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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