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ANEMIA.pdf
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- 2. Pathophysiology of anemia •Decreased oxygen carrying capacity leading to tissue hypoxia • Hypoxia brings about compensatory responses
- 3. Compensatory responses • Increasedrelease of oxygen from hemoglobin • Increased blood flow to tissues (Hyperdynamic circulation) • Maintenance of blood volume • Redistribution of blood to vital organs • Compensatory stimulation of respiratory center
- 4. • After apoint compensationstop • Impairment of tissue system functioning • Degree of impairment is directly proportionalto degree of oxygen deficiency • Manifestationof symptoms & signs
- 5. Clinical symptoms inanemia are due to: • Tissue hypoxia • Compensatorymechanisms
- 6. Clinical symptoms &signs • Generalised muscular weakness,tiredness & fatigability (due to muscle hypoxia) • Pallor of skin & mucus membrane: Due to deficiency of Hb in the blood • Respiratory system: Breathlessness & tachypnea (Compensatory stimulationof respiratory center due to hypoxia)
- 7. • Cardiovascularmanifestations - Palpitation,tachycardia (due to compensatorymechanisms increasing the cardiac output) - Cardiac murmurs (due to raised cardiac output & decreased viscosity of blood; turbulence of blood occur while passing through cardiac valves) • Central nervous system manifestations - Headache, lethargy, faintness, confusion& drowsiness(due to cerebral hypoxia)
- 8. • Gastrointestinalsystem symptoms: anorexia,nausea • Reproductive system involvement: Menstrual disturbancessuch as amenorrhea & menorrhagia • Renal system involvement: Proteinuria
- 9. Signs & Symptomsof Iron deficiency Anemia
- 10. Investigations in anemia •Hb estimation • Total RBC count • PCV / Hematocrit • Peripheral blood smear examination • Blood indices • Osmotic fragility • Serum Fe & TIBC • Reticulocyte count • WBC & platelet count • ESR • Bone marrow examination
- 11. Bone marrow examination •Adult : Sternum • Children : Tibia or Pelvic bone • Punctured using needle • Red bone marrow is aspirated • Myeloid : Erythroid = 3: 1
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- 13. Iron deficiency anemia •Commonest nutritional deficiency disorder in developing countries • Most common cause of anemia in India • Daily requirement of Iron • Adult male is 5-10 mg/day • Adult female is 20 mg/day • Pregnant & lactating women 40 mg/day • Dietary sources: Meat, liver, green leafy vegetables, jaggery
- 14. Absorption of iron •From small intestine (especially duodenum) • Ferrous form only is absorbed • Facilitated by acidic contents of stomach (Gastrectomy lead to iron deficiency anemia)
- 15. • Ascorbic acid& other reducing agents promote iron absorption - By reducing ferric iron to ferrous form - By preventing iron from forming insoluble iron complexes within the chyme
- 16. • Free ironenter the capillaries through basal part of intestinal epithelial cells • Free iron + Apotransferrin→Transferrin • Iron transported in plasma as plasma transferrin
- 17. INTESTINE Fe2+ BLOOD VESSEL Fe2+ Apotransferrin TRANSFERRIN + LIVER , BoneMarrow Fe2+ Apoferritin + FERRITIN-storageform HEMOSIDERIN- insoluble Hemolysis of RBCs Excess iron METABOLISM OF IRON
- 18. Etiology 1) Inadequate dietaryintake of iron • Milk fed infants • Poor socioeconomic status • Anorexia (pregnancy) • Old age individuals
- 19. 2) Increased lossof iron (as in blood loss) • Uterine bleeding in females (Excessive menstruation,repeated miscarriages etc) • Conditions of chronic bleeding as GI bleeding (peptic ulcer, hook worm infestation, hemorrhoids etc)
- 20. 3)Increased demand ofiron • Infancy, childhood,adolescence • Menstruating females • Pregnant & lactating females 4)Decreased absorptionof iron • Partial or total gastrectomy • Achlorhydria • Intestinal malabsorptiondisorders
- 21. Clinical findings • Generalisedfeatures of anemia Pallor
- 22. • Characteristic features: •Nails become dry, soft & spoon-shaped (koilonychia) Koilonychia
- 23. • Tongue -Atrophic glossitis
- 24. Angular stomatitis • Mouth -Angular stomatitis
- 25. • Oesophagus -Dysphagia • (Membranous webs at the postcricoid area: Plummer-Vinson syndrome)
- 26. • Pica (eatingnon food items like clay, paper, ash, dirt…) occur frequently
