1. Anemia
Dr Namal Herath
Registrar in Internal Medicine (Teaching Hospital Jaffna)
Lecturer in Physiology
Department of Physiology
FMAS, RUST
2022.07.15
3. Type of cell Too many Too few
Polycythemia Anemia
Leukocytosis Leukopenia
Thrombocytosis Thrombocytopenia
4. All blood cells are being
produced by a single
common cell type, the
Hemopoietic Stem
Cells.
Let’s see how different
types of cells are being
produced.
8. Hemoglobin molecule
•Has two Alpha globin chains
and two beta globin chains.
•Each globin chain has
separate heam group.
(Ferrous atom surrounded by
pyrrole rings.)
13. Anemia is a decrease in hemoglobin in the blood below
the reference level for age and sex of the individual.
Male : 13- 17 g/dl
Female : 12-15 g/dl
Males have higher hemoglobin level as androgens
promote erythropoiesis.
Females generally has low hemoglobin level as they
don’t have androgens and they tend to lose blood with
menstruation
Anemia
14.
15. Red cell indices
Red cell indices Reference value
MCV (Mean corpuscular volume) 80-96 ft
MCH (Mean Corpuscular Haemoglobin) 27-32 pg
MCHC (Mean corpuscular Haemoglobin
concentration)
30-35 g/dl
17. MCV (Mean Corpuscular Volume)
• Its the average volume of a single red blood cell
• Given in femtoliters
• MCV in femtoliters [fL] =HCT (L/L)x 1000
RBC [10 12/L])
• When MCV is < 80 fL we call it as microcytic
• When MCV is > 96 fL we call it as macrocytic
18. Mean Corpuscular Heamglobin
• Average haemoglobin amount in one red cell
• Given in picograms (pg)
• MCH= Heamoglobin (g/dL) x 10
RBC count (millions/ μm3)
• When MCH is < 27 pg, we call it as hypochromic
19. Mean Corpuscular Haemoglobin Concentration
• It’s the average concentration of heamoglobin in red blood cells
• Given in g/dL
• MCHC= Haemoglobin (g) x 100
Packed cell volume (dL)
• When MCHC < 30 g/dL, we call it as hypochromic
20. Red Cell Distribution Width
• Is a measure of variation of red cell volume
• Given in a percentage
• If RDW is high, it means the red cell volume varies within a
large rage. This indicates that there are red cells of various
sizes.
21. Classification of anemia
•Commonest way is to classify by the MCV
1.Microcytic with a low MCV
2.Normocytic with a normal MCV
3.Macrocytic with a high MCV
In some disease conditions more than one type o
anemia can present.
25. Iron Deficiency Anemia (IDA)
Is the commonest type of anemia in Sri Lanka
Sources of iron
1. Heam iron from animal products
• Iron presents as heam therefore can be directly utilized.
2. Non- heam iron from plan products (Grains/ Green leaf
vegetables)
• Iron presents in oxidized ferric form.
• Need to be reduced into ferrous before absorption.
• Therefore, not well absorbed compared to heam iron.
26. • Absorption is mainly from the duodenum
• Key molecule regulating the iron absorption is hepcidin
• Iron is transported within the blood as transferrin ( Iron + apo
transferrin)
• Iron is stored in the body as ferritin mainly in the cells of
reticulo-endothelial system and the liver.
27.
28. • Daily iron requirement is around 9mg/day for men over 18
years and 15mg/ day for women over 18 years.
• The requirement varies with the demand.
• During growth in adolescents and during pregnancy the
demand for iron increases and therefore during these periods
its more likely to develop IDA.
• Iron is lost
• ~ 1mg/day with faeces
• ~25mg during menstruation
29. Causes for IDA
1. Poor intake
2. Decreased absorption
• Structural defects in brush border of the duodenum
• Partial or total gastrectomy (due to reduced acid secretion)
• Dietary factors like high calcium, caffeine, tannin, phytic acid in cereals, phosphates
and oxalates.
