ANEMIA

1. RBC Disorders

3. Approach to anemia

4. Definition
Reduction in the concentration of
hemoglobin or red cells
to below normal

5. Definition
►Hemoglobin, hematocrit, RBC count
►Hemoglobin preferred
 Accurate and reproducible
 Most indicative of pathophysiologic cause
of anemia

6. Normal values
►Adult male: 14 – 18gm/dl
►Adult female: 12 – 16gm/dl
►1 – 2 years: 11 – 15gm/dl
►Hb falls in old age

7. Cut-off values (WHO 1998)
Age group Hemoglobin
6 months to 5 years 11 g /dl
5 years to 11 years 11.5 g /dl
Adult male 13 g /dl
Adult female 12 g /dl
Previous value is important
 14gm/dl with 15.5gm/dl in the previous
week

8. Spurious values
►Expansion of plasma volume
3rd trimester pregnancy -Decreases RBC conc
►Hemoconcentration
Dehydration ,A/c reduction in plasma vol
Increases RBC conc

9. Evaluation
►Anemia may be primary disorder or
secondary to other systemic process
►Aim is not just to diagnose anemia but to
find the cause of anemia
►A systematic approach is very essential
►Avoids expensive and invasive diagnostic
tests

10. Evaluation
►Clinical examination
 History
 Physical examination
►Hematological examination
 Complete hemogram
 Peripheral smear examination

11. Evaluation
History
 Personal : menstrual history, blood loss
 Past : diabetes mellitus, TB
 Drug : marrow suppression
 Occupational : welders exposed to lead
 Social : IV drug users
 Dietary
►Different types of food and their quantity
►Pica

12. Evaluation
Physical examination
 Pallor
 Angular cheilitis
 Koilonychia: Iron deficiency anemia
 Petechiae: Acute leukemia
 Splenomegaly: Hemolytic anemia
 Neurological : Vit B12

14. Classification
►Morphological classification
 Based on the size of red cells
►Pathogenetic classification / ETIOLOGICAL
CLASSIFICATION
 Based on the cause of anemia

15. Morphologic classification
►Normocytic normochromic anemia
►Microcytic, hypochromic anemia
►Macrocytic anemia

17. Normocytic Microcytic
Macrocytic Macrocytic

18. Microcytic hypochromic anemia
►Disorders of iron metabolism
Iron deficiency anemia ,Anemia of chronic disorders
►Disorders of globin synthesis
Thalassemias
►Disorders of heme and porphyrin synthesis
►Sideroblastic anemia
►Lead poisoning

19. Thalassemia

20. Sideroblastic anemia

21. Macrocytic anemia
Megaloblastic anemia
 Vit B12 deficiency
 Folate deficiency
 Combined folate and Vit B12 deficiency
 Inherited disorders of DNA synthesis
 Drug induced disorders of DNA synthesis
 Erythroleukemia

22. Macrocytic anemia
Non-Megaloblastic anemia
 Post hemorrhagic anemia
 Hepatic disorders
 Refractory anemia
 Alcoholism
 Hypothyroidism
 COPD

23. Normocytic normochromic anemia
Increased erythrocyte production
 Post hemorrhagic anemia
 Hemolytic anemia
Impaired marrow response
 Hypoplastic / Aplastic anemia
 Infiltrative disorders of marrow
 Myelodysplastic syndrome
 Dyserythropoeitic anemia

24. Normocytic normochromic anemia
Decreased erythropoietin secretion
 Anemia of chronic disorders
 Anemia of renal insufficiency
 Anemia of endocrine deficiency

25. Pathogenetic classification
Anemia due to blood loss
A/c post hemorrhagic anemia ,C/c blood loss
Impaired red cell production
 Nutritional anemias
Iron def anemia, Vit B12 and/or folate def
 Defect in stem cell proliferation
Aplastic anemia, pure red cell aplasia
 Infiltrative disorders of marrow
 Anemia of chronic disorders
 Congenital anemias

26. Pathogenetic classification
Increased red cell destruction -Hemolytic anemia
►HA due to intrinsic mechanisms
►HA due to extrinsic mechanisms
Splenic pooling and sequestration

27. Hemolytic anemia
HA due to intrinsic mechanisms-
Congenital
►Defects in red cell membrane
Hereditary spherocytosis, Hereditary elliptocytosis
►Defects in globin structure
Sickle cell anemia, Unstable Hb disease
►Defects in globin synthesis
Thalassemia
►Deficiency of red cell enzymes
G6PD deficiency, Pyruvate kinase deficiency
Acquired
Paroxysmal nocturnal hemoglobinuria

28. Hemolytic anemia
HA due to extrinsic mechanisms
 Immune hemolytic anemia
HDN, blood transfusion reactions, autoimmune HA
 Red cell fragmentation syndromes
Microangiopathic HA, HA due to prosthetic valves
 HA associated with infections
Black water fever, Clostridial sepsis
 HA caused by chemical agents
Snake and spider venoms, acute drug reactions
 HA caused by physical agents
Thermal injury

29. Diagnosis
►Detailed history
►Physical examination
►Complete hemogram
 Hb, Hematocrit, RBC count
►Red cell indices
 MCV, MCH, MCHC ,RDW

30. Parameters-
Automated blood cell counter
►WBC
►RBC
►HGB
►HCT
►MCV
►MCH
►MCHC
►PLT
( CBC 8 )
LYM %
MXD %
NEU %
LYM #
MXD #
NEU #
RDW
MPV
PDW
P-LCR

31. RBC indices
► MCV ( fL ) = HCT % X 10 6
RBC (x10 /uL )
► MCH ( pg ) = HGB( g/dL ) X 10 6
RBC ( x10 /ul )
► MCHC (g/dL) = HGB (g/dL) X 100
HCT ( % )

34. Diagnosis
►Peripheral smear examination
 Most informative and rewarding diagnostic
procedure
►Reticulocyte count
►Bone marrow examination
 Aspiration
 Trephine biopsy

35. Peripheral smear

36. Diagnosis
►Iron studies
 Serum iron, TIBC
 Bone marrow iron stores
►Serum Vit B12, folate
►Occult blood
►Radiography
►Invasive tests
 Endoscopy

37. Complications
►Cardiac failure
►Peripheral neuropathy
►Muscular weakness
►Retinopathy

38. Pathogenetic classification of
anaemia
Anemia
Blood loss
A/C or C/C
Rate of Destruction
(Hemolytic Anemia)
Red cell production
Proliferation of
Intra
corpuscular
Extra
corpuscular
Stem cells
Aplastic anemia
RBC
Fe. B12. F olate

39. Anemia –Morphological classification
Blood smear
Colour of RBC
Normochromic Hypochromic

40. Anemia
RBC Size
Blood smear
MCV>100
Macrocytic
MCV 80-100
Normocytic
MCV<80
Microcytic

41. Anemia- Morphologic Classfn.
Microcytic: iron def, lead toxicity & thalassemia
Normocytic: blood loss, hemolysis, c/c disease,
infiltrative, sequestration
Macrocytic: Vit B12 &folate def, liver disease,
uremia, dilanton, hypothyroid, aplastic
anemia, dyserythropoeisis

42. Microcytic Hypochromic
Are iron reserves
Low or Absent?
Yes
Iron def
No
Thalassemia
Hemoglobinopathy
Sideroblastic anemia

43. Pathogenetic
classification
Megaloblastic
anemia
B12
Deficiency
Folate
Deficiency
Combined
deficiency
Disorders- DNA
Synthesis

44. Microcytic Anemia (IDA)

45. Macrocytic Anemia (Meg.):