 g/L in the normovolemic patient without cardiac disease.
• ƒ Comorbid factors often necessitate transfusion at a higher threshold.
o In most patients requiring transfusion, hemoglobin levels of 100 g/L
are sufficient to keep oxygen supply from being critically low.
Severe acquired aplastic anemia can be cured by replacement of the
absent hematopoietic cells (and the immune system) by stem cell
transplant, or it can be ameliorated by suppression of the immune
system to allow recovery of the patient's residual bone marrow function.

Hematopoietic growth factors have limited usefulness and


glucocorticoids are of no value.

Suspect exposures to drugs or chemicals should be discontinued;


however, spontaneous recovery of severe blood count depression is rare,
and a waiting period before beginning treatment may not be advisable
unless the blood counts are only modestly depressed.
Hematopoietic Stem
Cell Transplantation
• Severe acute AIHA can be a medical emergency.
• The immediate treatment almost invariably includes transfusion of red cells.

• This may pose a special problem b/c if the antibody involved is unspecific, all
the blood units cross-matched will be incompatible (presence of auto Ab
directed at a core component of Rh locus, w/ch is present on RBCs of all
potential donors, regardless of Rh subtype).

• In these cases it is often correct, paradoxically, to transfuse incompatible


blood, the rationale being that the transfused red cells will be destroyed no
less but no more than the patient's own red cells, but in the meantime the
patient stays alive.

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Complications
• High-output cardiac failure
• End-organ ischemia or infarct, including
o Myocardial infarction
o Stroke
• Hypovolemic shock
• Death

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