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Anaemia clinical presentation, CE, treatments, diagnosis

Anaemia

What is Anamia
A reduction the Hb concen­tration below normal ranges (M: <13g/dL / F: <12­g/dL)
Aetiology
1. Decreased RCB production 2. Loss of RBCs 3. Increased RBC destru­ction

Anaemia Main Categories

Microc­yctic / hypochomic
Low MCV / Low MCH
Normoc­yctic / normoc­homic
Normal MCV / Normal MCH
Macroc­yctic / hyperc­homic
High MCV / High MCH

Clinical Presen­tation

fatigue
dyspnoea
chest pain
dizziness
palpit­ations
headaches
worsening of other conditions - interm­ittent claudi­cation

Normocytic Anaemia

Normal MCV, indicating normal sized RBCs
DDx: Anaemia of chronic diseas­e/i­nfl­amm­ation
Haemolysis
 
Bone marrow infilt­ration
 
Acute blood loss

Normocytic Anaemia

Invest­iga­tions
FBC
Low Hb, normal MCV
Blood Film
Normoc­ytic, normoc­hromic RBCs
Iron Studies
normal/low serum iron, low TIBC, normal­/high serum ferritin
+/- other Ix
Serum erythr­opo­ietin (EPO) level is decreased in CKD
Management
Manage underlying cause
consult haem/m­edical team
EPO replac­ement
RCC transf­usion if severe or sympto­matic
Iron supple­men­tation may or may not be needed

Normocytic Anaemia Causes

Anaemia of Chronic Diseases
Chronic renal disease, rheumatic disease, congestive heart failure
Mechanism
depends on underlying pathology
 
decrease in release of stored iron
 
shortened red cell survival
 
impaired marrow response in red cell relacement

Macrocytic Anaemia

Macrocytic Anaemia
Large RBCs and increased MCV
Aetiology
Megalo­blastic
B12 or folate deficiency
Normob­lastic
alcohol excess, reticu­loc­ytosis, liver disease
Mechanism
Megalo­blastic
Impaired DNA synthesis
Normob­lastic
Unkown
Signs and symptoms
General symptoms of anaemia
 
Pallor +/- glossitis, angular stomatitis
 
B12 deficiency can lead to neurologic syndrome

Megalo­blastic Anaemia

Vit B12
Found in animal sources
Causes of deficiency
Pernicious anaemia (autoi­mmune disorder)
 
Veganism
 
Gastre­cto­my/­gastric absorptive disease
 
Chron's diseas­e/c­oeliac
Folate
green veg,, organ meat, fortified cereals
Causes of deficiency
Poor dietary intake
 
Alcohol
 
Anti-e­pil­eptic drugs (pheny­toin)
 
Methot­rexate
 
Coeliac disease

Management Macrocytic Anaemia

Treat underlying cause
consult haem/m­edical team
B12 deficiency
IM hydrox­oco­balamin (B12): replenish levels with frequent admini­str­ation then gradually reduce frequency
Folat deficiency
Oral folate replac­ement: folic acid 5mg OD
 

Signs - on CE

Jaundice
can occur in haemolysis
Koilon­ychia
spoon shaped nails in IDA
conjun­ctive pallor
ensure looking at palpebral conjun­ctiva
sclera icterus
jaundice (haemo­lysis)
angular stomatitis
B12/fo­lat­e/iron deficiency
systolic flow murmur
mid-sy­stolic ejection murmur due to increased semi-lunar blood flow

Anaemia Differ­ential Diagnosis

Microcytic Anaemia
Normocytic Anaemia
Macrocytic Anaemia
Iron deficiency anaemia (50% of cases)
Anaemia of chronic disease
Vitamin B12
Thalla­saemia
Inflam­mation:
Chronic diseases
Chronic infection

Iron Deficiency Anaemia

4 main causes
Decreased intake (infan­t/v­egan)
 
Decreased absorption (gastr­ectomy, IBD, coeliac disease)
 
Increased demand (child­hood, pregnancy)
 
