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Iron deficiency anemia
 

Iron deficiency anemia

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    Iron deficiency anemia Iron deficiency anemia Presentation Transcript

    • Anemia, Iron deficiency anemia Dr. Kalpana Malla MD Pediatrics Manipal Teaching Hospital Download more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
    • ANEMIA
    • What is Anemia?• Reduction of the red blood cell (RBC) volume or hemoglobin concentration below reference level for the age and sex of the individual• Hb < - 2SD or 95th centile for age and sex
    • Anemia BasicsAll anemias are either due to….1. Ineffective RBC production or2. Accelerated destruction of the RBC
    • Classification• By RBC morphology and By Etiological factors responsible for anemia
    • Microcytic hypochromic anemia1. Iron deficiency anemia – nutritional, - posthemohragic2. Ineffective Erythropoiesis - hemoglobinopathies, Thalassemia - Lead poisoning, Sideroblastic anemia - Cu deficiency, Pyridoxine deficiency -Chronic ds - infection, inflammations , renal ds
    • Macrocytic anemia• Megaloblastic Erythropoiesisa) Nutritional - Folate deficiency, B12 deficiencyb) Toxic – Treatment with antifolate compound – methotrexate,, and drugs that inhibit DNA replication – zidovudine, phenytoinc) Congenital disorders of DNA synthesis like Orotic aciduria etc.d) Malabsorption - liver ds
    • Macrocytic anemia Non - Megaloblastic Erythropoiesisa) Chronic hemolytic anemiab) Liver dsc) Hypothyroidismd) Diamond blackfan syndrome
    • Normocytic, Normochromic anemia1. Impaired cell production (low reticulocyte count) - aplastic anemia - pure red cell aplasia - physiological anemia of infancy - infections - Systemic diseases like endocrinal, renal and hepatic diseases - bone marrow replacement – leukemia, tumors, storage ds, myelofibrosis, osteopetrosis2 Hemolytic anemia ( reticulocyte count high)
    • DIMORPHIC ANEMIA• When two causes of anemia act simultaneously, e.g : macrocytic hypochromic due to hookworm infestation leading to deficiency of both iron and vitamin B12 or folic acid• following a blood transfusion
    • ETIOLOGICAL CLASSIFICATION OF ANEMIA• Blood loss Acute Chronic• Decreased iron assimilation - Nutritional deficiency - Hypoplastic or aplastic anemia - Bone marrow infiltration like leukemia & other malignancies, - Myelodysplastic syndrome - Dyserythropoietic anemia
    • ETIOLOGICAL CLASSIFICATION OF ANEMIA• Increased physiologic requirement- Extracorpscular - - Alloimmune & isoimmune hemolytic anemia - Microangiopathic anemias - Infections - Hypersplenism
    • ETIOLOGICAL CLASSIFICATION OF ANEMIA- Intracorpsular defect – Red cell membranopathy i.e. congenital spherocytosis,elliptocytosis – Hemoglobinopathy like HbS, C,D,E etc. Thalassemia syndrome – RBC enzymopathies like G6PD deficiency, PK deficiency etc.
    • Follow-up• Re-check CBC 4-6 weeks (to confirm response)• Continue iron 3-4 months (to replace stores)• If no improvement on adequate iron therapy, consider evaluating the child for lead poisoning or thalassemia
    • Differential of Anemia Hgb, indices, retic count and smear Inadequate response (RPI<2) Adequate response (RPI>3) r/o blood loss/hemolytic disHypochromic, microcytic Normochromic,normocytic Macrocytic hemoglobinopathy iron def chronic dis B12/folate def enzymopathy thalssemia Ca/BM failure Liver disease membranopathy chronic disease Transient erythroblastopenia Down Syndrome extrinsic factors of childhood (DIC,HUS,TTP) lead poisoning Renal disease Drugs (etoh) Immune Hemolytic anemia
    • IRON DEFICIENCY ANEMIA
    • IDA• Most common cause of anemia worldwide• Most important cause of iron deficiency anemia is parasitic infection - hookworms, whipworms and roundworms
    • GENERAL FEATURES Newborn contains 0.5g of iron, adult contains 5g A diet containing 8–10mg of iron daily is necessary for optimal nutrition 1mg of iron must be absorbed each day - Absorbed in the proximal small intestine Absorbed 2-3 times more efficiently from human milk than from cows milk
    • Iron sources:• Meat• Liver• Kidney• Egg-yolk• Green vegetables• Fruits**** Cow’s milk- poor source of iron
    • Iron metabolism:Distribution of body iron: (adults) - Hemoglobin: 2.3 gm - Storage (ferritin / haemosiderin) : 1.0 gm - Non-available tissue iron: 0.5 gm - Transport iron: 3-4 mg - Total : ~5 gm
    • Iron absorption: Depends upon – Body stores of iron - Rate of erythropoiesis - Iron needs of the body Increased absorption in presence of: - vitamin C - fruit juices - lactose - amino acids- cystine, lysine , histidine, - gastric Hcl Decreased absorption : - phytates - tannic acid - calcium salts - phosphates
    • Iron Metabolism: Figure 16-8: Iron metabolism
