Anemia clinical approach

1. Approach to the Patient with
ANEMIA
BY
DR Abd El Moneam Ahmed
ASS.Prof of internal medicine
–

2. Objectives
Define Anemia
Review basic science of the RBC
Review key aspects of history, physical
and lab evaluation for anemia.
Review a systematic approach to the
diagnosis

3. Objectives
Define Anemia
Review basic science of the RBC
Review key aspects of history, physical
and lab evaluation
Review a systematic approach to the
diagnosis

4. Definition
Anemia is a blood disorder characterized by
reduction in one or more of the major RBC
measurements:
hemoglobin concentration(Hgb) or
hematocrit(Hct)
according to age and sex
Hgb : men < 13.5 gm%& women < 11.5gm%
Hct : men < 38 % women <36%

5. Anemia reduced oxygen
carrying capacity of the blood
tissue dysfunction manifestations

6. Manifestaions
Decreased oxygen delivery to tissues
– Exertional dyspnea
– Dyspnea at rest
– Fatigue
– Lack of concetntaion
– Signs and symptoms of hyperdynamic state
Bounding pulses
Palpitations
– Life threatening: heart failure, angina, myocardial
infarction

7. Anemia is the most common blood
disorder
Anemia is a sign, not a disease
denotes a complex of signs and symptoms
that underlie certain disease(role
of physician to pick up)
Its never normal to be anemic.

8. Objectives
Define Anemia
Review basic science of the RBC
Review key aspects of history, physical
and lab evaluation
Review a systematic approach to the
diagnosis

9. RBC-The important players
Hemoglobin
– reversibly binds and transports oxygen from
lungs to tissues
– composed of 4 globin chains & iron

10. RBC-The important players
Iron
– key element in the production of hemoglobin
Transferrin
– iron transporter in blood circulation
Ferritin
is a blood protein that contains iron
– measure of iron stores ( can be measured in
labs)

11. The haematocrit (Ht or HCT)
is the volume percentage (vol%) of RBCs in blood .
The measurement depends on the number and size of
red blood cells.
It is normally 40.7–50.3% for males and 36.1–44.3%
for females.
It is a part of a person’s complete blood count results

12. hemaocrit

13. Objectives
Review basic science of the RBC
Define Anemia
Review clinical approach for
anemia.
A systematic approach to the diagnosis

14. Clinical approach
two key players

15. 1- history &physical examination
AND
2- laboratory approach ( two items)

16. Value of history and clinical
examination
Onset
1- new onset or acute anemia????
(acute blood loss, hemolytic anemia, bone
marrow failure )
2- long or chronic or recurrent history of
anemia

17. HISTORY
– Is the patient bleeding? (Actively, In past)
– Is there evidence for increased RBC
destruction?(jaundice , dark urine)
– Is the patient nutritionally deficient?( Pica,
vegetarian)
– PMH including medication review, toxin
exposure
– Family history (inherited hemolytic anemia)

18. Evaluation of the Patient (3)
PHYSICAL EXAM
•Stable or Unstable?
-Vitals
•Pallor
•Jaundice
-hemolysis
•Lymphadenopathy
•Hepatosplenomegally
•Bony Pain
•Petechiae
•Rectal-? Occult blood

19. Two main laboratory approaches
1. kinetic approach.
2. RBCs Morphology.

20. Kinetic approach
Anemia (balance
between
Production? Survival/Destruction?
The key test is the …..

21. The reticulocyte count
(kinetic approach)
It is Red cells newly released from the bone marrow
that have shed their nuclei but still contain some nuclear
material in the cytoplasm are called reticulocytes.
Reticulocytes were traditionally measured through
supravital staining on fresh smears,
but now are most frequently measured by flow
cytometry technology .

23. Value of retics
1- Reticulocyte counts are helpful in the initial approach
to anemia in distinguishing anemias due to
underproduction of red cells from those associated with
adequate or overproduction but shortened survival in the
circulation.
2- During treatment of anemia, increases in the
reticulocyte count can predict response to therapy

24. The reticulocyte count
can be expressed either as a percentage of all RBCs,
the absolute reticulocyte count or the corrected
reticulocyte count,
To be accurate the reticulocyte count must be adjusted
for the patient's hematocrit or RBCs count .. Thus:
Corrected retic.(CRC) = Patients retic.
x (Patients Hct/45) (normal 0.5 to 1.5%)
Absolute reticulocyte count =
retic x RBC number.(normal 150
-250 thousands)

25. Reticulocyte test
The result will be reticulocytopenia ( low
count )
Or
reticulocytosis (high count)

26. Kinetic classification
Hypoproliferative
Low retics
Ineffective
Erythropoesis( low)
Hemolytic
High retics
Intrinsic marrow lesion
 Stem cell dysfunction
Aplastic anemia
RBC aplasia
 Marrow replacement
Fibrosis
Tumor
 Myelophthisic anemia
 Mild marrow failure in the elderly
(etiology unknown).
Erythropoietin Deficient
 Renal disease
 Nutritional
 Endocrine ((pituitary, adrenal,
thyroid, testis)
Iron deficient erythropoiesis
 Iron deficiency anemia
 Anemia of chronic disease
 Inflammation
Megaloblastic
 Vitamin B12 deficiency
 Folate deficiency
 Vitamin C deficincy
 Copper deficiency
Microcytic/Normocytic
 Thalassemia
 Myelodysplastic syndrome
 Sideroblastic anemia
Intrinsic
 Membrane
Alterations
 Metabolic
 Hemoglobinopathy
Extrinsic
 Splenomegaly
 Mechanical
 Lytic agents
Immunologic
 Idiopathic
 Autoimmune
 Secondary:
Drugs
Leukemia/
Lymphoma
Collagen vascular
disease

