ANEMIA

A m elia Feb rin a

07120110089

DEFINITION
Condition in which a number of red blood cell is
insufficient to meet the bodys physiologic needs.
Which Characterized
Hb concentration decrease followed by decreased
hematocrit and decrease erythrocyte count.
Depends on sex, age, altitude
Blood Hb and Ht (Adult)
Males
: Hb <130 g/L or Hct <39%
Females : Hb <120 g/L or Hct <37%

GENERAL SYMPTOMPS

Anemia

Blood loss

Underproduction

Destruction of
RBCs

ETIOLOGI
1. Blood Loss
Acute : hemorrhage
Chronic : low volume loss
2. Destruction of RBCs
Hereditary : erythrocyte membrane, enzyme defect,
hemoglobinopathy
Acquired : immunologic defect, obstetric infection,
chemistry, physic, mechanic abnormalities
3. Underproduction
Nutritional anemia
Bone marrow failure
Decrease marrow response to erythropoetin

HISTORY TAKING
1. Onset, duration, progress
Insidious onset, long duration, gradual progress : nutritional anemia, anemia
chronic disease, anemia chronic blood loss
Rapid onset, short duration, rapid progress : acute leukemia, acute hemolytic
anemia, aplastic crisis in hemolytic anemia, acute blood loss anemia, infiltrative
disorder of the bone marrow
Genitourinary, gastrointestinal, other blood loss
Angina or cerebral hypoxia symptoms
High colored, dark tea urine : hemolysis
Bone pain, backache, abdominal pain sickle cell
2. Age & Sex & Nutrition
Pregnant woman >>, vegetarian : B12, lack of green leafy : folate deficiencies,
lack of vitamin C red meat etc : iron deficiencies
Detailed menstrual cycle history, history of reproductive performance
3. Occupation
Farmer bare foot ankylostomiasis iron deficiencies
Exposure to lead containing chemical lead poisoning
Exposure to benzene group myelodisplasia, aplastic anemia

1. Drug Ingestion
Long term aspirin blood loss, rifampicin or
alphamethyldopa autoimmune hemolytic anemia,
chemothepy drugs bone marrow depression,
pancytopenia
2. ETC
Family history, jaundice, gallstone or splenectomy
Transfusion history, past blood count measurement,
nutritional habit, acute or chronic illness : weight loss
night fever.

PHYSICAL
EXAMINATION
1. Iron Deficiency Anemia
Smooth pale bald tounge, brittle flat concave nail, bilateral painless
parotid enlargement iron deficiencies
Skin pigmentation perioral over knuckles region megaloblastic anemia
Jaundice hemolytic anemia
Skin pigmentation various skeletal muscle symptoms hypoplastic
anemia
Ptechiae hemorrhage marrow infiltrative disease (leukimia, lymphoma,
metastasis disease etc)
Non healing ulcers on the leg sickle cell, sideroblastoma anemia
Facies cooley thalasemia
Hypertension edema chronic disease (renal insufficiency)
Lymphadenopaty leukimia or lymphoma
Organomegaly : minimal nutrition deficiencies, larger infection
(malaria) or infiltrative disorder

INVESTIGATION
BASIC
1. CBC
2. Peripheral blood smear
3. Reticulocyte Count
SPECIAL
4. Iron studies
Serum iron, TIBC, transferin saturation
5. RBC Folate
6. Vit B 12
Schillings test
7. Hemolytic Anemia
Hemoglobin electrophoresis, estimation of fetal hemoglobin, sickling
test, Coombs test
8. Bone Marrow Biopsy

GOALS OF
TREATMENT
1. Increase the RBC count and/or hemoglobin level
2. Treat the underlying condition or cause of the anemia
a) Depends on the type cause and severity of condition
include

Dietary changes or supplements

Medicine
Procedure

TREATMENT
Symptom Control
1. Blood Transfusion
2. Bone marrow transplant
Treat Underlying Causes
3. Iron deficiency anemia
Iron Sulfate 325 mg PO TDS, iron gluconate 300 mg PO TDS. (6 weeks to correct,
6 months to replete iron stores)
4. Anemia Chronic Disease
EPO (epoetin alfa 50 200 U/kg/week SC/IV 3x/week) or antibiotics
5. Autoimmune Hemolytic Anemia
Steroid (prednisone 1 mg/kg PO daily, taper after stable)
IVIG, Splenectomy
Immunosuppresion
6. Folate Deficiency
Folate 0.4 mg PO/IM daily x 4 for 5 days
7. Vit B12 Deficiency
Vitamin B12 1000 mcg IM daily x 5 10 days then 1000 mcg IM qweek x 4 weeks
then every month

DIAGNOSTIC APPROACH

Anemia

Blood loss

Underproduction

Destruction of
RBCs

ACUTE BLOOD LOSS ?

