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CLUES TO THE DIAGNOSIS IN ANEMIA PRINCIPLES 4 Anemia is not a disease 4 There is usually a cause 4 investigation should be logical 4 Start with CBC and.

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Presentation on theme: "CLUES TO THE DIAGNOSIS IN ANEMIA PRINCIPLES 4 Anemia is not a disease 4 There is usually a cause 4 investigation should be logical 4 Start with CBC and."— Presentation transcript:

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2 CLUES TO THE DIAGNOSIS IN ANEMIA

3 PRINCIPLES 4 Anemia is not a disease 4 There is usually a cause 4 investigation should be logical 4 Start with CBC and Blood film 4 Leads to other tests –non specific –specific 4 Guides therapy

4 Further Principles 4 Symptoms are more related to rate of fall in hemoglobin not level. 4 Non specific symptoms 4 More specific symptoms 4 Drug History 4 Physical examination –splenomegaly

5 Starts With CBC 4 High yield parameters –Hgb –MCV –RBC # 4 Morphology 4 Confirmatory tests 4 Lets apply

6 4 Test results  Hgb 77 g/L  MCV 66  f/L  RBC 3.2 x10 12 /L  WBC 5.6 x10 6 /L  Plat 525 x10 9 /L 4 Blood film This is a 55 year old woman who has fatigue. Her only other symptom is a craving for chewing ice cubes. Apart from being pale her examination is normal.

7 Microcytic, hypochromic

8 STAGES OF IRON DEPLETION Loss of body stores Fall in serum iron Anemia develops Microcytosis Hypochromasia

9 ASSESSMENT OF IRON STATUS 4 Identify high risk groups 4 Children 4 Menstruation 4 Pregnancy - Lactation 4 Frequent Blood Donors 4 Chronic GI loss 4 Malabsorption 4 Diet

10 IRON BALANCE ; Ingest mg. per day ; Absorb 1-3 mg. per day ; Lose 1 + mg per day –menstrual loss ml ; Total iron mg/kg ; Stores 1 gram ; Easy to achieve negative balance

11 Dx of IRON DEFICIENCY ; Symptoms and signs ; CBC - Anemia - microcytosis - Hypochromia ; Blood Film - Oval - pencil - Tear ; Serum Fe and TIBC Fe low TIBC high ; Serum Ferritin ; Cause of Iron Deficiency

12 INVESTIGATION OF CAUSE ; Investigate when cause not Clear ; Symptoms of cause often unreliable ; Upper GI cause higher Yield ; If upper GI lesion found then a colonic lesion unlikely ; TESTS - Radiologic, Endoscopic Biopsy, Angiographic.

13 THERAPY Replace iron

14 Anemia of Chronic disease 4 Usually mild to moderate anemia 4 normocytic normochromic 4 low retic count 4 Low serum Fe and low TIBC sat % Ferritin normal or high 4 A responsible disease is present 4 Usually a systemic disorder

15 Very High Iron

16 Hemochromatosis

17 4 Fe overload 4 Genetic predisposition to increased Fe absorption 4 Common 4 Screen with Fe saturation (ferritin) 4 Confirm with Genetic testing 4 2 genes 282Y H63D 4 Treatment - phlebotomy

18 4 Test results  Hgb 85 g/L  MCV 110  fL  RBC 3.9 x10 12 /L  WBC 2.4 x10 6 /L  Plat 89 x10 9 /L 4 Blood Film A 65 year old woman is referred to you because of memory loss. Her family physician had received tests which included bilirubin of 28  mol/L and an LDH of 1560 U/L. He was puzzled by these results.

19 Oval Macrocytes Hypersegmented neutrophils

20 Megaloblastic Anemias Vitamin B12 Folic Acid

21 Reasons for measuring B12 4 Investigation of macrocytic anemia 4 Investigation of any anemia 4 Investigation of fatigue 4 Routine Geriatric Screen 4 Investigation of neurologic symptoms

22 Symptom Complex 4 Classic presentation uncommon 4 Often a screen in older patients 4 Memory loss prominent 4 Neuropathy 4 Changes in evoked potential 4 Non specific symptoms of anemia

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24 Causes Pernicious anemia 4 10 % of all cobalamin deficiencies 4 Majority are due to malabsorption

25 Causes of Low Serum B12 Malabsorption of free cobalamin 4 Pernicious anemia 4 Post gastrectomy state 4 Small bowel diseases

26 Causes of Low Serum B12 Malabsorption of food cobalamin 4 Atrophic gastritis 4 Postgastrectomy state 4 Chronic nonspecific gastritis (H pylori ?) 4 H2 receptor blocking agents

27 Tests 4 CBC - RBC indices –Most are macrocytic 4 Blood film –Macro-ovalocytes - hypersegmented polys 4 Biochemical abnormalities –LDH bilirubin 4 Serum B12 4 Schilling test (never done)

28 Folic acid deficieny 4 Dietary source is vegetables 4 Absorption no specific carrier 4 Deficiency mainly dietary. 4 Alcoholism a risk 4 Anemia macrocytic 4 No neurologic symptoms 4 Measure Serum folate (food supplementation)

29 Therapy Replace B12 - folic acid

30 Therapy 4 Vitamin B12 4 IM 4 Oral 4 Folic acid –pregnancy –treatment

31 Hemolytic anemias 4 History of jaundice and anemia 4 May have splenomegaly 4 May have a family history 4 anemia with reticulocytosis 4 specific morphologic changes 4 serum bilirubin and LDH as markers 4 Specific tests follow morphology

32 What is the abnormality ? Spherocytes

33 What is the abnormality ? Bite cells Oxidative hemolysis

34 What is the abnormality fragment

35 Which anemia is this ?

36 A Common Condition

37 Common anemias 4 Iron deficiency 4 Megaloblastic anemias 4 Secondary anemias of chronic diseases Anemia of chronic disease 4 Hemolytic anemias Spherocytic fragmentation

38 PRINCIPLES 4 Anemia is not a disease 4 There is usually a cause 4 investigation should be logical 4 Start with CBC and Blood film 4 Leads to other tests –non specific –specific 4 Guides therapy


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