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Anemia :

Diagnostic approach
Anemia : diagnostic approach

 Definition

 Diagnostic approach :
• History
• Physical Examination
• Basic laboratory data
Definition
Anemia is functionally defined as an insufficient
RBC mass to adequately deliver oxygen to
peripheral tissue

For practical purposes, any of the three


concentration measurements are used to
establish the presence of anemia :
Hemoglobin (Hb ) level (g/dl)
Hematocrit (%)
RBC number (1012/L)
Wintrobe’s 2004
Definition

 Most references consider Hb


concentration of 14 g/dl and 12 g/dl as the
lower limits of normal, at sea level, in adult
men and women respectively
Diagnostic Approach

 History
 Physical examination
 Basic hematology laboratory data
History

 Duration of the symptoms and their onset


 Family history
 Occupation
 Travel history
 Drug history
 Dietary history
History
 Change in stool habit
 Menstruation
 Fever
 Pains in limbs, paresthesis, difficulty in
walking
 Bruises : ecchymoses and petechiae
 Underlying disease : chronic renal
disease, liver disease, chronic infection,
endocrinopathy, malignancy
Physical examination

 Scleral icterus : hemolytic anemia


 Sternal tenderness : acute leukemia
 Liver, spleen, lymphadenopathy : infection,
lymphoma, leukemia, metastatic carcinoma,
extrimity : skin, hair, and nail
Evaluation of basic
hematology laboratory data
 Hb
 White blood cell
 Platelet
 Peripheral blood smear
 Reticulocyte
 MCV ( mean cell volume)
 MCH ( mean cell hemoglobin)
 MCHC ( mean cell hemoglobin concentration)
Evaluation of basic hematology
laboratory data
 Is anemia associated with other hematologic
abnormalities ?
 Is there an appropriate reticulocyte response to
anemia ?
 If anemia is associated with reticulocytosis, is
there any evidence for hemolysis ?
 If anemia is assocciated with a less than
appropriate reticulocyte repsonse, what are the
red cell indices ?
Evaluation of basic hematology
laboratory data
 Is the anemia associated with a low reticulocyte
response and microcytic red blood cells ?
 Is the anemia associated with a low reticulocyte
response and macrocytic red blood cells ?
 Is the anemia associated with a low reticulocyte
response and normocytic red blood cells ?
 Is the anemia associated with populations of red
cells of different size ?
Evaluation of basic hematology
laboratory data

 Is the anemia associated with abnormalities


seen on the blood smear ?
 Is a bone marrow examination needed to clarify
the cause of anemia ?
Evaluation of basic hematology
laboratory data
 Reticulocyte count :
 % reticulocytes in RBC population
 Corrected for anemia =
% reticulocytes x patient Ht
45
 Normal : 0.5 – 1.5%
Evaluation of basic hematology
laboratory data
 Reticulocyte count : absolute numbers :

 Absolute reticulocyte count =


% reticulocytes x RBC count/L3
 Normal value : 25 to 75 x 109 /L
Initial evaluation of anemia

Is anemia associated with other hematologic abnormalities ?

Yes No

Is there an appropriate reticulocyte response to anemia ?


BM exam to asses for :
Leukemia
Yes No
Aplastic anemia
Myelodysplasia Is there any evidence of What are the RBC indices ?
hemolysis ?
Myelofibrosis Bilirubin, LDH
Myelopthisis Haptoglobin MCV > 100 MCV 80 - 100 MCV < 80
Megaloblastic anemia
Evaluate for Evaluate for Evaluate for
Yes No macrocytic normocytic microcytic
anemia anemia anemia
Evaluate for Evaluate for
cause of hemorrhagic
hemolysis cause
Macrocytic anemia
Hypersegmented neutrophils or macroovalocytes

Yes

Megaloblastic anemia - BM examination to


confirm ; test for vit B12 and folat

B12 deficiency No deficiency Folate deficiency

Schilling test Poor diet


Inherited disorders of
corrects with Drug- induced malabsorption
DNA synthesis
intrinsic factor Jejunal resection
Drugs that interfere
Tropical sprue
with DNA
gluten deficiency
Yes No
Increased need associated
with pregnancy or chronic
Pernicious Ileal disease hemolysis
anemia Small bowel bacterial
Gastric overgrowth Fish tapeworm
resection Drug-induced malabsorption
Macrocytic anemia
Hypersegmented neutrophils or macroovalocytes

No

Nonmegaloblastic anemia

Reticulocyte

Increased Normal or decreased

Hemolytic anemia Alcohol toxicity


Hemorrhagic anemia Hypothyroidism
Liver disease

If above negative, get BM examination

MDS
Red cell aplasia
Acquired sideroblastic anemia
Hereditary dyserythropoietic
anemia (types I and III)
Macrocytic erythrocyte
Macrocytic erythrocyte
Giant stab cell
Neutrophyl: hypersegmentation
Microcytic Anemia

Reticulocytes

Low / normal

Serum Fe Serum Fe Normal serum Fe Serum Fe


TIBC Normal or TIBC Normal TIBC Normal TIBC
Ferritin Normal or ferritin Normal Ferritin Ferritin

Fe deficiency Increased sedimentation Hb BM


rate, CRP or other studies electrophoresis examination
consistent with underlying with iron stains
inflammatory disorder

 - thalassemia trait Sideroblastic


 - thalassemia trait anemia
Anemia of chronic disease Hb E syndrome
Hb C disorders
Normal erythrocyte
Hypochromic microcytic
Target cell in Thalassemia
Normocytic anemia

Reticulocyte

Increased

History of jaundice ; splenomegaly ;


Presence of blood smear
abnormalities ; Elevated bilirubin or
LDH

Yes No

Hemolysis Hemorrhagic anemia


Normocytic anemia
Reticulocytes

Normal / decreased

Renal, hepatic, endocrine Serum Fe


disease erythropoietin
level, thyroid studies
Normal / high Low

Positive Negative BM aspirate and biopsy • Anemia of


chronic disease
Anemia of renal • Infiltrative disorders • Early Fe
disease Anemia (leukemia, myeloma,
myelofibrosis,metastase) deficiency
of liver disease
Anemia due to • Red cell aplasia
endocrine • MDS
failure
• Dyserythropoietic
anemia (type II)
Summary
 Anemia defined as an insufficient RBC
mass to adequately deliver oxygen to
peripheral tissue.

 The diagnostic approach has to include


history, physical findings and basic
laboratorium data
Nama Lengkap :
Prof. H. Iman Supandiman, dr., SpPD-KHOM
Tempat/Tgl. Lahir :
Bandung, 7 Desember 1937
Pendidikan :
S1 / Dokter Umum Th. 1965 FK. UNPAD
S2 / Spesialis Th. 1972 FK. UNPAD
S3 / Doktor Th. FK.
Profesor Th. FK.
Jabatan Sekarang :
Kepala Subbagian Hematologi – Onkologi Medik Bagian Ilmu
Penyakit Dalam Perjan RS. Dr. Hasan Sadikin – Bandung
Tahun 2006 Organisasi : PAPDI, PHTDI

Karya Ilmiah :

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