27. First, measure the size of the RBCs
either by :
1- Use of volume-sensitive automated blood cell counters,
such as the Coulter counter.
2 - By calculation from an independently-measured red
blood cell count and hematocrit:
MCV (femtoliters) = 10 x HCT(percent) ÷
RBC (millions/µL)
Normal MCV :80 -100 FL
RBCs Morphological Approach
(big versus little)

28. Microcytic Anemia
MCV <80
Due to :
Reduced iron
availability
Reduced heme
synthesis
Reduced globin
production

29. Microcytic Anemia
REDUCED IRON AVAILABILTY
Iron Deficiency
– Deficient Diet/Absorption
– Increased Requirements
– Blood Loss( genito urinary &GIT)
– Iron Sequestration
Anemia of Chronic Disease
– Low serum iron, low TIBC, normal or increased serum
ferritin
Chronic infection, inflammation, cancer, liver disease

30. Microcytic Anemia
REDUCED HEME SYNTHESIS
Lead poisoning
Acquired or
congenital
sideroblastic anemia
Characteristic smear
finding: Basophilic
stippling

31. Microcytic Anemia
REDUCED GLOBIN PRODUCTION
Thalassemias
Smear Characteristics
– Hypochromia
– Microcytosis
– Target Cells
– Tear Drops
Confirmed by Hb
electrophoresis & family
history

32. Macrocytic Anemia
MCV > 100
Megaloblastic:Abnormalitie
s in nucleic acid
metabolism
– B12, Folate
Non-
megaloblastic:Abnormal
RBC maturation
– Myelodysplasia
liver disease ,
hypothryroidism,
chemotherapy/drugs

33. Noromcytic normochromic
anemia
MCV 80-100 fl
Due to
1- hemolytic anemia
Or
2- bone marrow disorders

34. Hemolytic anemia
Due to increased destruction of RBCs
1- immune mediated
2- non immune mediated

35. Increased Destruction
IMMUNE MEDIATED
Cold Agglutinin
– Paroxysmal nocturnal hemoglobinuria
– Post mycoplasmal hemolytic anemia
Warm Agglutinin
– Drug induced
– Autoimmune hemolytic anemia
– Transfusion reaction

36. Increased Destruction
NON-IMMUNE MEDIATED
Extra-corpuscular
– Macro-circulatory
Hypersplenism
Extracorporeal circulation
– Micro-circulatory
DIC
TTP
HUS
Intra-corpuscular
– RBC Wall (membrane or enzyme defects)
– Heme or globin abnormalities (HbS, C)

37. Sickled
cells
Bite
cells
Schisto-
cytes
Acantho-
cytes
Sphero-
cytes
Target
cells
parasite
inclusions
DAT
(+)
DAT
(-)
Hgb electro-
phoresis
G6PD
level
PT/PTT
Crea
platelets
Auto-
Immune
Hemo-
lytic
Anemia
Heredi-
tary
Sphero-
cytosis
Sickle
Cell
Ds
G6PD
Deficient
Vs
Unstable
Hgbs
Thalas-
semias
Hemo-
globino-
pathy
Liver Ds
Liver
Ds
Malaria
Babe-
siosis
Barto-
nella
TTP-HUS
DIC
Prosthe-
tic Valve
Malignant
HTN
Hemolytic Anemia (CRC>2% + no blood loss)

38. Normocytic
&Underproduction (2)
Normocytic
Anemia of chronic
disease
Renal failure
Bone marrow failure
Stem cell dysfunction
Aplastic anemia
RBC aplasia
Marrow replacement
Fibrosis
Tumor
Myelophthisic anemia
Mild marrow failure in
the elderly (etiology
unknown).
Endocrine ((pituitary,
adrenal, thyroid, testis)

39. Objectives
Review basic science of the RBC
Define Anemia
Review key aspects of history, physical
and lab evaluation
Review a systematic approach
to the diagnosis

40. Clinical Approach to
Anemia
< 80
Microcytic
Low
hypoproliferative
High
Hemolytic anemia
Reticulocyte index
80< x <100
Normocytic
> 100
Macrocytic
MCV
CBC w/ Diff, smear
Complete History and Physical
Hgb < 12
(Investigate)

41. Evaluation of
anemia Low Hgb/Hct
Corr. Retic
Ct >2%
Corr. Retic
Ct <2%
Acute
Blood Loss
MCV>100
MCV 80-
100
MCV<80
EVALUATE &
TREAT
APPRO-
PRIATELY
Evaluate for
Hemolytic
Anemias
Evaluate for
microcytic
anemias
Evaluate for
macrocytic
anemias
Evaluate for
normocytic
anemias

42. Take home message
1- anemia is alarming sign to specific
disease
2- never treat the patient with blood
transfusion & multivitamins without
knowing what is the cause
3- clinical approach &LAB approach are
essential for diagnosis of anemia

43. References
Schrier, Stanley.Approach to the patient with
anemia. Up to Date. 2004
Schrier, Stanley. Anemia of Chronic Disease. Up
to Date. 2004
Schrier, Stanley. Anemias due to decreased red
Cell Production. Up to Date 2004
Schrier, Stanley. Causes and diagnosis of
anemia due to iron deficiency. Up to Date. 2004
Tierney, et al. Anemias. Current Medical
Diagnosis and treatment. 2003. Pp469-489

44. Thank you