    • Pathogenesis of IDA:Increased physiological demand: - growing children (6-24 months) - adolescence - women during reproductive agesPathological blood loss: -chronic lossInadequate intake of diets rich in iron: -nutritional deficiency -decreased absorption- gastroenterostomy/ tropical sprue/ coeliac disease
    • • High Hb conc of the newborn falls during the first 2– 3 mo - considerable iron is stored - usually sufficient for blood formation in the first 6–9 mo of life in term
    • ETIOLOGY• The most important cause world-wide is infestation with parasitic worms (hookworms- suck 0.03- 0.2 ml of blood per worm /day ),whipworms, roundworms• Dietary insufficiency• Malabsorption
    • ETIOLOGY• Chronic blood loss - occult bleeding : peptic ulcer, Meckel diverticulum, polyp, hemangioma, inflammatory bowel disease, Intravascular hemolysis and hemoglobinuria• Chronic diarrhea• Milk allergy
    • Risk factors for IDA• Demograpghic – Eldery, Teenager, Female• Dieatary – low Iron, low Vit C, excess phytate,tea coffee,• Social and physical – poverty,alcohol abuse,GIT ds
    • CLINICAL FEATURESPallor is the most important signLook for pallor : FACE, nails, palms, conj, mucus membranesPagophagia (pica for ice) / picaAnxiety , Poor appetiteBelow 5g/dL: irritability and anorexia are prominentTachycardia and systolic murmurs- dyspnea , Palpitations
    • CLINICAL FEATURES• Hair loss and lightheadedness• Fainting• Sleepiness, Tinnitus• Mouth ulcers, Glossitis ,Angular cheilitis• Constipation• Depression, Twitching muscles, Tingling, numbness or burning sensations
    • CLINICAL FEATURES• Koilonychia (spoon-shaped nails) ,• Platynychia• Weak,brittle nails• Pruritus• Dysphagia due to formation of esophageal webs (Plummer-vinson syndrome
    • Koilonychia - spoon shaped nail
    • CLINICAL FEATURESNeurologic and intellectual functionAffects attention span, alertness,Verbal learning and memoryMonoamine oxidase (MAO), an iron dependent enzyme, has a crucial role in neurochemical reactions in the CNSbreath-holding spells
    • Response to low Hb:First: Tissue iron stores represented by bone marrow hemosiderin disappear Serum ferritin decreasesNext: Serum iron level decreases Serum transferrin,S. iron-binding capacity of the - increases Percent saturation (transferrin saturation) falls below normal Free erythrocyte protoporphyrins (FEP) accumulates
    • Response to low Hb:Later:Microcytosis, hypochromia, poikilocytosis,and increased RBC distribution width (RDW)
    • Diagnosis - LABORATORY INVESTIGATIONS 1.complete blood count (CBC) - High RBC distribution width (RDW) - reflecting an increased variability in the size of red blood cells (RBCs). - A low MCV,MCH and MCHC2. Hemoglobin (Hb)&hematocrit (Hct) value – low3. Reticulocyte - normal or moderately elevated
    • Diagnosis - LABORATORY INVESTIGATIONS3.Peripheral blood smear – microcytic hypochromic anemia, target cells, hypochromic pencil-shaped cells, and occasionally small numbers of nucleated RBC• Thrombocytosis -activate thrombopoietin receptors in precursor cells which make platelets
    • LABORATORY INVESTIGATIONS4. Diagnostic tests –- Serum ferritin- low- Serum iron - low- Serum transferrin -elevated- Total iron binding capacity (TIBC) - high5.Stool for occult blood6.Stool R/M/E - hookworm and whipworm
    • LABORATORY INVESTIGATIONS• Ratio of serum iron to TIBC (called iron saturation or transferrin saturation index - is the most specific indicator of iron deficiency - < 5% - indicates iron deficiency
    • DiagnosisLABORATORY INVESTIGATIONS Gold standard• Bone marrow aspiration, with the marrow stained for iron -Bone marrow is hypercellular, with erythroid hyperplasia• Leukocytes and megakaryocytes are normal• No stainable iron in marrow reticulum cells
    • TREATMENT• Oral administration - ferrous salts (sulfate, gluconate, fumarate) -4–6mg/kg of elemental iron• Consumption of milk should be limited• Blood loss from intolerance to cows milk proteins is reduced• The amount of iron-rich foods is increased
    • Oral iron failure?• Incorrect diagnosis (eg, thalassemia)• Patient is not taking the medication• Not absorbed (enteric coated?) malabsorption syndromes gastrectomy/celiac disease• Rapid iron loss?• Anemia of chronic disease-impairs bone marrow response
    • TREATMENT• Parenteral iron preparation (iron dextran) : Intolerance to oral iron, severe gastrointestinal complaints• Packed or sedimented RBCs : with Hb values < 4g/dL• congestive heart failure: fresh-packed RBCs should be considered
    • RESPONSES TO IRON THERAPY12–24 hr• Replacement of intracellular iron enzymes; subjective improvement; decreased irritability; increased Appetite36–48 hr• Initial bone marrow response; erythroid hyperplasia48–72 hr• Reticulocytosis, peaking at 5–7 days4–30 days• Increase in hemoglobin level1–3 mo• Repletion of stores
    • Thank youDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]