Increased loss (chronic slow bleed)
Potential Symptoms
GI blood loss, heavy menstrual bleeding, Pica

IDA Invest­iga­tions and Management

Invest­iga­tions
FBC
decreased Hb and MCV. Check WCC & platelets (expect normal in IDA)
Iron Studies
decreased serum iron, serum ferritin, transf­errin sat., increased TIBC
Blood Film
microcytic and hypoch­romic RBCs, Poikil­ocy­tosis / Anisoc­ytosis
+/- other Ix
Faecal occult blood (FOB), OGD, colono­scopy
Management
Manage underlying cause
consult haem/m­edical team
Start supple­mental iron
Aim 1-2g raise in Hb every week
1st line: oral iron replac­ement eg. Ferrous fumerate
2nd line: IV iron replac­ement (Ferri­nject)
3rd line: RCC transf­usion (if severe)
Don't forget to type and screen if giving a blood transf­usion

Microcytic Anaemia

Low Hb & MCV, indication RBCs
Causes of microcytic anaemia; mnemonic TAILS
Mechanism:
Defect in synthesis of haem
 
Thalas­saemia - defect in synthesis of globin chain
DDX:
T - Thalas­semia
A - Anaemia of chronic disease
I - Iron deficiency anaemia
L - lead poisoning
S - sidero­blastic anaemia

Macrocytic Anaemia

Invest­iga­tions
FBC
Low Hb, MCV is elevated
B12/Folate Deficiency
check levels
Anti-p­arietal cell anti-body & intrinsic factor antibody
screening for pernicious anaemia
Anti-tTG & IgA
screening for coeliac disease
LFTs
GGT may be elevated in alcohol excess
Peripheral blood smear
anisoc­ytosis, poikil­oct­yosis, hypers­egm­ented neutro­phils
Don't forget to ask about diet (vegan), alcohol intake, medica­tions

IDA Iron Studies

Serum iron levels
LOW
measures amount of iron in transit in blood
Serrum ferritin
LOW
total iron stored in the body
Total iron binding capacity
HIGH
TIBC increases in order to try and maximise use of the little iron available
Transf­errin saturation
LOW
level of saturation of transf­erring with iron: normal is 30%. Reduced in iron deficiency states

Autoimmune Haemolytic Anaemia (Haemo­lysis)

Warm AIHA
Antibody active at body temp
 
Aetiol­ogies include: rheumatic disease and lympho­pro­lif­erative disorders
 
IgG antibodies +/- complement
Cold AIHA
Antibody active only at lower temps
 
Aetiol­ogies include: infections (eg. mono) and lymphoma
 
IgM antibodies

Haemolytic Anaemia

Invest­iga­tions
FBC
Low Hb, normal MCV
Reticu­locytes
elevated
LDH
elevated
Haptog­lonbin
low
LFT's
unconj­ugated Bilirubin - elevated
Direct Antiog­lobin (Coombs) Test
if + then autoimmune haemolysis likely
Blood Film
look for specific abnorm­alities
Management
Treat underlying cause
consult haem/m­edical team
Stabilize pt
consult haem re. need for transf­usion
Warm AIHA
1st line: cortic­ost­eroids, 2nd line: Rituximab, Azathi­oprine, Cyclos­porin, 3rd line: splectomy
Cold AIHA
Avoid cold temps & treat underlying cause +/- immuno­sup­pre­ssant (ritux­imab)

Haemolytic Anaemia

Haenolytic Anaemia
Haemol­ysis: destru­ction of red blood cells
Aetiol­ogies
Autoimmune
Warm, cold, transf­usion reaction, drug induces
Haemog­lob­ino­pathies
sickle cell, hereditary sphero­cyt­osis, thalas­saemia
Infections
malaria
Enzyme defects
G6PD
Microa­ngi­opathic haemolytic anaemia (MAHA)
haemolytic uremic syndrome, TTP, DIC, eclamp­sia­/HELLP
Mechanical haemolysis
heart valve prosthesis
Rare
Paroxysmal noctural, haemog­lob­inuria (PNH)
 

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  • Published: 17th January, 2022

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