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Transcript of anemia-100512030027-phpapp01
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Anemia Overview
Ruozhi Xiao
The Third Hospital of Sun Yat-sen University
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Erythrocytes parameters
RBC = red blood cells
Hgb= hemoglobin
Mean corpuscular volume (MCV)
N: 80-100 fl RDW(Red cell Distribution Width)
Mean corpuscular hemoglobin (MCH) N: 27-34 pg
Mean corpuscular hemoglobin concentration (MCHC) N: 310 370 g/lRBC (31-37 g/dl)
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Survival and Production of RBC
Formed in bone marrow
Life span is 120 days (+/-20 days)
Cleared in spleen Reticulocytes are newly formed RBC in
circulation
If no new production, Hgb drops 1gm/week
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ERYTHROPOIESIS
In developing from the stem cell, the RBC has to
undergo the most changes, which can becategorized into several morphological/stainable
stages
Proerythroblast RBC
*
-blast is the common suffix for an immature form of a cell
Early
erythroblastIntermediate
erythroblast
Late
erythroblast
Reticulocyte
Stem cell
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Hematocrits
Normal, Hemorrhage, IDA, Leukemia, Hemolysis, B12, P Vera
Plasma
White cells
Red cells
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Definitinon
Low blood
Anemia is simply a hemoglobin level
lower than the normal range for aparticular age and sex of the patient.
Most common hematologic disorder by
far
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The normal range for Hb and RBC
Hb RBC
Males 120160g/L (4.0-5.5)x 1012/L
Females 110150g/L (3.5-5.0)x 1012/L
Neonates170200g/L (6.0-7.0)x 1012/L
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Anemia classification
Based on general mechanisms
morphological classification
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Anemiamorphological classification
Microcytic
Normocytic
Macrocytic
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morphological classification
Type MCVfl MCHpg MCHC%
Macrocytic anemia 100 32 32-35
Normocytic anemia 80-100 27-32 32-35
Microcytic anemia 80 27 32
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Normal Red Blood Cells - Peripheral Blood Smear
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Normal Red Blood Cells
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Microcytic anemia
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Thalassemia
Thalassa= the sea
Defective globin synthesis
Normal a = b (a/b = 1)
a, b, db, gdb thalassemia
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b-Thalassemia
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Macrocytic anemia
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General mechanisms of anemia
1. RBC Loss without RBC destruction
2. Deficient RBC production: Marrowfailure
3. Increased RBC destruction overproduction: Hemolysis
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ANEMIACauses - Cytoplasmic Protein Production
Decreased hemoglobin synthesis
Disorders of globin synthesis
Disorders of heme synthesis
Heme synthesis
Decreased Iron
Iron not in utilizable form
Decreased heme synthesis
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Pathophysiology
Decreased RBC productiona. Iron deficiency
b. Folic acid deficiency
c. Aplastic anemia
Increased RBC loss or destruction
a. sickle cell anemia
b. blood lossc. infection
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The third hospital of Sun yat-sen university
:Leukemia
:trauma,surgery
:cancer and ulcer,menstrual periods
:Renal disease
: Malaria:Leadpoisoning
:SLE
:PNH
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Bone Marrow Disorders
Aplastic anemia
Myelodysplastic Syndromes
Acute Leukemia
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Aplastic Anemia
Blood Bone Marrow Biopsy
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Bone Marrow (BM) Biopsy
Normal Aplastic
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Definitions
Aplastic Anemia (AA)
Pancytopenia
Hypocellular bone marrow
Myelodysplastic Syndrome(MDS)
Cytopenias with hypercellular
bone marrow
Acute Leukemia (AL)
Malignant proliferation of
immature cells
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Aplastic Anemia: Signs andSymptoms
Anemia (low Hb, Hct)
fatigue, lassitude, dyspnea
Thrombocytopenia (low platelets) bruises, petechiae
serious bleeding
Neutropenia (low neutrophils, a type ofwhite cell)
infections
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Acquired Aplastic Anemia
Drugs
Chemicals
Viruses Immune diseases
Paroxysmal nocturnal hemoglobinuria
(PNH) Pregnancy
IDIOPATHIC
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Myelodysplastic Syndromes (MDS)
