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Understanding the full blood count in 15mins - A quick lit review
1. Understanding the Full blood count
in 15 mins - a âquick-lit-reviewâ.
Simon Mark Daley (2018)
2. Constituents of the FBCâŠ
âȘRed Blood Cells
âȘ Haemoglobin, Mean cell volume, Reticulocyte count, Red cell count,
Haematocrit / Packed cell volume, Mean corpuscular haemoglobin,
Red blood cell distribution width.
âȘPlatelets
âȘWhite Blood Cells
âȘ Neutrophil count, Lymphocyte count, Monocyte count, Eosinophil
count, Basophil count.
3. Red blood cellsâŠ
Constituents of the red blood cell.
âȘ Haemoglobin (Hb); concentration of haemoglobin in the blood. Hb in the protein that
carries oxygen in the blood. Low Hb = anaemia.
âȘ Mean cell volume (MVC); mean volume of the red cells (â-cyticâ). This is used to classify
anaemia type. âMVC = microcytic, âMVC = macrocytic.
âȘ Reticulyte count; concentration of immature red blood cells â increased in blood loss and
haemolytic anaemia because the bone marrow works harder to replace lost cells.
âȘ Red cell count (RCC); concentration of red blood cells within the blood.
âȘ Haematocrit (HCT) / packed cell volume (PCV); volume percentage of red blood cells
within the blood.
âȘ Mean corpuscular haemoglobin (MCH); mean haemoglobin quantity with the blood cells â
affects the colour of the cells (â-chromicâ).
âȘ most normocytic/macrocytic anaemias rare normochromic, most microcytic anaemias are hypochromic.
âȘ Mean corpuscular haemoglobin concentration (MCHC); mean haemoglobin
concentration within the blood cells.
âȘ Red blood cell distribution width (RDW); measure of the variation of red blood cell
volumes. It is used in conjunction with MCV to determine if anaemia is due to mixed or
single cause. Raised RDW = âanisocytosisâ.
MOSTIMPORTANTLESSIMPORTANT
4. Red blood cellsâŠ
Anaemia.
Anaemia = a reduced concentration of haemoglobin within the blood.
Other relevant tests;
âȘ WCC and platelet count; if both also abnormal, a bone marrow cause is likely
âȘ Reticulocyte count; if raised, the cause is blood loss or haemolytic anaemia
âȘ Mean cell volume (MCV);
Causes of anaemia by MVC
Microcytic
âȘ Sideroblastic
âȘ Iron deficiency
âȘ Thalassaemia
Normocytic
âȘ Acute blood loss
âȘ Haemolytic anaemia
âȘ Sickle cell anaemia
Macrocytic anaemia
âȘ Megaloblastic
âȘ âB12, âfolate
âȘ Non-megaloblastic
âȘ Alcohol, reticulocytosis,
liver disease, pregnancy
Chronic disease Hypothyroidism
Bone marrow failure
(aplastic anaemia, myelodyplastia, leukaemia, myelofibrosis)
5. Red blood cellsâŠ
Anaemia.
Tests for specific causes;
âȘ Haematinics; B12 % folate, ferritin.
âȘ Iron studies: Iron, transferritin / total iron binding capacity (TIBC), transferritin
saturation, ferritin, soluble transferritin receptor.
âȘ TFTs
âȘ Blood film +/- bone marrow biopsy (if bone marrow cause/haemolytic
anaemia/sideroblastic anaemia suspected).
âȘ Hb electrophoresis (if thalassaemia / sickle cell suspected)
âȘ Bilirubin (raised in haemolysis)
6. Red blood cellsâŠ
Anaemia.
Commonest causes.
âȘ Iron-deficiency anaemia.
âȘ Physiology: Iron is found in red meats (haem iron) and cereal (non-haem iron). In humans, 2/3 is stored
as haem, 2/9 as ferritin, 1/9 as haemosiderin. Fe2+ (ferrous) is absorbed; Fe3+ (ferric) is consumed and
used.
âȘ Causes:
âȘ Chronic blood loss (Menstrual loss, GI tract loss (âurea in UGI bleed), urinary tract loss).
âȘ âdemand (pregnancy, growth).
âȘ âabsorption (coeliacs, gastrectomy).
âȘ Poor intake.
âȘ Investigations if no clear cause: upper GI endoscopy + colonoscopy, coeliacs screen, urine dipstick.
âȘ Treatment: treat cause, ferrous sulphate tablets, transfusion if Hb<70.
âȘ B12-deficiency anaemia.
âȘ Physiology: Vitamin B12 is found in meat and dairy products. The stomach produces intrinsic factor which
binds to B12, allowing it to be absorbed in the terminal ileum, Body stores last up to 4 years.
âȘ Causes: Pernicious anaemia, malabsorption (eg gastrectomy or terminal ileum disease/resection).
