SEEING RED: A BASIC APPROACH TO ANAEMIA

WHAT IS ANAEMIA?

malabsorption.4

1
The diagnosis
TABLE 1: CAUSES OF IRON DEFICIENCY
Physiological Causes
Increased
requirements menstruation, blood donation
Dietary
Pathological
Malabsorption Gastrectomy, atrophic gastritis,
2
Although a thorough
surgery and coeliac disease.
Chronic blood • Gastrointestinal: Oesophageal varices,
loss Helicobacter pylori, hiatus hernia,

GETTING TO KNOW THE FBC AND ITS ROLE IN THE WORK-UP

OF ANAEMIA angiodysplasia, haemorrhoids, etc.
• Renal: Haematuria or haemoglobinuria
• Pulmonary: Haemoptysis, pulmonary
haemosiderosis
• Bleeding disorder
ethnicity and pregnancy.3 When interpreting a FBC, the •
Drug related

pump inhibitors

• 7

• Thus, it is critical to note that a normal FBC does not

• RBC count
•

An increased RDW usually indicates that a multitude

TABLE 2: THE SEQUENCE OF EVENTS IN THE DEVELOPMENT OF

underlying pathology.
IRON DEFICIENCY ANAEMIA
THE MEAN TEAM STEP 1 STEP 2 STEP 3
Depletion
erythropoiesis anaemia
stores • When the iron stores • Hypochromic,
as small, normal or large.
• The serum are depleted, the microcytic red
WHAT IF THE MCV IS LOW (SMALL RBCS)? cells present
on the blood
anaemia is smear.
present. • The MCV
and MCH are
receptors increases.
• • At this stage, the reticulocyte
haemoglobin, mean
cell haemoglobin

3
These are the most common
2

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ANAEMIA OF CHRONIC DISEASE TABLE 4: DIFFERENTIATING BETWEEN MACROCYTIC ANAEMIA
BASED ON MORPHOLOGY OF THE RED CELLS
Megaloblastic Non megaloblastic
(oval macrocytes) (round macrocytes)
It is caused by inadequate Alcohol, liver disease,
aplastic anaemia,
the macrophage iron stores to the red cell precursors in
dysplastic syndrome,
11
The pathogenesis also includes an
myelodysplastic syndrome. myeloma, drugs, etc.
decreased EPO production and shortened red cell
survival.

macrocytes are present, megaloblastic anaemia needs

impairment, rheumatoid arthritis and other

TABLE 5: CAUSES OF VITAMIN B12 AND FOLATE
DEFICIENCIES
• Malignancy

Dietary restrictions
alcoholics and the elderly
Malabsorption: Pernicious

IDA and ACD can be especially challenging.12 disease

ileal resections
TABLE 3: HOW TO DIFFERENTIATE BETWEEN CAUSES OF
MICROCYTIC ANAEMIA pump inhibitors anticonvulsants, alcohol
Test Iron Chronic Thalas- Sidero-
saemia blastic Pregnancy, chronic
mation anaemia haemolysis
Blood
MCV/MCH
Serum iron N
N
testing and a reticulocyte count.12 In elderly patients,
Bone marrow
Iron stores Absent Present Present Present
syndrome. Again, the morphology reported on the
Sideroblasts Absent Absent Present Ringed
sideroblasts
Haemoglobin Normal Normal HbA2 Normal
electrophoresis

elevated.

WHAT IF THE MCV IS NORMAL?

WHAT IF THE MCV IS HIGH A normal MCV denotes a normocytic anaemia.
(RED BLOOD CELLS ARE TOO BIG)?

•
• Haemolytic anaemia
8
Further subdivision into • Acute blood loss
•
•

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Appropriate initial investigations include a reticulocyte
count. A high reticulocyte count indicates the increased

due to increased red cell production. Normal bone 10

myelodysplastic syndrome, certain viruses, e.g. HIV,

response. Figure 1 summarises a diagnostic approach to

anaemia.13

Anaemia (low Hb)

MCV

Normal = normocytic High = macrocytic

Ferritin

Normal
Normal/raised

Establish Cause Cause not Establish cause

cause chronic disease or obvious: obvious:
haemoglobinopathy e.g. drugs/ Consider bone
alcohol

Reticulocyte count

•
Haemolysis disease
High •
or blood loss
•
•

FIGURE 1: A DIAGNOSTIC APPROACH TO ANAEMIA

GETTING TO KNOW THE LINGO

TABLE 6: ELABORATION OF TERMINOLOGY USED IN THE FBC REPORT

What is seen under the microscope What to consider Additional tests
Spherocytes Haemolysis Haemolytic screen

Hb electrophoresis
Iron studies
cells and elliptocytes Hb electrophoresis
Thalassaemia
Possible haemolysis Haemolytic screen
Polychromasia Blood loss Haemolytic screen
Haemolysis

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TABLE 6: ELABORATION OF TERMINOLOGY USED IN THE FBC REPORT (continued)
What is seen under the microscope What to consider Additional tests
DIC screen
DIC, TTP, HUS, HELLP syndrome ADAMSTS13
Haemolytic screen

Megaloblastic anaemia Vitamin B12

neutrophils and megaloblasts Folate

Liver disease, hyperlipidemia,

hypothyroidism

Malaria parasites Malaria Malaria antigen testing

Malaria PCR

KEY MESSAGES

REFERENCES

−9.
13. Moore C. Basic Approach to Abnormal FBC: Part I
regional, and national incidence, prevalence, and −2. Available

2017; 390:1211−

2016; 387:907−916.

−1843.
8. Alli N, Vaughn, J Patel M. Anaemia: Approach to
−27.

chronic disease. Blood Rev. 2002; 16:87–96.

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