Title: Approach to the Patient with ANEMIA
1Approach to the Patient with ANEMIA
- Lisa Mohr, MD
- Mike Tuggy, MD
2Objectives
- Review basic science of the RBC
- Define Anemia
- Review key aspects of history, physical and lab
evaluation - Review a systematic approach to the differential
diagnosis - Case-based application of clinical concepts
3Erythropoesis-Brief Hematology Review
- Bone marrow
- Pluripotent stem cells
- Chemical regulation
- Cytokines
- Erythroid specific growth factor
- Erythropoietin (EPO)
- Life span
- Reticulocyte- 4 days
- RBC 120 days
4RBC-The important players
- Hemoglobin
- reversibly binds and transports 02 from lungs to
tissues - 4 globin chains iron
5RBC-The important players (2)
- Iron
- key element in the production of hemoglobin
- absorption is poor
- Transferrin
- iron transporter
- Ferritin
- iron binder, measure of iron stores, also acute
phase reactant
6Definitions
- Anemia-values of hemoglobin, hematocrit or RBC
counts which are more than 2 standard deviations
below the mean - HGB
- HCT
7CASE
- ML is a 64-year old male who has not had any
primary care for several years. When he tried to
give blood last week, he was told that he was
anemic. He presents to your clinic for
evaluation. - What would you do??
8Evaluation of the Patient
- HISTORY
- Is the patient bleeding?
- Actively? In past?
- Is there evidence for increased RBC destruction?
- Is the bone marrow suppressed?
- Is the patient nutritionally deficient? Pica?
- PMH including medication review, toxin exposure
9Evaluation of the Patient (2)
- REVIW OF SYMPTOMS
- Decreased oxygen delivery to tissues
- Exertional dyspnea
- Dyspnea at rest
- Fatigue
- Signs and symptoms of hyperdynamic state
- Bounding pulses
- Palpitations
- Life threatening heart failure, angina,
myocardial infarction - Hypovolemia
- Fatiguablitiy, postural dizziness, lethargy,
hypotension, shock and death
10Evaluation of the Patient (3)
- PHYSICAL EXAM
- Stable or Unstable?
- -ABCs
- -Vitals
- Pallor
- Jaundice
- -hemolysis
- Lymphadenopathy
- Hepatosplenomegally
- Bony Pain
- Petechiae
- Rectal-? Occult blood
11Laboratory Evaluation
- Initial Testing
- CBC w/ differential (includes RBC indices)
- Reticulocyte count
- Peripheral blood smear
12Laboratory Evaluation (2)
- Bleeding
- Serial HCT or HGB
- Iron Deficiency
- Iron Studies
- Hemolysis
- Serum LDH, indirect bilirubin, haptoglobin,
coombs, coagulation studies - Bone Marrow Examination
- Others-directed by clinical indication
- hemoglobin electrophoresis
- B12/folate levels
13Differential Diagnosis
- Classification by Pathophysiology
- Blood Loss
- Decreased Production
- Increased Destruction
- Classification by Morphology
- Normocytic
- Microcytic
- Macrocytic
14Blood Loss
- Acute
- Traumatic
- Variety of sources
- Melena, hematemesis, menometrorrhagia
- Chronic
- Occult bleeding
- Colonic polyp/carcinonma
15Decreased Production
- Infectious
- Neoplastic
- Endocrine
- Nutritional Deficiency
- Anemia of Chronic Disease
16Decreased ProductionINFECTIOUS
- Bacterial
- Tuberculosis
- MAI
- Viral
- HIV
- Parvovirus
17Decreased ProductionNEOPLASTIC
- Leukemia
- Lymphoma/Myeloma
- Myeloproliferative Syndromes
- Myelodysplasia
18Decreased ProductionENDOCRINE
- Thyroid Dysfunction
- Hypothyroidism
- Erythropoietin Deficiency
- Renal Failure
19Decreased ProductionNUTRITIONAL DEFICIENCY
20Macrocytic Anemia
- MCV 100
- MegaloblasticAbnormalities in nucleic acid
metabolism - B12, Folate
- Non-megaloblasticAbnormal RBC maturation
- Myelodysplasia
- ETOH, liver dz, hypothryroidism,
chemotherapy/drugs
21Microcytic Anemia
- MCV
- Reduced iron availability
- Reduced heme synthesis
- Reduced globin production
22Microcytic AnemiaREDUCED IRON AVAILABILTY
- Iron Deficiency
- Deficient Diet/Absorption
- Increased Requirements
- Blood Loss
- Iron Sequestration
- Anemia of Chronic Disease
- Low serum iron, low TIBC, normal serum ferritin
- MANY!!
