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 10-20 mg. per day ; Absorb 1-3 mg. per day ; Lose 1 + mg per day –menstrual loss 30-50 ml ; Total iron 35-50 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 % 15-20 4 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

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