APPROACH TO PATIENT WITH ANEMIA

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Definition
in RBC mass men : Ht < 41 % or Hb < 13.5 g/dl Women : Ht < 36% or Hb < 12 g/dl

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CLINICAL MANIFESTATION

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SIGN
O2 delivery

pallor (skin & mucous membranes) tachycardia orthostatic hypotension

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SYMPTOMS
O2 delivery

Fatigue Malaise Fever weight loss night sweats

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OTHER FINDINGS

jaundice (hemolysis) splenomegaly (thalassemia, neoplasm, chronic hemolysis) petechiae/purpura (bleeding disorder) glossitis (iron, folate, vit B12 defic.) koilonychia (iron defic.)
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DIAGNOSTIC EVALUATION

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HISTORY

Is the patient bleeding?

Actively? In past?

Is there evidence for increased RBC destruction? Is the bone marrow suppressed? Is the patient nutritionally deficient? Pica?

PMH including medication review, toxin 6/5/12 exposure

RIVIEW THE SYMPTOMS

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 Fatiguablitiy, postural dizziness, lethargy,

Hypovolemia
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LABORATORY EVALUATION

Bleeding

Serial HCT or HGB

Iron Deficiency

Iron Studies

Hemolysis

Serum LDH, indirect bilirubin, haptoglobin, coombs, coagulation studies

Bone Marrow Examination Others-directed by clinical indication

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hemoglobin electrophoresis

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DIFFERENTIAL DIAGNOSIS

Classification by Patophysiology

Blood Loss Decreased Production Increased Destruction Normocytic Microcytic Macrocytic

Classification by Morphology

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Blood Loss

Acute

Traumatic Variety of sources

Melena, hematemesis, menometrorrhagia

Chronic

Occult bleeding

Colonic polyp/carcinonma

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Decreased Production

Infectious Neoplasm Endocrine Nutritional Deficiency Anemia of Chronic Disease

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Increased Destruction

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MCV > 100

Macrocytic Anemia

Megaloblastic: Abnormalities in nucleic acid metabolism

B12, Folate

Non megaloblastic:Abnormal RBC maturation

Myelodysplasia

liver dz, hypothryroidism, chemotherapy/drugs

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Microcytic Anemia

MCV <80 Reduced iron availability Reduced heme synthesis Reduced globin production

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Microcytic Anemia

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Microcytic Anemia REDUCED IRON AVAILABILTY

Iron Deficiency

Deficient Diet/Absorption Increased Requirements Blood Loss Iron Sequestration Low serum iron, low TIBC, normal serum ferritin MANY!!

Anemia of Chronic Disease

Chronic infection, inflammation, cancer, liver disease

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Microcytic Anemia REDUCED HEME SYNTHESIS

Lead poisoning Acquired or congenital sideroblastic anemia Characteristic smear finding: Basophylic stippling
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Thalassemias

Microcytic Anemia REDUCED GLOBIN PRODUCTION

Smear Characteristics

Hypochromia Microcytosis Target Cells Tear Drops

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Lab tests of iron deficiency of increased severity

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Normositic Anemia

Sideroblastic anemia Anemia of chronic disorders

Anemia of chronic inflamation Renal failure epo Edocrine deficiencies Hypometabolism Ineffective erythropoiesis

Pure red cell aplasia

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TREATMENT

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Iron deficiency

Fe supplementation

6 weeks to correct anemia 6 month to replete Fe stores

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Thallasemia

Folate Tranfusion + deferoxamine ( oral ion chelator) Splenectomy if > 50% in tranfusions

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Anemia of chronic inflamation

Treat the underlying disease Erythropoietin

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Sideroblastic anemia

Treat reversible causes Supportive transfusion for severe anemia High doses pyridoxine for some heriditery cases

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Folate deficiencies

Folate 1-5 mg po qd

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Vit B12 deficiencies

1 mg B12 IM qd for 7 days 1 mg B12 IM once a week untill 4-8 weeks 1 mg B12 IM once a month for life Neurologic abnormalities are refersible if treated with in 6 months Folate can reverse hematologic abnormalities of B12 deficiencies but not 6/5/12 neurologic changes

Sickle cell anemia

Supportive care

Follic acid hydration, oksigen and analgesia Simple change transfusion

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THANK YOU

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