Approach to acute anemia

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Approach to acute anemia

  1. 1. Approach to Anemia * วินิจฉัยว่ามี Anemia * หาสาเหตุของ Anemia
  2. 2. วินิจฉัยว่ามี Anemia อาการ - ซีด เพลีย เหนื่อยง่าย หน้ามืด เวียนศีรษะ ขาดสมาธิ เบื่ออาหาร decreased libido, organ hypoxia (angina in patients with CAD, worsening dementia / intermittent claudication ) อาการแสดง - Pallor of skin & mucous membrane, modest tachycardia, increased pulse pressure, postural hypotension (acute blood loss), systolic ejection murmur, mild peripheral edema, retinal hemorrhage (severe anemia)
  3. 3. Normal Ranges of Erythrocyte Measurements in Adults Females Males Hemoglobin (g/dl) 12 - 16 13 - 17 Hematocrit (%) 36 - 48 40 - 52 Red blood cells (x 10 6 /ul) 4.0 - 5.4 4.5 - 6.0 Mean cell volume ( MCV ; fl) 80 - 95 80 - 95 วินิจฉัยว่ามี Anemia
  4. 4. <ul><li>ผู้ป่วยหญิงไทยคู่ อายุ 26 ปี ปวดท้อง 1 วัน และมีอาการหน้ามืดคล้ายจะเป็นลม 2 ชั่วโมงก่อนมาโรงพยาบาล ไม่มีเลือดออกที่ใด ผู้ป่วยไม่มีประจำเดือนมา 2 เดือน </li></ul><ul><li>การตรวจร่างกาย </li></ul><ul><li>BP 90/60 mmHg, P 120/min </li></ul><ul><li>GA : drowsiness, markedly pale, mild jaundice, no petechiae or ecchymosis, no cyanosis </li></ul><ul><li>Abdomen - soft, mildly generalized tenderness, no guarding </li></ul><ul><li>PR - no melena </li></ul><ul><li>CBC : Hb 7 g/dL, Hct 21%, Wbc 13,000/mm3, Platelet 260,000/mm3 ; Polychromasia 2+ </li></ul><ul><li>จงให้การวินิจฉัย และการรักษา </li></ul>
  5. 5. Internal Bleeding <ul><li>Abdominal Trauma </li></ul><ul><ul><li>Tearing or rupture of Liver , spleen </li></ul></ul><ul><li>Local Intraabdominal pathology </li></ul><ul><ul><li>Ruptured Ectopic Pregnancy </li></ul></ul><ul><ul><li>Ruptured Hepatoma </li></ul></ul><ul><ul><li>GI Bleeding </li></ul></ul><ul><li>Underlying bleeding disorders </li></ul><ul><ul><li>Retroperitoneal hemorrhage </li></ul></ul>
  6. 7. Acute Bleeding <ul><ul><ul><li>- Replace volume : Crystalloid, Colloids , PRC, WB (Universal donor = gr.O Rh-negative blood) </li></ul></ul></ul><ul><ul><ul><li>- depend on host status (age, heart disease, peripheral vascular disease, previous Hb level), volume loss </li></ul></ul></ul><ul><ul><ul><li>- Correct cause of bleeding : may need Surgical intervention </li></ul></ul></ul>
  7. 8. <ul><li>ผู้ป่วยชายอายุ 22 ปี มีไข้ปวดเมื่อย 5 วัน ปัสสาวะสีเข้ม 3 วัน และเริ่มอ่อนเพลีย เหนื่อยง่าย </li></ul><ul><li>การตรวจร่างกาย T 38 o c, BP 100/60 , P 110 </li></ul><ul><li>Alert, moderately pale, mild jaundice, no edema </li></ul><ul><li>Liver just palpable, spleen not palpable </li></ul><ul><li>No lymphadenopathy </li></ul><ul><li>CBC : Hb 5.5 g/dl, Hct 17 %, Wbc 5000 , Platelet 120,000 </li></ul><ul><li>จงให้การวินิจฉัย และการรักษา </li></ul>
  8. 10. G6PD Deficiency <ul><li>X-linked recessive </li></ul><ul><li>Clinical </li></ul><ul><ul><li>Neonatal jaundice </li></ul></ul><ul><ul><li>acute hemolytic anemia : Drug (primaquine, sulfa, dapsone), infection ; beware of acute renal failure </li></ul></ul><ul><ul><li>Exaggerated jaundice in acute viral hepatitis </li></ul></ul>
  9. 11. <ul><li>Lab </li></ul><ul><ul><li>Blood smear during attack : Bite cell, Blister cell, polychromasia </li></ul></ul><ul><ul><li>Hemoglobinemia, Hemoglobinuria </li></ul></ul><ul><ul><li>G6PD assay, Methemoglobin Reduction Test </li></ul></ul><ul><li>Management </li></ul><ul><ul><li>Correct precipitating causes </li></ul></ul><ul><ul><li>Symptomatic & Supportive treatment </li></ul></ul><ul><ul><li>Hydration to increase renal blood flow (prevent ARF) </li></ul></ul>G6PD Deficiency
