This is a summarized presentation that can be used by medical students

1. APPROACH TO ANAEMIA
Presenter: BIMENYIMANA Phocas, Medical student, doc III, UR
Supervisor: Dr. MUHIZI Epaphrodite, Resident/internal medicine
Dr. NIYIGENA Olivier, Internist, CHUB

3. Outline
• Clinical case
• Introduction
• Epidemiology
• RBC life cycle
• Severity rating of anemia
• Etiological classification of anemia
• Morphological classification of anemia
• Approach to the diagnosis of anemia
• Principles of management of anemia

4. Clinical case
A 18 yrs F patient came to you complaining of weakness, lethargy and inability to do her
work for the past 2 months. Up on questioning she just had her menstrual cycle last month
and it lasted for 25days. Also this month she is having heavy periods. Today is her 15th
day. She has breathlessness and palpitations while climbing stairs. She also had episodes of
dizziness but not fainting. Family hx is positive for menorrhagia.
• PE Vitals, HR=115bpm, T=36.8, RR=20cpm, BP=110/74mmhg
• CVS: overall pallor, pale nail beds, pale conjunctiva, pale gums, regular tachycardia
• Resp: normal breath sound, no sign of RD
• GIT: soft, flat no organomegaly or mass, present BS (DRE heme negative)
• Other systems: NAD(no abnormality detected)
WHAT IS YOUR NEXT STEP?

5. Introduction
Anemia refer to a decrease in the total number of circulatory
red cells with decrease in HB,PCV below the previously
established normal values, health person of same age group,
gender race, and similar environmental conditions.
It is also Anemia is strictly defined as a decrease in red blood
cell (RBC) mass.
Anaemia is a sign of a disease that requires investigations to
determine its cause.

6. Epidemiology
• WHO estimates that 42% of children less than 5 years of age
and 40% of pregnant women worldwide are anemic.
• Anemia is a significant public health problem affecting
around 1.93 billion people worldwide.
• It affects 29.4% of Women of Reproductive Age (WRA) and
38.2% of pregnant women

7. Epidemiology cont’d
• Anemia remains a public health problem in Rwanda, affecting 38% of
young children and 17% of reproductive-aged women.
• The 2014–15 Demographic and Health Survey (DHS) report estimated
the prevalence of anemia among WRA in Rwanda to be 19.2% . the
prevalence had risen from 17% in 2010.
• Moreover, 11 of 30 districts in Rwanda reported much higher
prevalence than the national average; with some districts even
reporting prevalence of more than 30%

8. Review of RBC’s Life Cycle

9. Severity rating of anemia
• Hb: 10 g / dL up to Normal lower limit
• Hb : 7 – 10 g / dl: Moderate anaemia
• Hb : < 7 g / dl :Severe anaemia

10. Mechanism/Classification of Anemia
I. Etiologic Classification
1. Impaired RBC production
2. Excessive destruction
3. Blood loss
II. Morphologic Classification
1. Macrocytic anemia
2. Microcytic hypochromic anemia
3. Normochromic normocytic anemia

11. Impaired RBCs production
1. Abnormal bone marrow
1.1 Aplastic anemia
1.2 Myelophthisis : Myelofibrosis, Leukemia, Cancer metastasis
2. Essential factors deficiency
2.1 Deficiency anemia : Fe, Vit. B12, Folic acid, etc
2.2 Anemia in renal disease : Erythropoietin
3. Stimulation factor deficiency
3.1 Anemia in chronic disease
3.2 Anemia in hypopituitarism
3.3 Anemia in hypothyroidism

12. Excessive Destruction of RBC
2. Extracorpuscular defect
2.1 Mechanical : March hemolytic anemia,
MAHA(Microangiopathic HA)
2.2 Chemical/Physical
2.3 Infection: Clostridium tetani
2.4 Antibodies: SLE(Systemic lupus erythematosus)
2.5 Hypersplenism

13. Excessive Destruction of RBC(cont.)
• Hemolytic anemia
1. Intracorpuscular defect:
1.1 Membrane : Hereditary spherocytosis,Hereditary
ovalocytosis, etc.
1.2 Enzyme : G-6PD deficiency, PK deficiency, etc.
1.3 Hemoglobin : Thalassemia, Hemoglobinopathies

