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Anemia
Anemia
Objectives
Review basic science of the RBC Define Anemia Review key aspects of history, physical and lab evaluation Review a systematic approach to the differential diagnosis Case-based application of clinical concepts
Transferrin
iron transporter
Ferritin
iron binder, measure of iron stores, *also acute phase reactant*
Definitions
Anemia-values of hemoglobin, hematocrit or RBC counts which are more than 2 standard deviations below the mean
HGB<13.5 g/dL (men) <12 (women) HCT<41% (men) <36 (women)
CASE
ML is a 64-year old male who has not had any primary care for several years. When he tried to give blood last week, he was told that he was anemic. He presents to your clinic for evaluation. What would you do??
Is there evidence for increased RBC destruction? Is the bone marrow suppressed? Is the patient nutritionally deficient? Pica? PMH including medication review, toxin exposure
Hypovolemia
Fatiguablitiy, postural dizziness, lethargy, hypotension, shock and death
Laboratory Evaluation
Initial Testing
CBC w/ differential (includes RBC indices) Reticulocyte count Peripheral blood smear
Iron Deficiency
Iron Studies
Hemolysis
Serum LDH, indirect bilirubin, haptoglobin, coombs, coagulation studies
Differential Diagnosis
Classification by Pathophysiology
Blood Loss Decreased Production Increased Destruction
Classification by Morphology
Normocytic Microcytic Macrocytic
Blood Loss
Acute
Traumatic Variety of sources
Melena, hematemesis, menometrorrhagia
Chronic
Occult bleeding
Colonic polyp/carcinonma
Decreased Production
Infectious Neoplastic Endocrine Nutritional Deficiency Anemia of Chronic Disease
Viral
HIV Parvovirus
Erythropoietin Deficiency
Renal Failure
Macrocytic Anemia
MCV > 100 Megaloblastic:Abnormaliti es in nucleic acid metabolism
B12, Folate
Microcytic Anemia
MCV <80 Reduced iron availability Reduced heme synthesis Reduced globin production
Microcytic Anemia
REDUCED IRON AVAILABILTY
Iron Deficiency
Deficient Diet/Absorption Increased Requirements Blood Loss Iron Sequestration
Microcytic Anemia
REDUCED GLOBIN PRODUCTION
Thalassemias Smear Characteristics
Hypochromia Microcytosis Target Cells Tear Drops
Differential Diagnosis-Revisited
Classification by Pathophysiology
Blood Loss Decreased Production Increased Destruction
INCREASED DESTRUCTION
Immune Mediated Non-immune Mediated
Warm Agglutinin
Drug induced Autoimmune hemolytic anemia Transfusion reaction
Micro-circulatory
DIC TTP HUS
Intra-corpuscular
RBC Wall (membrane or enzyme defects) Heme or globin abnormalities (HbS, C)
More on M.L.
P.E. findings
T 98.4 HR 98 Resp 20 BP 112/70 Gen: NAD, appears younger than stated age HEENT: skin and conjunctiva slightly pale NECK: no adenopathy or thyromegally Chest: CTAB CV: RRR, no murmur ABD: no HSM, soft, normoactive bowel sounds GU: normal male Rectal: no masses, prostate smooth/not enlarged, guaiac negative stool
Initial Thoughts?
Blood loss?
Age places him at risk for colon CA
Decreased Production?
Alcohol use, Iron deficiency
Increased Destruction?
Darker urine lately
Further Work-up
CAGE questions Peripheral Blood Smear Reticulocyte count Iron Studies
Ferritin TIBC % Saturation
More Results
CAGE screen reveals no positive responses Smear reveals microcytic, microchromic RBCs Retic count is interpreted as low Urinalysis negative for hemoglobin FOBT: not completed by patient Iron Studies
Ferritin: 10 TIBC: 350 % Sat: 15
Whats next?
Rule out Sources of Bleeding
Counseling regarding colon CA and referral for colonoscopy
Consider oral iron therapy Dietary counseling (iron sources, limiting etoh, etc) Encourage follow-up for health care maintenance
Vaccinations (Tetnus/pneumovax) Other cancer screening Cholesterol Screen
Diagnosis
Colonoscopy revealed small suspicious lesion in sigmoid colon, pathology revealing adenocarcinoma. Excised surgically, no mets. Routine labs, one year later, reveal an HCT of 40%. He feels better than ever!
References
Schrier, Stanley.Approach to the patient with anemia. Up to Date. 2004 Schrier, Stanley. Anemia of Chronic Disease. Up to Date. 2004 Schrier, Stanley. Anemias due to decreased red Cell Production. Up to Date 2004 Schrier, Stanley. Causes and diagnosis of anemia due to iron deficiency. Up to Date. 2004 Tierney, et al. Anemias. Current Medical Diagnosis and treatment. 2003. Pp469-489