3. Increased demand during pregnancy and adolescence
4. Excessive loss ( Menorrhagia, worm infestation, bleeding eg:
Hemorrhoids, gastric ulcers)
32. Investigations
for IDA
• Full blood count
• Low Hemoglobin
• Low MCV
• Low MCH
• Low MCHC
• High RDW
• Blood picture
• Hypochromic
microcytic cells
• Anisocytosis
• Poikilocytosis
• Iron studies
• Low serum iron
• Low serum
ferritin
• High total iron
binding capacity
33. Blood picture
• Hypochromic microcytic cells
• Anisocytosis ( having different
sizes)
• Poikilocytosis (Having different
shapes)
34. How do we treat them?
• Find the etiology for IDA and if treatable correct the cause
• Vegetarian : Supplement iron
• Menorrhagia: Treat menorrhagia
• Worm infestation: Treat worm infection
• Bleeding hemorrhoids: Surgical treatment for hemorrhoids
• Iron supplements either oral or intravenous
• Blood transfusion in severe anemia
35. Other causes
of hypochromic
microcytic
anemias
Thalassemia
Defect in globin chain synthesis
Two types
1. α Thalassemia
2. β Thalassemia
What we commonly see is β thalassemia.
It has two presentations
1. β Thalassemia major: Severe transfusion
dependent anemia
2. β Thalassemia minor: Mild form, no additional
treatment required
Bone deformities may be seen in affected children
36. Other causes
of hypochromic
microcytic
anemias
Sideroblastic Anemia
•Defective synthesis of heam
•Defect in ALA synthase enzyme required for the first
step of heamsynthesis is seen in majority of
sideroblastic anemias.
•Ring sideroblastsare seen in bone marrow
•Accumulation of iron in mitochondria as granules
near the nucleus with Pearl’s reaction
37. Macrocytic
anemias
Is in two types
•Megaloblastic anemia
(Megaloblasts are seen in
bone marrow)
•Non megaloblastic
anemia (Megaloblasts are
not seen in bone marrow)
39. • Megaloblasts are immature large erythroblasts
• They shows delayed nuclear maturation due to
defective DNA synthesis
• Hyper segmented (> 6 segments) neutrophils are
seen in bone marroe
• Main causes
1. Vit B 12 deficiency
2. Folate deficiency
40.
41.
42. Vitamin B 12 deficiency
• Vitamin B 12 is a cobalt containing porphyrin named cobalamin
• Available only in animal-based food products.
• No available in plants
• Dietary sources
• Food of animal origin
• Fermented foods: Marmite
• Synthesized by gut microbiota
• Normal daily requirement is 1-2 μg
43. • Dietary vit B 12 is released from the attached proteins by HCL in
stomach
• Immediately it binds with the intrinsic factor
• Both HCL and intrinsic factor are secreted by gastric parietal cells.
• Vitamin B 12 + intrinsic factor complex is absorbed at the terminal
ileum
• A small amount of Vit B 12 is stored inside the liver, this store is
adequate for ~ 2 years
44. Causes of vitamin B 12 deficiency
1. Dietary deficiency is seen in vegetarians
2. Malabsorption syndromes
3. Gastric causes
• Pernicious anemia (Lack of intrinsic factor)
• Total/Partial gastrectomy (Lack of HCL)
4. Intestinal causes
• Diseases affecting the terminal ileum (Eg: Crohn’s disease)
• Resection of terminal ileum
45. Specific clinical features
• Can have peripheral neuropathy (reduced sensitivity of fingers and
toes)
• Can have subacute combine degeneration of the spinal cord which
cause reduced proprioception (balance sensation). Therefore,
patients tend to fall.
Can treat with oral or Intramuscular vitamin B 12 supplements
46. Folate deficiency
• Daily requirement is around 100 μg
• Dietary sources mainly include fresh vegetables
• Highly unstable in heat
• Absorbed mainly in the jejunum
• Stored in the liver in small amounts and can last only for four
months
47. Causes for folate deficiency
• Dietary deficiency: Poor intake of vegetables
• Malabsorption syndromes: E.g. Celiac disease
• Increased demand: Pregnancy
• Drug induced: Anticonvulsants, oral contraceptives
48. Maternal folate deficiency
• Folate is an essential micronutrient needed in closure of neural
tybe during 1st trimester
• If deficient during pregnancy, newborn can end up with life
threatening neural tube defects
1. Spina bifida
2. Anencephaly
3. Encephalocele
Therefore, it is recommended for all women expecting to become
pregnant to take folate acid starting from three months before
pregnancy.