Clonal diseases
Neoplastic
Refractory anemias Potential for acute myeloid leukemia (AML)
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Anemia
Check MCV
MCV < 80
Microcytic
anemia
MCV 80 - 100
Normocytic
anemia
MCV > 100
Macrocytic
anemia
Defective synthesis of:
Heme
iron deficiency anemia
anemia of chronic diseasesideroblastic anemia
lead poisoning
Globin chains
thalassemiasHbE
Fe
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Clinical features
Mild:Mild dyspnea on exertion, palpitation
Moderate: As with MILD ANEMIA, mayalso have excessive dyspnea
Severe:Anemia:Dyspnea at rest,tachycardia with pounding pulse,weakness, dizziness, headache, insomnia
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Diagnosis of Anemia
History
Diet
Blood loss
Family history
Recent illness or immunizationHistory of anemia and cause
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Diagnosis of Anemia
Physical ExaminationEvaluate conjunctiva and mucous
membranes for paleness
Cardiovascular system for murmur
Liver
Spleen
Nodes
Look for jaundice or purpura
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Diagnosis of Anemia
Labs
Complete blood count with differentialand platelets
Evaluation of smear with red cell indicesReticulocyte count
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Diagnosis of Anemia
Other tests
Serum bilirubin, LDH, urinaryhemosiderin, hgb electrophoresis,quantitative hgbA2 and F
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Common treatment to All Anemias
Support
Hematopoietic growth factors Blood transfusions, blood substitutes
Iron
Cure Stem cell transplant
Gene therapy
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IRON DEFICIENCY
ANEMIA
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Terms
Fe = iron
TIBC = total iron binding capacity RDW = red cell distribution width
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CASE 1
A 50 year old man comes to see youbecause of fatigue and a change in bowelhabit. He is found to have a hemoglobin
of 105 g/L (normal 120-170) and MCV of78 fL (80-100). Peripheral blood filmshows microcytes and hypochromia. He
previously had a hemoglobin of 165 g/Lthree years ago, with a normal MCV.
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Case 1 Question 1
What is your approach to the history andphysical examination?
C 1 Q i 1
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Case 1 - Question 1Discussion
iron deficiency most likely
symptoms suspicious for lower GI tractmalignancy.
still ask about chronic inflammatorydiseases
ask about melena, hematochezia, weightloss, family history of colon ca
rectal exam indicated
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CASE 1 - Question 2
What other investigations are appropriate?
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Investigations
serum ferritin 12 ug/L (30-400)
iron 8 umol/L (10-28)
TIBC 80 umol/L (38-76) transferrin sat. 10 % (20-55)
Conclusion: Iron deficiency anemia
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IRON DEFICIENCY ANEMIAPrevalence
Country Men (%) Women(%)
PregnantWomen (%)
S. India 6 35 56
N. India 64 80Latin America 4 17 38
Israel 14 29 47
Poland 22
Sweden 7
USA 1 13
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IRON
Functions as electron transporter;vital for life
Must be in ferrous (Fe+2) state foractivity
Ferric (Fe+3) ions cannot transportelectrons or O2
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IRON DEFICIENCY ANEMIA
IRON METABOLISM
ABSORPTION IN DUODENUM
TRANSFERRIN TRANSPORTS IRON TO THE
CELLS
FERRITIN AND HEMOSIDERIN STORE IRON
10% of daily iron is absorbed
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Iron Metabolism
Heme Iron
Hemoglobin and myoglobin
Non-heme Iron
Breast milk
Cow milk
All supplements
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Iron Absorption
Heme Iron
Well absorbed
Not dependent on
Iron deficiencystatus
Not limited by diet
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Iron Absorption
Non-heme Iron
Absorption is sporadic, generally poor
Improved absorption
Iron deficient status
Heme iron (ie red meat, fish, chicken)
Vitamin C
Worsened absorption Cows milk, cheese
Cereal
Tea
IRON
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IRONBody Compartments - 75 kg man
Stores1000mg
Tissue500 mg
Red Cells2300 mg
3 mgAbsorption < 1 mg/day
Excretion < 1 mg/day
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Iron deficiency anemia
Causes:
inadequate dietary iron intake
Malabsorption: gastrectomy, chronic diarrhea,
increased iron needs: pregnancy and lactation
chronic occult blood loss: bleeding ulcers, GIinflammation, hemorrhoids, cancer, chronic
hemoglobinuria Menstrual blood loss