  10. 12. Acute Anemia <ul><li>Bleeding </li></ul><ul><li>Hemolysis </li></ul><ul><li>Dilutional </li></ul>
  11. 13. Clinical approach to patients with suspected hemolysis <ul><li>History </li></ul><ul><ul><li>Onset/duration (hereditary versus acquired) </li></ul></ul><ul><ul><li>History of fatigue </li></ul></ul><ul><ul><li>History of jaundice </li></ul></ul><ul><ul><li>Abdominal pain/ cholelithiasis (chronic hemolysis) </li></ul></ul><ul><ul><li>Medications (may exacerbate enzyme def.) </li></ul></ul><ul><ul><li>Travel (consider malaria) </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Vascular/cardiac surgery </li></ul></ul><ul><ul><li>History of blood transfusion </li></ul></ul><ul><ul><li>Blood loss (DDx of anemia with reticulocytosis) </li></ul></ul><ul><ul><li>Discolored urine </li></ul></ul><ul><ul><li>Complete family history (jaundice, gall stone, splenectomy, hereditary anemia) </li></ul></ul>
  12. 14. <ul><li>History </li></ul><ul><li>Physical Exam </li></ul><ul><ul><li>Pallor </li></ul></ul><ul><ul><li>Increased temperature </li></ul></ul><ul><ul><li>Rapid pulse </li></ul></ul><ul><ul><li>Jaundice </li></ul></ul><ul><ul><li>Thalassemic face </li></ul></ul><ul><ul><li>Mechanical click from prosthetic valve </li></ul></ul><ul><ul><li>SLE signs </li></ul></ul><ul><ul><li>Splenomegaly </li></ul></ul>Clinical approach to patients with suspected hemolysis
  13. 15. <ul><li>History & Physical Exam </li></ul><ul><li>Screening Lab </li></ul><ul><ul><li>CBC , blood smear , Absolute reticulocyte count </li></ul></ul><ul><ul><li>Haptoglobin (decreased), LDH (elevated), Indirect bilirubin </li></ul></ul>Clinical approach to patients with suspected hemolysis
  14. 19. Schistocyte <ul><li>TTP/HUS (thrombocytopenia) </li></ul><ul><li>Heart valves (mechanical , infected) </li></ul><ul><li>DIC </li></ul><ul><li>Vasculitis </li></ul><ul><li>Etc. </li></ul>
  15. 21. <ul><li>History & Physical Exam </li></ul><ul><li>Screening Lab </li></ul><ul><ul><li>CBC , blood smear , Absolute reticulocyte count </li></ul></ul><ul><ul><li>Haptoglobin (decreased), LDH (elevated), Indirect bilirubin </li></ul></ul><ul><li>Further lab </li></ul><ul><ul><li>Direct Coombs’ test, Inclusion body (HbH) </li></ul></ul><ul><ul><li>Intravascular – Hemoglobinemia, Hb.uria, Hemosiderinuria </li></ul></ul><ul><ul><li>G6PD, osmotic fragility, Blood bank consultation </li></ul></ul>Clinical approach to patients with suspected hemolysis
  16. 22. Conditions mistaken for hemolytic anemia <ul><li>Anemia and unconjugated hyperbilirubinemia without reticulocytosis </li></ul>
  17. 23. Conditions mistaken for hemolytic anemia <ul><li>Anemia and unconjugated hyperbilirubinemia without reticulocytosis </li></ul><ul><ul><li>Internal bleeding </li></ul></ul><ul><ul><li>Ineffective erythropoiesis </li></ul></ul>
  18. 24. Conditions mistaken for hemolytic anemia <ul><li>Unconjugated hyperbilirubinemia without anemia or reticulocytosis </li></ul>
  19. 25. Conditions mistaken for hemolytic anemia <ul><li>Unconjugated hyperbilirubinemia without anemia or reticulocytosis </li></ul><ul><ul><li>Gilbert syndrome </li></ul></ul><ul><ul><li>Crigler-Najjar </li></ul></ul><ul><ul><li>Neonates </li></ul></ul>