14. Blood Loss
1. Acute blood loss : Accident, GI bleeding
2. Chronic blood loss : Hypermenorrhea, Parasitic infestation

15. Morphological classification

16. Macrocytic Anemia
MCV > 94, MCHC > 31
• 1. Megaloblastic dyspoiesis
• 1.1 Vit. B12 deficiency : Pernicious anemia
• 1.2 Folic acid deficiency : Nutritional megaloblastic anemia, Sprue,
Other malabsorption
• 1.3 Inborn errors of metabolism : Orotic aciduria,etc.
• 1.4 Abnormal DNA synthesis : Chemotherapy, Anticonvulsant, Oral
contraceptives

17. Microcytic Hypochromic Anemia
MCV < 80 MCHC < 31
1. Fe deficiency anemia : Chronic blood loss, Inadequate diet,
Malabsorption, Increased demand, etc.
2. Abnormal globin synthesis : Thalassemia with or without
Hemoglobinopathies
3. Abnormal porphyrin and heme synthesis : Pyridoxine
responsive anemia, etc.
4. Other abnormal iron metabolism :

18. Normocytic Normochromic Anemia
MCV 82 – 92 MCHC > 30
1. Blood loss
2. Increased plasma volume : Pregnancy, Over hydration
3. Hemolytic anemia : depend on each cause
4. Hypoplastic marrow : Aplastic anemia, RBC aplasia
5. Infiltrate BM : Leukemia, Multiple myeloma, Myelofibrosis, etc.
6. Abnormal endocrine : Hypothyroidism, Adrenal insufficiency, etc.
7. Kidney disease / Liver disease / Cirrhosis

20. Approach to diagnosis

21. Diagnosis
• Anemia is one of the major sign of disease, it is never normal
and always has to sought.
• The history, physical examination, and simple laboratory
testing are all useful in evaluating the anemic patient
• Symptoms depends on the magnitude and rate of reduction
in oxygen carrying capacity of the blood

22. Workup should answer the following questions
Is the patient bleeding (now or in the past)?
Is there evidence for increased red blood cell (RBC)
destruction (either intravascular or extravascular)?
Is the bone marrow suppressed? If so, why?
Is the patient iron deficient? If so, why?
Is the patient deficient in folate or vitamin b12? If so,
why?

23. Other important questions
• Is there a recent history of loss of appetite, weight loss, fever, and/or
night sweats that might indicate the presence of infection or
malignancy?
• Is there a history of, or symptoms related to, a medical condition that
is known to result in anemia (eg, tarry stools in a patient with ulcer-
type pain, significant blood loss from other sites, rheumatoid arthritis,
renal failure)?
• Is the anemia of recent origin, subacute, or lifelong? Recent anemia is
almost always an acquired disorder, while lifelong anemia, if
accompanied by a positive family history, is likely to be inherited (eg,
the hemoglobinopathies, thalassemia, hereditary spherocytosis).

24. Clinical presentation
Fatigue
Malaise
Dyspnea on exertion
Loss of stamina
Palpitations
Complaints related to
Exertion
Reduced exercise capacity
Pounding sensation in ears
Night sweats

26. History
History of Hemoglobinopathies, Bleeding Disorders
History of Jaundice, Gallstones, Splenectomy and Bleeding
Travel History
Drug History
Dietary History
History of any major surgeries
History of malnutrition, vegans…

27. History cont’d
 History of any worm in stool and dark tarry stools
 History of Fever – can be seen in Infections, Malignancies and
Connective tissue disorders
 Menstrual History (Defined as excessive flow – Duration exceeds 7
days More than 12 pads used Clots after 1st day of menstruation)

28. Physical examination
The major aim of physical examination is:
to find signs of organ or multisystem involvement
to assess the severity of the patient's condition
Vital signs
 Thus, the presence or absence of tachycardia, dyspnea, fever, or
postural hypotension should be noted.
 While evaluation for jaundice and pallor is a standard part of the
physical examination

