Anemia.mansfans.com

Approach to Patients with

Anemia Prof. Dr / Nabil Lymon

Blood Cells and Hemoglobin structure www.MansFans.com

:Definitions : Anemia is defined as the lowering of hemoglobin concentration below the established normal :levels .In male < 13.5 gm/dl & In female < 11.5 gm / dl Anemia is a clinical sign not a diagnostic .entity

:)Hematocrit )Hct is the proportion, by volume, of the blood occupied by red blood cells. The hematocrit (Hct) is expressed as a percentage, normal : levels are in Adult male & 0.37 - 0.47 in Adult 0.54 - 0.4

:Definitions Red Cell Indices Are measurements that indicate the size :and hemoglobin content of red cells

)M.C.V )Mean Corpuscular Volume M.C.H )Mean Corpuscular )Hemoglobin M.C.H.C)Mean Corpuscular Hemoglobin

www.MansFans.com )Concentration

M.C.V:))Mean Corpuscular Volume Referred to the average volume of red cells , normally = 76 96 fl It can be calculated from an independently-measured red :blood cell count and hematocrit

MCV  )femtoliters) = 10 x HCT)percent) ÷ RBC ))millions/µL  : MICROCYTOSIS & MACROCYTOSIS By definition, microcytosis is taken to mean the presence of RBCs with a MCV less than normal, while macrocytosis means the presence of RBCs with an MCV greater than .normal

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M.C.H)Mean Corpuscular :)Hemoglobin or "mean cell hemoglobin" (MCH), is a measure of the mass of hemoglobin contained by a red blood cell. It is diminished in microcytic anemias, and increased in macrocytic anemias. It is calculated by dividing the total mass of hemoglobin by the -: RBC count

MCH=Hb/RBC A normal value in humans is 27 to 32 picograms/cell

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M.C.H.C Mean Corpuscular Hemoglobin) :)Concentration is a measure of the concentration of hemoglobin in a .given volume of packed red blood cell It is diminished)"hypochromic") in microcytic anemias, and normal)"normochromic") in macrocytic anemias (due to larger cell size, though the hemoglobin amount or MCH is high, the .(concentration remains normal It is calculated by dividing the hemoglobin by the :hematocrit

Signs &Symptoms of Anemia

: Cardiovascular -

E xertional DyspneaP alpitations Orthopnea T achycardiaA ngina Claudications C ardiomegallyBounding peripheral Pulses M urmursV ascular bruits Pedal edema

: Neurological H Dizziness

eadacheT

innitus

Signs &Symptoms of Anemia

: Skin -

P.allor of skin , mucous membranes, nail beds and palms

: Gastrointestinal A Constipation Diarrhea

norexiaN

ausea

: Respiratory Increased Respiratory Rates

: Genitourinary M enstrual irregularityA Menorrhagia Loss of libido or potency

: Fundus Examination -

menorrhea

Is the patient Anemic or not ? Anemic means single or total decrease in : - Hb - Hct - RBCscount in?…But millions ?..What Type of Anemia This depends on the RBCs indices

Red Cell Indices According to MCV & MCH

Normal

Decreased

Normocytic Normochro mic Anemia Increased Macrocytic Anemia

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Microcytic Hypochromi c Anemia

Anemia

It may be due to :

- Acute Blood Loss

Thalasemia)

- Aplastic Anemia - Hemolytic Anemia ( Except

- A.O.C.D (Anemia Of Chronic Which of Which ….? (Diseases

Do Reticulocytic Count

Normal A.O.C.D :.e.g TB, SLE, Malignancy, Rh. Arthritis

Low or Absent B.M.F Aplastic“ ”Anemia

:Note Evidence of the cause

BM biopsy or BM aspiration : show

High Acute Blood Loss search for ) evidence of (the cause

Hemolytic -

-

low Hb &/or Hct & /or RBCs count Normal RBCs indices Reticulocytosis

Do Indirect Serum Billirubin

billirubinemia

Unconjugated Hyper-

jaundice”

“

Other Evidences of Hemolysis e.g.:- Hemoglobinuria - Hemoglobinemia (increased free Hb) - Decreased Haptoglobin.

What is the Further ?..………Step Coombs Test

Coombs Test Positive Immune Hemolytic :Anemia

Negative Non-immune Hemolytic :Anemia

Iso immune Auto immune -

: May be due to e.g.Membrane Defect Spherocytosis (lab show increased O.F.) & P.N.H Enzyme Defect (e.g. G6PD (lab : Enz. assay Hb Defect ((Hemoglobinopathy

Red Cell Indices According to MCV & MCH

Decreased Microcytic Increased Macrocytic Anemia

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Hypochromi c Anemia

Microcytic Hypochromic Anemia - The Commonest Cause is: -Other Causes:

Iron Deficiency Anemia

- Thalasemias - Sedroplastic Anemia - Lead Poisoning - A.O.C.D

Which of Which ….?