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Most body iron is present in hemoglobin incirculating red cells
The macrophages of the
reticuloendothelial system store ironreleased from hemoglobin as ferritin andhemosiderin
Small loss of iron each day in urine, faeces,skin and nails and in menstruating femalesas blood (1-2 mg daily)
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IRON DEFICIENCY ANEMIA
ETIOLOGY: CHRONIC BLEEDING
MENORRHAGIA
PEPTIC ULCER
STOMACH CANCER
ULCERATIVE COLITIS
INTESTINAL CANCER
HAEMORRHOIDS
DECREASED IRON INTAKE
INCREASED IRON REQUIRMENT (JUVENILE AGE,PREGNANCY, LACTATION)
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IRON DEFICENCY - STAGES
Prelatent reduction in iron stores without reduced serum iron levels
Hb (N), MCV (N), iron absorption (), transferin saturation(N), serum ferritin (), marrow iron ()
Latent iron stores are exhausted, but the blood hemoglobin levelremains normal
Hb (N), MCV (N), TIBC (), serum ferritin (), transferrinsaturation (), marrow iron (absent)
Iron deficiency anemia blood hemoglobin concentration falls below the lower limit ofnormal
Hb (), MCV (), TIBC (), serum ferritin (), transferrinsaturation (), marrow iron (absent)
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IRON DEFICIENCY ANEMIA
GENERAL ANEMIAS SYMPTOMS: FATIGABILITY DIZZENESS
HEADACHE
IRRITABILITY
ROARING
PALPITATION
CHD, CHF
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CHARACTERISTICS SYMPTOMS
GLOSSITIS, STOMATITIS DYSPHAGIA ( Plummer-Vinson syndrome)
ATROPHIC GASTRITIS
DRY, PALE SKIN SPOON SHAPED NAILS, KOILONYCHIA,
BLUE SCLERAE
HAIR LOSS
PICA (APETITE FOR NON FOOD SUBSTANCES SUCH AS
AN ICE, CLAY) SPLENOMEGALY (10%)
INCREASED PLATELET COUNT
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KOILONYCHIA
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Smooth tongue
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IRON DEFICIENCY ANEMIA
MCV
MCH
MCHC N
Fe
TIBC
TRANSFERIN SATURATION
FERRITIN
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BLOOD ROUTINE
BLOOD AND
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BLOOD ANDBONE MARROW SMEAR
BLOOD: microcytosis, hipochromia, anisocytosis poikilocytosis
BONE MARROW high cellularity mild to moderate erythroid hyperplasia (25-35%; N
16 18%)
polychromatic and pyknotic cytoplasm oferythroblasts is vacuolated and irregular in outline(micronormoblastic erythropoiesis)
absence of stainable iron
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Anemia: Lab Evaluation
Normal Periperhal Smear Iron Deficiency Anemia
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IDA blood smear
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IDA bone marrow
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Normal store iron(blue)
IDA
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IDA
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Reticulocytes up
Using special stains such as methylene blue
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Using special stains such as methylene blue
or brilliant cresyl blue, reticulocytes stain with
dark blue granules whereas mature
erythrocytes evenly stain pale blue.
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Management
History and physical examination issufficient to exclude serious disease(e.g pregnant or lactating women,
adolescents)- CURE ANEMIA
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Management
History and/or physical examination isinsufficient (e.g old men, postmenopausalwomen)
- FIND ETIOLOGY OF ANEMIA ANDCURE (CAUSAL TREATMENT)
Benzidine test
Gastroscopy Colonoscopy
Gynaecological examination
IRON DEFICIENCY ANEMIA
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IRON DEFICIENCY ANEMIACURE
ORAL 300 mg of iron daily after meal
How long? 3-6 months to restore iron reserve
Absorption is enhanced: vit C, meat, orange juice, fish
is inhibited: tea, milk
IRON DEFICIENCY ANEMIA
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IRON DEFICIENCY ANEMIACURE
PARENTERAL IRON SUBSTITUTION
Bad oral iron tolerance (nausea, diarrhoea)
Negative oral iron absorption test
Necessity of quick management (CHD, CHF)
R b
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Remember:
Iron deficiency anemia is a
manifestation of an underlying
process.
Look for and treat the cause of
the iron deficiency.
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Look for the cause
colonoscopy reveals colon carcinomawhich is subsequently resected.
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Iron Deficiency anemia
Diagnostics: Iron levels
Total iron-binding capacity (TIBC)
Serum Ferritin
Medications:
Iron supplements, oral or parenteralVit. C
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