Anaemia

Definition Classification by mechanism of anaemia

 Men: Hb <14 g/dL ↓ RBC production  Fe, B12 or folate deficiency
 Women: Hb <12 g/dL  Hypoplasia
 Malignant invasion of bone marrow
Symptoms: ↑ RBC loss  Blood loss
 Fatigue  Anorexia  Haemolysis
 Dyspnoea  Dyspepsia  Hypersplenism
 Palpitations  Bowel disturbance
 Headache  Angina – pre-existing CAD Classification by MCV
 Dizziness, postural hypoTN  Pica—compulsive eating of  Normal / Low MCV:
 Tinnitus non-nutritive substance e.g.
Reticulocyte count
ice, dirt, paint
Normal / Low High
Signs:
 Pallor
Jaundice + pallor = Haemolytic anaemia until proven otherwise
 Jaundice
 Retinal hemorrhages PBF  Bleeding
 Hyperdynamic circulation ∼ Tachycardia  Haemolysis
∼ Systolic murmurs
∼ Cardiac enlargement
 Heart failure ∼ Edema ~ gallop
∼ Cardiac dilatation ~flow murmur  Hypochromia  Target cells  Dimorphic  Non-specific
• Postural drop in BP  Low MCV  Basophilic
stippling
Bone marrow Ferritin
History: Ferritin biopsy  Normal or high
 Fe loss: GI symptoms and menstrual history.  Low
 Poor Fe / folate intake - diet (eg vegans) and Sx resection of stomach / Hb electropho-
small bowels resis for HbA2
 Chronic diseases
 FMHx of haemolytic anaemia or pernicious anaemia
 Drugs – may cause blood loss (aspirin, NSAIDs), haemolysis or Fe Deficiency  Raised: β Sideroblastic ?Anaemia of
thalassaemia Chronic Dz
aplasia  Normal: α
 Jaundice – haemolytic anaemias Invx cause thalassaemia

Causes of anaemia: Consider bone

marrow biopsy
∼ Commonest cause: Fe deficiency due to blood loss.
and iron
studies
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 High MCV Low MCV  Fe deficiency (commonest  Thalassaemia
cause)  Sideroblastic anaemia (rare)
Check Hx: Normal MCV  Haemolysis  Bone marrow failure
 EtOH  Anaemia of Chronic Dz  Renal failure
 Liver dz  Pregnancy  Hypothyroidism
 FMHx pernicious anaemia High MCV  B12 / folate deficiency  Reticulocytosis eg
 Hypothyroid  Antifolate drugs eg phenytoin haemolysis Myelodysplastic
 Drugs  Alcohol syndromes
 Prev. abdo Sx  Liver disease  Marrow infiltration
 Hypothyroidism  Cytotoxics
*Haemolytic anaemias may be normo- or macro-cytic. Suspect if
reticulocytosis is present
PBF + Reticulocyte count

Investigations – Anaemia workup:

• FBC • U/E/Cr
Hypersegmented polymorphs Drugs/cytotoxics • Reticulocyte count • LFT – liver dz & ↑LDH in haemolytic anaemia
• PBF • TFT
• Fe / TIBC / Ferritin • Fecal occult blood
• Folate + B12 • Direct Coomb’s test – Haemolytic anaemias
Folate, B12 levels Low Invx & treat • Hb electrophoresis • ± OGD for UGI bleed/colonoscopy for LGIB
• ±Bone marrow biopsy
Target cells, stomatocytes LFT
Interpreting Plasma Iron Studies
Iron TIBC Ferritin
Dysplasia / cytopenia ?Myelodysplasia Fe deficiency ↓ ↑ ↓
Marrow Anaemia of Chronic dz ↓ ↓ ↑
Chronic haemolysis ↑ ↓ ↑
Dimorphic ?Sideroblastic Haemchromatosis ↑ ↓/N ↑
Pregnancy ↑ ↑ N
Sideroblastic anaemia ↑ N ↑
Polychromasia / High Retic count

?Bleeding ↑ Bilirubin & LDH

Haemolytic anaemias
- look for fragments

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Iron Deficiency Anaemia
 Causes: 1. menorrhagia 6. diverticulitis
2. oesophagitis haemorrhoids Sideroblastic Anaemia
3. PUD 7. hookworms  Dyserythropoiesis + iron loading (bone marrow + haemosiderosis ie
4. GI CA 8. poor diet / special diet endocrine, liver and cardiac damage)
5. colitis 9. malabsorption (celiac  Causes: Idiopathic, Congenital (rare, X-linked), EtOH or lead excess,
dz) myeloproliferative disease, malignancy, malabsorption, anti-TB drugs
 Hypochromic RBC on PBF + sideroblasts in marrow.
 Rx: Oral iron (eg Fe sulfate 200mg/12-8h PO) – should
increase Hb by 1 g/dl/week. SE: constipation, black
stools

Haemolytic Anaemias
 Causes:
Membrane problems  Hereditary spherocytosis
 Elliptocytosis
Enzyme problems  G6PD deficiency
 Pyruvate kinase deficiency
Hb problems  Thalassaemia
 Sickle cell disease
Others  Infection: Malaria, HUS
 Hypersplenism
 Mechanical heart valves
 Autoimmune Ab (AIHAs)
 Snake venom

 Investigations
 ↓ Hb  ↑ Unconjugated Bilirubin
 ↑ LDH  ↑ Reticulocyte count
 ↓ haptoglobulin  DCT: + in AIHA

Anaemia of Chronic Disease

 Causes: Infection, collagen vascular dz, rheumatoid arthritis,
malignancy, renal failure
 Rx: treat underlying cause. Recombinant erythropoietin for renal
failure

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