Sign :
Hypotension
Tachycardia
Large Ecchymoses
Symptoms
Hematemesis
Melena
Rectal Bleedig
Hematuria
Vaginal bleeding
Hemoptysis

First
First step
step in
in
evaluating
evaluating anemia
anemia are
are
looking for
for acute
acute
blood loss
loss and
checking
checking the
the RPI
RPI in
in
patients
patients who
who are not
acutely bleeding

UNDERPRODUCTION
VS HEMOLYSIS
Low or normal reticulocyte counts underproduction
High reticulocyte counts Responds to blood loss/ hemolysis/
Replacement of iron B12 or folat.
Reticulocyte Production Index
[Retic count x (hematocrit in %/45)]/ maturation factor
-

RPI Normal : 1.0

Anemia :
-

<2.0 : Underproduction

>2.0 : Hemolysis

Iron
Iron Deficiency
Deficiency

Microcytic
Microcytic Anemia
Anemia
MCV
MCV <80
<80 mcm
mcm

Thalassemia
Thalassemia

Anemia
Anemia of
of
inflammation/chroni
inflammation/chroni
cc disease
disease

Vit
Vit BB Deficiency
Deficiency

Megaloblastic
Megaloblastic
anemiia
anemiia
MCV
MCV Studies
Studies

Folate
Folate Deficiency
Deficiency

Antimetabolite
Antimetabolite
drugss
drugss
(MTX/Zidofudine)
(MTX/Zidofudine)

Macrocytic
Macrocytic Anemia
Anemia
MCV
MCV >100
>100 mcm
mcm

Non
Non megaloblastic
megaloblastic
Anemia
Anemia

Inflammation/Chron
Inflammation/Chron
ic
ic Diasease
Diasease

Early
Early irondeficiency
irondeficiency
Normocytic
Normocytic Anemia
Anemia
Bone
Bone marrow
marrow
suppression
suppression

Endocrine
Endocrine

Alcohol,
Alcohol, Liver
Liver
disease,
disease, hipotiroid,
hipotiroid,
myelodisplastic
myelodisplastic

MICROCYTIC ANEMIA
Diagnostic hypotheses

Demographic risk
factor symp and signs

Important Tests

Iron Deficiency

Pica, blood loss

Serum ferritin, tansferin

saturation

Thalassemia

Ethnic background,
history of transfusion

Hgb electrophoresis,
DNA testing

Chronic disease

Renal/liver disease,
inflammation, infection,
malignancies

Iron TIBC, ferritin

creatinin, transaminase,
ESR, CRP

NORMOCYTIC ANEMIA
Diagnostic
hypotheses

Demographic risk
factor symp and
signs

Important Tests

Acute bleeding

Melena hematochezia
hematemesis
menorrhagia

History
Rectal exam for gross
blood

Hemolysis

Fatigue

Reticulocyte count,
haptoglobin Coombs
test, smear

Marrow infiltration

Pancytopenia bleeding
malaise

Bone Marrow

Anemia of
inflammation

Acute inflammation,
AKI, chronic
inflammatory disease

Fe/TIBC ferritin bone

marrow

MACROCYTIC ANEMIA
Diagnostic
hypotheses

Demographic risk
factor symp and
signs

Important Tests

B12 Deficiency

Vegan diet, elderly,

neurologic symptoms

B12 level,
homocysteine level,
MMA

Folate Deficiency

Alcohol abuse,
starvation, pregnancy

Serum folate level

RBC folat level

Hypothyroidism

Constipation weight
gain fatigue cold
intolerance

TSH, free T4

THANKYOU