  20. 26. Conditions mistaken for hemolytic anemia <ul><li>Anemia and reticulocytosis without unconjugated hyperbilirubinemia </li></ul>
  21. 27. Conditions mistaken for hemolytic anemia <ul><li>Anemia and reticulocytosis without unconjugated hyperbilirubinemia </li></ul><ul><ul><li>Bleeding </li></ul></ul><ul><ul><li>Recovery from aplastic or nutritional anemia (iron, vit.B12, folate) </li></ul></ul>
  22. 28. <ul><li>Myobloginuria </li></ul><ul><ul><li>Dark urine </li></ul></ul><ul><ul><li>No hemoglobinemia </li></ul></ul><ul><ul><li>Normal haptoglobin </li></ul></ul><ul><ul><li>Elevated muscle enzyme: CPK </li></ul></ul>Conditions mistaken for hemolytic anemia
  23. 30. หาสาเหตุของ Anemia การแบ่งชนิดของ Anemia * แบ่งตาม pathogenesis - Disorders of erythrocyte production - Acute bleeding - Hemolysis * แบ่งตามขนาดเม็ดเลือดแดง - Microcytic anemia (MCV < 80 fl) - Normocytic anemia (MCV 80-100 fl) - Macrocytic anemia (MCV > 100 fl)
  24. 31. แบ่งตาม pathogenesis <ul><li>Disorders of RBC production </li></ul><ul><ul><li>Hypoproliferative anemia </li></ul></ul><ul><ul><ul><li>Stem cell : aplastic anemia(AA), pure red cell aplasia(PRCA), Myelodysplastic syndrome (MDS) </li></ul></ul></ul><ul><ul><ul><li>drug, chemicals, radiation </li></ul></ul></ul><ul><ul><ul><li>ขาดสารกระตุ้น เช่น Chronic renal failure, hypothyroidism </li></ul></ul></ul><ul><ul><ul><li>Myelophthisis - leukemia, lymphoma, metastatic tumor, disseminated TB/Fungus, myelofibrosis (MF) </li></ul></ul></ul><ul><ul><ul><li>Iron deficiency, anemia of inflammation </li></ul></ul></ul><ul><ul><li>Maturation defects </li></ul></ul><ul><ul><ul><li>Thalassemias, sideroblastic anemia </li></ul></ul></ul><ul><ul><ul><li>Megaloblastic anemia ( ขาด folate, vitamin B12 ) </li></ul></ul></ul>
  25. 32. <ul><li>Acute bleeding </li></ul><ul><li>Hemolysis </li></ul><ul><ul><li>Intracorpuscular defects </li></ul></ul><ul><ul><ul><li>Hereditary - Membrane defects : hereditary spherocytosis </li></ul></ul></ul><ul><ul><ul><ul><ul><li>- Enzyme defects : G-6PD deficiency </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>- Globin defects : Thalassemia, Hemoglobinopathy </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Acquired : PNH ( paroxysmal nocturnal hemoglobinuria ) </li></ul></ul></ul><ul><ul><li>Extracorpuscular defects </li></ul></ul><ul><ul><ul><li>Immune hemolysis : AIHA, hemolytic transfusion reaction </li></ul></ul></ul><ul><ul><ul><li>Infections : malaria, clostridial infection </li></ul></ul></ul><ul><ul><ul><li>Microangiopathy : TTP / HUS </li></ul></ul></ul><ul><ul><ul><li>Drug or chemicals : lead poisoning </li></ul></ul></ul>แบ่งตาม pathogenesis
  26. 33. <ul><li>Microcytic anemia </li></ul><ul><ul><li>Iron def., Thalassemia, anemia of chronic disease ( บางราย ), sideroblastic anemia </li></ul></ul><ul><li>Normocytic anemia </li></ul><ul><ul><li>Primary marrow disorders (AA, PRCA,MDS,Myelophthisis,MF), anemia of chronic disease, CRF, Mild iron deficiency, acute bleeding, hemolysis ( ยกเว้น thalassemia), endocrine disorders </li></ul></ul><ul><li>Macrocytic anemia </li></ul><ul><ul><li>Megaloblastic anemia, liver disease, alcoholism, reticulocytosis, primary marrow disorders บางราย , drugs(AZT,MTX,chemotherapy), hypothyroidism บางราย </li></ul></ul>แบ่งตามขนาดเม็ดเลือดแดง (MCV)