- Chronic infection, inflammation, cancer, liver
disease
23Microcytic AnemiaREDUCED HEME SYNTHESIS
- Lead poisoning
- Acquired or congenital sideroblastic anemia
- Characteristic smear finding Basophylic stippling
24Microcytic AnemiaREDUCED GLOBIN PRODUCTION
- Thalassemias
- Smear Characteristics
- Hypochromia
- Microcytosis
- Target Cells
- Tear Drops
25Lab tests of iron deficiency of increased severity
26Differential Diagnosis-Revisited
- Classification by Pathophysiology
- Blood Loss
- Decreased Production
- Increased Destruction
27INCREASED DESTRUCTION
- Immune Mediated
- Non-immune Mediated
28Increased DestructionIMMUNE MEDIATED
- Cold Agglutinin
- Paroxysmal nocturnal hemoglobinuria
- Post mycoplasmal hemolytic anemia
- Warm Agglutinin
- Drug induced
- Autoimmune hemolytic anemia
- Transfusion reaction
29Increased DestructionNON-IMMUNE MEDIATED
- Extra-corpuscular
- Macro-circulatory
- Hypersplenism
- Extracorporeal circulation
- Micro-circulatory
- DIC
- TTP
- HUS
- Intra-corpuscular
- RBC Wall (membrane or enzyme defects)
- Heme or globin abnormalities (HbS, C)
30Back to M.L.-You appropriately decide to obtain
more history!
- HPI Ive been a little more tired than usual,
but Ive been busy at work. Im getting close to
retirement. Nothing else is unusual. I avoid
doctors if I can - PMH Inguinal hernia repair 20 yrs ago
- FH F MGF-heart attack(age 80),
brother-alcoholism - SH Married x44yr, smokes 1ppd, a couple
beers/night - MEDS daily multivitamin
- ALLERGIES none
- ROSfatigue, urine seems a little darker lately
31More on M.L.
- P.E. findings
- T 98.4 HR 98 Resp 20 BP 112/70
- Gen NAD, appears younger than stated age
- HEENT skin and conjunctiva slightly pale
- NECK no adenopathy or thyromegally
- Chest CTAB
- CV RRR, no murmur
- ABD no HSM, soft, normoactive bowel sounds
- GU normal male
- Rectal no masses, prostate smooth/not enlarged,
guaiac negative stool
32M.L.s Initial Labs
- Only a CBC w/ diff was obtained
- WBC 8.2, HCT 32.2, MCV 79, Platelets 221,
differential - normal
33Initial Thoughts?
- Blood loss?
- Age places him at risk for colon CA
- Decreased Production?
- Alcohol use, Iron deficiency
- Increased Destruction?
- Darker urine lately
34Further Work-up
- CAGE questions
- Peripheral Blood Smear
- Reticulocyte count
- Iron Studies
- Ferritin
- TIBC
- Saturation
- Urinalysis
- FOBT or colonoscopy referal
35More Results
- CAGE screen reveals no positive responses
- Smear reveals microcytic, microchromic RBCs
- Retic count is interpreted as low
- Urinalysis negative for hemoglobin
- FOBT not completed by patient
- Iron Studies
- Ferritin 10
- TIBC 350
- Sat 15
36Whats next?
- Rule out Sources of Bleeding
- Counseling regarding colon CA and referral for
colonoscopy - Consider oral iron therapy
- Dietary counseling (iron sources, limiting etoh,
etc) - Encourage follow-up for health care maintenance
- Vaccinations (Tetnus/pneumovax)
- Other cancer screening
- Cholesterol Screen
37Diagnosis
- Colonoscopy revealed small suspicious lesion in
sigmoid colon, pathology revealing
adenocarcinoma. Excised surgically, no mets. - Routine labs, one year later, reveal an HCT of
40. He feels better than ever!
38References
- Schrier, Stanley.Approach to the patient with
anemia. Up to Date. 2004 - Schrier, Stanley. Anemia of Chronic Disease. Up
to Date. 2004 - Schrier, Stanley. Anemias due to decreased red
Cell Production. Up to Date 2004 - Schrier, Stanley. Causes and diagnosis of anemia
due to iron deficiency. Up to Date. 2004 - Tierney, et al. Anemias. Current Medical
Diagnosis and treatment. 2003. Pp469-489