âȘ Investigations for pernicious anaemia: Parietal cell antibodies, intrinsic factor antibodies, Schillingâs test.
âȘ Treatment: Treat cause, hydroxocobalamin (B12) injections 3-monthly.
7. Red blood cellsâŠ
Anaemia.
âȘ Folate-deficiency anaemia.
âȘ Physiology: folate is found in green vegetables. Body stores only last 4 months (therefore deficiency
develops earlier in malabsorption/pregnancy).
âȘ Causes:
âȘ Dietary (alcoholism, neglect).
âȘ ârequirements (pregnancy, haematopoiesis).
âȘ Malabsorption (coeliacs, pancreatic insufficiency, gastrectomy, crohns).
âȘ Drugs interfere with metabolism (phenytoin, methotrexate, trimethoprim).
âȘ Treatment: treat cause, oral folic acid supplements.
âȘ Anaemia of chronic disease.
âȘ Causes: any chronic disease.
âȘ Classically: âiron âTIBC ferritin normal (vs. iron deficiency anaemia: âiron, âTIBC, âferritin).
âȘ Treatment: treat cause, transfuse if Hb<70.
8. Red blood cellsâŠ
Anaemia.
âȘ Haemolytic anaemia.
âȘ Physiology:
âȘ When red cells are destroyed extravascularly by macrophages (normal process):
1. Hb â globulin (which is broken down to amino acids) + haem (which is broken down to bilirubin).
2. Bilirubin is then conjugated by the liver (a rate limited process0 and passed to the bowel in bile, where it is
converted to urobilinogen.
3. Some of this urobilinogen is passed in stool and some is reabsorbed and excreted in urine as urinary urobilinogen.
âȘ When red cells are destroyed intravascularly (abnormal process) â free Hb follows 1 of 3 pathways:
âȘ Some binds to haptoglobin (and is removed by liver).
âȘ Some is filtered by the glomerulus and passed as haemiglobinuria or haemosiderinuria.
âȘ Some is oxidised to methaemoglobulin which dissociates to globin + ferrihaem (most ferrihaem then binds to
albumin â methaemalbuminaemia).
âȘ Inherited causes:
âȘ Haemoglobinopathies: sickle cell, thalassaemia.
âȘ Membrane defects: hereditary spherocytosis, ellptocystosis.
âȘ Enzyme defects: G6PD deficiency, pyruvate kinase deficiency.
âȘ Acquired causes:
âȘ Immune mediated: autoimmune haemolytic anaemia, drug-induced haemolytic anaemia, alloimmune haemolytic
anaemia.
âȘ Non-immune mediated: DIC, TTP, physical damage by eg heart valves, toxins such as lead/uraemia/drugs, malaria,
paroxysmal nocturnal haemoglobulinuria.
9. Red blood cellsâŠ
Anaemia.
âȘ Investigations to confirm haemolysis;
âȘ Increased Hb breakdown: âunconjugated bilirubin, âLDH (from red cells), âurinary urobilinogen (on urine dipstick).
âȘ Increased Hb production: âreticulocytes.
âȘ Intravascular haemolysis: âfree haptoglobin, haemoglobinuria (on haematuric urine microscopy), âurinary
haemosiderin, red cell fragments on blood film.
âȘ Investigations to find cause:
âȘ Blood film: sickle cells scistocytes (microanglopathic haemolytic anaemia), inclusion bodies (malaria),
spherocytes/elliptocytes (hereditary spherocytosis/elliptocytosis), Heinz bodies (G6PD), bite/blister cells (G6PD),
distorted âprickleâ cells (pyruvate kinase deficiency).
âȘ Direct antiglobulin (Coombsâ) test (for autoimmune haemolytic anaemia).
âȘ Osmotic fagility testing (for membrane abnormalities).
âȘ Hb electrophoresis (for haemoglobulinopathies).
âȘ Enzyme assays (for enzyme defects).
10. Red blood cellsâŠ
Polycythaemia.
Polycythaemia = an increased concentration of red blood cells within the blood.
Causes:
âȘ Relative polycythaemia (ie âplasma volume).
âȘ Acute dehydration.
âȘ Chronic (associated with obesity, HTN, alcohol excess, smoking).
âȘ Absolute polycythaemia (ie âRBC mass)
âȘ Primary = polycythaemia ruba vera
âȘ Secondary = due to increased EPO (eg RCC) or chronic hypoxia (eg COPD, altitude, congenital
heart disease).
Investigations:
âȘ WCC and platelet count (both raised in primary absolute polycythaemia, but not in
secondary absolute polycythaemia).
âȘ 51Cr Red cell mass study (normal red cell mass in relative polycythaemia; raised red
cell mass in absolute polycythaemia).
âȘ Erythropoietin level
âȘ If polycythaemia rub vera suspected: bone marrow biopsy, JAK-2 mutation