  27. 34. แบ่งชนิด Anemia ตาม Onset <ul><li>Acute anemia ( ภายใน 1 สัปดาห์ ) </li></ul><ul><ul><li>Acute blood loss </li></ul></ul><ul><ul><li>Acute hemolysis </li></ul></ul><ul><li>Chronic anemia </li></ul><ul><ul><li>Iron def. anemia, megaloblastic anemia </li></ul></ul><ul><ul><li>Anemia of chronic disease, CRF, hypothyroidism </li></ul></ul><ul><ul><li>Primary marrow disorders </li></ul></ul><ul><ul><li>Thalassemia, PNH </li></ul></ul>
  28. 35. การซักถามประวัติเพื่อหาสาเหตุ <ul><li>ข้อมูลทั่วไป - เพศ , อายุ , อาชีพ , เศรษฐฐานะ </li></ul><ul><li>Onset of anemia : acute , chronic , การได้รับเลือดในอดีต </li></ul><ul><li>ประวัติชี้แนะสาเหตุ anemia </li></ul><ul><ul><li>Blood loss : melena, hematemesis, hemorrhoids, hypermenorrhea </li></ul></ul><ul><ul><li>Precipitating : fever -> anemia, ปัสสาวะสีเข้ม , jaundice (HbH,HS,G-6 PD def.) </li></ul></ul><ul><ul><li>WBC ต่ำ , Plt. ต่ำ : จุดจ้ำเลือด , ติดเชื้อบ่อย , bleeding (BM dis.,SLE,HIV,TTP) </li></ul></ul><ul><ul><li>อาการของ anemia บางชนิด : dark urine (G-6 PD def, PNH), แสบลิ้น ( glossitis) </li></ul></ul><ul><ul><li>อาการของโรคระบบต่างๆ : CRF, SLE, Hypothyroidism, TB, Cancer , MM </li></ul></ul><ul><ul><li>Drug : induce PU, hemolysis in G-6 PD def, Alcohol </li></ul></ul><ul><ul><li>การผ่าตัดทางเดินอาหาร / chronic diarrhea - vit.B12, Iron, folate def. </li></ul></ul><ul><ul><li>ประวัติซีดในครอบครัว : Thalassemia </li></ul></ul>
  29. 36. การตรวจร่างกาย <ul><li>V/S : postural hypotension (acute bl. loss), hypertension (CRF), Fever (Inf.,leukemia,SLE), bradycardia (hypothyroidism) </li></ul><ul><li>GA : Jaundice (hemolysis,liver dis), Thalassemic facies, edema(CRF,CHF), koilonychia (Fe def), myxedema, malar rash/DLE /oral ulcer/polyarthritis (SLE), oral thrush/OHL/PPE (HIV), Glossitis (Fe, B12 def), petechiae (plt ต่ำ ) , signs of chronic liver disease </li></ul><ul><li>splenomegaly (extravascular hemolysis, portal hypertension, Inf.,leukemia) </li></ul><ul><li>Lymphadenopathy (HIV, neoplasm, SLE, TB) </li></ul><ul><li>PR - melena, rectal shelf, hemorrhoids, prostate gland </li></ul>
  30. 37. CBC & Blood smear <ul><li>MCV </li></ul><ul><li>Reticulocyte count </li></ul><ul><li>Blood smear - blast cell, leukoerythroblastic blood picture, fragmented red cell, spherocyte, autoagglutination, macro-ovalocyte, hypersegmented neutrophil, burr cell, target cell, tear drop cell, polychromasia, malaria </li></ul>
  31. 38. Further investigations <ul><li>Serum ferritin, Iron study - Fe def anemia -> หาสาเหตุ Fe def </li></ul><ul><li>LDH, serum B12 level, folate level - Megaloblastic anemia </li></ul><ul><li>LDH, Bilirubin, haptoglobin - hemolysis </li></ul><ul><li>Coombs’ test - AIHA -> ANA </li></ul><ul><li>Calcium, globulin, BUN/Cr, Urine Bence Jones, BM study, Film skull - Multiple myeloma </li></ul><ul><li>Hemoglobin typing - thalassemia disease </li></ul><ul><li>BUN / Cr , urine exam - CRF </li></ul>
  32. 39. Approach to Anemia <ul><li>History </li></ul><ul><li>Physical examination </li></ul><ul><li>CBC , MCV </li></ul><ul><li>Blood smear </li></ul><ul><li>Reticulocyte count </li></ul><ul><li>Clinical diagnosis & decision making & initial management </li></ul><ul><li>Further investigation </li></ul>

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