1. APPROACH TO ANEMIA

2. Anemia is defined as either a reduction in number of red blood cells or a reduction in haemoglobin concentration in the blood( in comparision to the normal value for a given age group, sex and geographical location).
Because anemia has its principal effect by decreasing the oxygen- carrying capacity of blood, it is best expressed in terms of hemoglobin concentration.

4. Table 1: Normal Hemoglobin/Hematocrit Values with Age and Pregnancy
Age/Sex
Hemoglobin g/dL
Hematocrit %
At birth 17 52
Childhood 12 36
Adolescence 13 40
Adult man
16 (±2)
47 (±6)
Adult woman (menstruating)
13 (±2)
40 (±6)
Adult woman (postmenopausal)
14 (±2)
42 (±6)
During pregnancy
12 (±2)
37 (±6)

8. PRESENTATION AND SYMPTOMS
Careful history and physical examination.
Nutritional history related to drugs or alcohol intake.
Family history of anemia should always be assessed.
Bleeding, fatigue, malaise, dyspnoea, fever, weight loss, night sweats, and other systemic symptoms.
physical examination:
pallor,
icterus,
lymphadenopathy,
splenomegaly
petechiae
forceful heartbeat,
strong peripheral pulses,
systolic "flow" murmur.

9. Table 57–1 Laboratory Tests in Anemia Diagnosis
I. Complete blood count (CBC)
  A. Red blood cell count
    1. Hemoglobin
    2. Hematocrit
    3. Reticulocyte count
  B. Red blood cell indices
    1. Mean cell volume (MCV)
    2. Mean cell hemoglobin (MCH)
    3. Mean cell hemoglobin concentration (MCHC)
    4. Red cell distribution width (RDW)
  C. White blood cell count
    1. Cell differential
    2. Nuclear segmentation of neutrophils
  D. Platelet count
  E. Cell morphology
    1. Cell size
    2. Hemoglobin content
    3. Anisocytosis
    4. Poikilocytosis
    5. Polychromasia
II. Iron supply studies
  A. Serum iron
  B. Total iron-binding capacity
  C. Serum ferritin
III. Marrow examination
  A. Aspirate
    1. M/E ratioa
    2. Cell morphology
    3. Iron stain
  B. Biopsy
    1. Cellularity
    2. Morphology

10. Table 57–2 Red Blood Cell Indices
Index
Normal Value
Mean cell volume (MCV) = (hematocrit x 10)/(red cell count x 106)  
90 ± 8 fL
Mean cell hemoglobin (MCH) = (hemoglobin x 10)/(red cell count x 106)  
30 ± 3 pg
Mean cell hemoglobin concentration = (hemoglobin x 10)/hematocrit, or MCH/MCV
33 ± 2%

14. TREATMENT: Overiding principle is to reach to a diagnosis of anemia .
Treatment target to the underlying cause.
Anemia may be so acute and severe as to warrant immediate intervention such as blood transfusion.

15. IRON DEFICIENCY ANEMIA
Iron deficiency is one of the most prevalent forms of malnutrition.
Globally, 50% of anemia is attributable to iron deficiency
approximately 841,000 deaths annually worldwide.
Africa and parts of Asia bear 71%
North America represents only 1.4%

16. IRON CIRCULATION

17. Iron absorbed from the diet or released from stores circulates in the plasma bound to transferrin, the iron transport protein.
Interacts with specific transferrin receptors on the surface of marrow erythroid cells.
The complex is internalized where the iron is released at the low pH.
The iron is then made available for heme synthesis .
The transferrin-receptor complex is recycled to the surface of the cell, where the bulk of the transferrin is released back into circulation and the transferrin receptor reanchors into the cell membrane.
Within the erythroid cell, iron in excess of the amount needed for hemoglobin synthesis binds to a storage protein, apoferritin, forming ferritin.
The iron incorporated into hemoglobin subsequently enters the circulation as new red cells.
In a normal individual, the average red cell life span is 120 days

18. Table 103-1 Body Iron Distribution
Iron Content, mg
Adult Male, 80 kg
Adult Female, 60 kg
Hemoglobin
Myoglobin/enzymes
Transferrin iron
Iron stores
2500
500 3
600–1000
1700
300
0–300

19. Table 103-2 Causes of Iron Deficiency
Increased Demand for Iron 
  Rapid growth in infancy or adolescence
  Pregnancy
  Erythropoietin therapy
Increased Iron Loss 
  Chronic blood loss
  Menses
  Acute blood loss
  Blood donation
  Phlebotomy as treatment for polycythemia vera
Decreased Iron Intake or Absorption 
  Inadequate diet
  Malabsorption from disease (sprue, Crohn's disease)
  Malabsorption from surgery (postgastrectomy)
  Acute or chronic inflammation

20. Table 103-4 Diagnosis of Microcytic Anemia
Tests
Iron Deficiency
Inflammation
Thalassemia
Sideroblastic Anemia
Smear
Micro/hypo
Normal micro/hypo
Micro/hypo with targeting
Variable SI
<30
<50
Normal to high
TIBC
>360
<300
Normal
Percent saturation
<10
10–20
30–80
Ferritin (g/L)
<15
30–200
50–300
Hemoglobin pattern on electrophoresis
Abnormal with  thalassemia; can be normal with thalassemia

21. PRESENTATION /SIGNS AND SYMPTOMS:
Bleeding, fatigue, malaise, dyspnoea, dysphagia, fever, weight loss, night sweats, and other systemic symptoms.
physical examination:
pallor,
icterus,
angular stomatitis,
oesophageal webs,
lymphadenopathy,
koilonychia/platynychia,
splenomegaly,
petechiae,
forceful heartbeat,
strong peripheral pulses,
systolic "flow" murmur

22. TREATMENT OF IRON DEFICIENCY ANEMIA
Blood transfusion: reserved for individuals who have symptoms of anemia, cardiovascular instability, continued and excessive blood and require immediate intervention.
Parenteral iron therapy: Body weight (kg) x 2.3 x (15–patient's hemoglobin, g/dL) or 1000 mg (for stores).
unable to tolerate oral iron
whose needs are relatively acute
iron dextran
sodium ferric gluconate (Ferrlecit)
iron sucrose (Venofer)

23. Oral iron therapy:
asymptomatic patient with established iron-deficiency anemia.
Up to 300 mg of elemental iron per day is given, usually as three or four iron tablets (each containing 50–65 mg elemental iron) given over the course of the day.
Ideally, oral iron preparations should be taken on an empty stomach, since food may inhibit iron absorption.
The goal of therapy is not only to repair the anemia, but also to provide stores of at least 0.5–1 g of iron.
Sustained treatment for a period of 6–12 months after correction of the anemia will be necessary to achieve this.