- 27. Laboratory findings Blood picture& red cell indices • Hb concentration:Decreased • Microcytic hypochromic RBCs • Anisocytosis & poikilocytosis + • MCV, MCH & MCHC : Decreased
- 28. Bone marrow findings •Hypercellular BM • Myeloid: Erythroid ratio decreases (Erythroid hyperplasia)
- 29. Biochemical findings • Serumiron decreases • Serum ferritin is very low • Total iron binding capacity (TIBC) is increased
- 30. Treatment • Iron supplementation •Oral - Ferrous sulphate • Parenteral - Iron dextran complex (im) • Intolerance to oral iron • In need of rapid correction –Severe anemia
- 31. Long essay • 1.A 30 year old woman visits a clinic with the complaints of difficulty in breathing & fatigue. She has menorrhagia for the past 3 months. Her Hb level is 6 gm%, PCV 20% & the reticulocyte count is 8%. Answer the following: - Name the clinical condition. - Describe the blood picture in this condition. - Classify anemia based on etiology. - Describe iron deficiency anemia. (University exam August 2016)
- 32. • 2. A12 year old girl child complaints of lethargy & fatigability for the last three months. Physical examination revealed pallor. Routine blood investigation showed Hb-8% and peripheral smear revealed microcytic hypochromic RBCs. Answer the following: - Identify the clinical condition and what is the cause. - Define anemia. - Classify anemia based on etiology. - Enumerate stages of erythropoiesis and discuss the factors regulating them. (University exam January 2020)
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- 34. Megaloblastic anemia • Characterizedby the abnormally large cells of erythrocyte series with delayed nuclear maturation due to defective DNA synthesis Occur commonly in: • Vitamin B12 deficiency • Folate deficiency
- 35. Pathophysiological or biochemicalbasis • Role of folate & vitamin B12 in DNA synthesis
- 37. Etiology 1) Due tovitamin B12 deficiency • Inadequate dietary intake -Vegetarians & breast fed infants • Malabsorption of vitamin B12 - Gastric causes: Autoimmunecause of failure of secretion of Intrinsic Factor, gastrectomy & congenital lack of IF - Intestinal causes: Tropical sprue, ileal resection, Crohn’s disease, fish tapeworm infestation
- 38. 2) Due tofolate deficiency • Inadequate dietary intake: Less intake of vegetables, infants etc • Malabsorption: Coeliac disease, tropical sprue • Increased demand: Pregnancy, lactation & infancy • Effect of drugs eg: Some anticonvulsants, cytotoxic drugs
- 39. Pernicious anemia • Addisonianpernicious anemia • Megaloblastic anemia due to vitamin B12 deficiency • Due to failure of Intrinsic Factor secretion by stomach • As autoimmune atrophy of gastric mucosa • Autoimmune disease • 45-60 Years • Females > Males
- 40. Features of perniciousanemia • Features of megaloblastic anemia • Specific features of pernicious anemia - Anti-intrinsic factor antibodies in serum - Abnormal vitamin B12 absorptiontest corrected by the addition of intrinsic factor (Schilling test)
- 41. Treatment of perniciousanemia • Regular administrationof vitamin B12 by intramuscularroute • Physiotherapy
- 42. Clinical features ofmegaloblastic anemia • Generalised features of anemia • Characteristic features of megaloblastic anemia: - Icterus (Unconjugated hyperbilirubinemia) - Glossitis - Angular stomatitis
- 43. • Neurological manifestations Numbness& parasthesias Ataxia Decreased reflexes Subacute combined degeneration • Vitamin B12 is necessary for formation & maintenance of myelin sheath • Folate deficiency cause less neurological symptoms
- 44. Laboratory findings • Bloodpicture & red cell indices –Peripheral smear - Macrocytes, anisocytosis,poikilocytosis –↑MCV,↑MCH;but normal or ↓MCHC –Hypersegmented neutrophils (impaired DNA synthesis) –Thromobcytopenia
- 46. • Bone Marrowfindings – Hypercellular (Increased precursor cells) – Megaloblastic precursor cells (Promegaloblasts) – Defective nuclear maturation of blast cells (Indicated by more reticular chromatin)
- 47. • Biochemical findings •Serum bilirubin increased (unconjugated hyperbilirubinemia) • Urine urobilinogen increased • Serum iron & ferritin: Normal or increased • Serum vitamin B12: Decreased • Low serum folate levels • Low red cell folate levels
- 48. Treatment • Hydroxycobalamin asIM 1000µg for 3 weeks • Physiotherapy • Identification& elimination of possible cause • Supportive care