:Do Iron Studies Serum Iron Serum Ferritin (Total Iron Binding T.I.B.C -

(Capacity

Transferrin Saturation -

According to Iron Studies Iron Thalasse Sideropla stic Deficienc mia y Anemia Anemia

A.C.O.D

Serum Fe Serum Ferritin

Normal N or

T.I.B.C

Normal

Transferr in Saturatio

Iron Deficiency Anemia

Iron Deficiency Anemia Iron :Notes Studies Search For The Serum Fe :Cause :.e.g Serum Chronic Blood Loss Ferritin Ankylostoma T.I.B.C Cancer Colon Nutritional causes Transferri Severe Aniso-cytosis n :and Poikilo-cytosis Saturatio Increased R.D.W(N ≤ n (13%

Anisocytosis with hypochromia and microcytes((IDA

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Spoon Nails: If nails look scooped out, like a spoon, it could be a sign of iron.deficiency anemia

Plummer Vinson Syndrome Left : Spoon shaped finger nails

Right

:Showing angular cheilitis, and dry skin

Plummer Vinson Syndrome

Iron Deficiency Anemia

Thalassemia Iron :Notes Studies Hb Electrophoresis Serum Fe :will show Persistence of Serum ]Hb]f Ferritin Specific Clinical T.I.B.C Features of :Thalasemia Transferri Huge Spleen n Mongoloid Faces Saturatio Hemosedrosis n

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Thalassemia minor is an inherited form of hemolytic anemia that is less severe than thalassemia major .This blood smear from an individual with thalassemia shows small(microcytic), pale (hypochromic), variously-shaped (poikilocytosis )red blood cells .These small red blood cells(RBCs )are able to carry less oxygen than normal RBCs

Thalassemia, being a genetic disease, runs in a family .Most are silent carriers or suffer mild anemia .Severe cases such as the Hemoglobin H disease with enlarged spleen, small body and malnourished look shows more prominent symptoms .[Pic below: [Enlargement of spleen, small body

Sideroplastic Anemia Iron :Notes Studies Sedroplastic Anemia Serum Fe :is due to B6 Deficiency Serum Norma Drugs e.g.: INH Ferritin l Inherited T.I.B.C Norma :Blood film show l RBCs contain Iron Transferri Granules n Saturatio :Treated by n B6 supply

Many rounded sideroblasts are present in this field .This is the hallmark feature ofsideroblastic anemia

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Lead Poisoning :Notes .History is Suggestive .Elevated Serum Lead level Purely Motor Neuropathy (foot and (wrist drop :Blood Film show Basophilic Stippling of RBCs

Basophilic Stippling of RBCs

Basophilic stippling appears as round, darkblue granules in red blood cells on smears stained with supra vital stains such as brilliant cresyl blue. They may be observed inlead poisoning, exposure to some drugs, severe burns, anemia, or septicemia. The granules are precipitated ribosomes and mitochondria

Red Cell Indices According to MCV & MCH

Increased Macrocytic Anemia

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Macrocytic Anemia - In Which :

- low Hb &/or Hct & /or RBCs count - Increased RBCs indices

- Causes :

# Folic Acid Deficiency

# B12 Deficiency

- Search For The Cause:

# Pregnancy # Mal-absorption Syndrome # Chronic Gastritis # Atrophic Gastritis # Cancer Stomach # Iliac Resection # Drugs: Methotrexate / Metformin / Epanutin

- To be sure do the following tests: Serum Folic Acid / Serum B12 / Schilling test / FIGLU test

Schilling Test

The Schilling test is performed to evaluate vitamin B12 absorption. B12 helps in the formation of red blood cells, the maintenance of the central nervous system, and is important for metabolism. Normally, ingested vitamin B12 combines with intrinsic factor, which is produced by cells in the stomach. Intrinsic factor is necessary for vitamin B12 to be absorbed in the small intestine. Certain diseases, such as pernicious anemia, can result when absorption of vitamin B12 is

FIGLU test

a test of vitamin b12 deficiency, folic acid deficiency, liver disease, or genetic deficiency of glutamate formimino-transferase, based on urinary excretion offormiminoglutamic acid (figlu), an intermediate metabolite in histidine catabolism in the conversion of histidine to glutamic acid, with the formimino group being transferred to .tetrahydrofolic acid www.MansFans.com www.MansFans.com