29. Physical exam cont’d
• Pallor: The sensitivity and specificity for pallor in the palms, nail beds,
face, or conjunctivae as a predictor for anemia varies from 19 to 70
percent and 70 to 100 percent.
• Jaundice: may be difficult to detect under artificial (nonfluorescent)
lighting conditions. Even under optimal conditions, it may be missed.
• Look at the nail beds/plates: Koilonychia is a common finding in
Hypochromic anemia especially in IDA ;

30. Physical exam cont’d
• It is also important to look for signs of other hematologic
abnormalities, including petechiae due to thrombocytopenia,
ecchymoses, and other signs of bleeding due to abnormalities of
coagulation.
• One should also look for signs and symptoms of recurrent infections
secondary to neutropenia or immune deficiency states.
• Stool obtained during the examination should always be tested for
the presence of occult blood.

31. Other physical findings
• The presence or absence of lymphadenopathy,
• hepatosplenomegaly,
• Bone tenderness, especially over the sternum.
• Bone pain may signify expansion of the marrow space due
to infiltrative disease, as in chronic myeloid leukemia, or
lytic lesions, as in multiple myeloma or metastatic cancer.

32. Laboratory evaluation
1.complete" blood count (CBC). This routinely includes: hemoglobin,
hematocrit (HCT), red blood cell (RBC) count, RBC indices, and white
blood cell (WBC) count.
Red blood cell indice
mean corpuscular volume (MCV), 80 to 100 fL
mean corpuscular hemoglobin (MCH),
mean corpuscular hemoglobin concentration (MCHC)

33. Investigations
• FBC
• Peripheral blood film
• Reticulocyte count
• Reticulocyte Production Index
• RBC Indices
• Bone marrow aspiration

37. • Evaluation for iron deficiency: More complete evaluation for iron
deficiency is indicated when the history (menometrorrhagia,
symptoms of peptic ulcer disease) and preliminary laboratory data
(low MCV, low MCH, high RDW, increased platelet count) support this
diagnosis.
• The plasma levels of iron, iron binding capacity (transferrin),
transferrin saturation, and ferritin should be measured

38. General principles of management of anaemia
• Identify treatable causes and treat e.g
Malaria, Hookworm , PUD , Schistosomiasis,
Surgically treatable GIT abnormalities,...
• SPECIFIC REPLACEMENT THERAPY WITH
Iron, Folic acid or Vitamin b12
• SUPPORTIVE THERAPY :
PRBCs transfusions for chronic blood loss
Education : to the patient and community
• PREVENTION AND PROPHYLAXIS:
Iron/folate supplements in pregnancy ,prematurity, chronic
haemolysis

39. Take a home message
• Anaemia is a sign of a disease that requires investigations to determine its cause
• Classification of anaemia is helpful to widen the diagnostic spectrum
• The history, physical examination, and simple laboratory testing are all useful in
evaluating the anemic patient
• Symptoms like fainting/dizziness and heart attack on anemic patients show
severe anemia.
• Knowing the underlying cause of anemia is a key to maximize the management.
• Prevention and prophylaxis such as: Iron/folate supplements in pregnancy
,prematurity is contributing too much in reduction of prevalence

40. References
• Lawrence LK Leung, MD, Apr 10, 2020. Approach to the adult with anemiaavailable
from: https://www.uptodate.com/contents/approach-to-the-adult-with
anemia?search=anemia&source=search_result&selectedTitle=1~150&usage_type=
default&display_rank=1
• Dieudonne Hakizimana, Marie Paul Nisingizwe, Jenae Logan and Lex Wong.11
December 2019. Identifying risk factors of anemia among women of reproductive
age in Rwanda – a cross-sectional study using secondary data from the Rwanda
demographic and health survey 2014/2015.
https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-8019-z
• World Health Organization. The global prevalence of Anaemia in 2011. WHO Rep
[Internet]. 2015;48. Available
from: http://apps.who.int/iris/bitstream/10665/177094/1/9789241564960_eng.pdf
?ua=1
• Faustin Habyarimana, Temesgen Zewotir and Shaun Ramroop, Prevalence and Risk