Approach to the patient with anemia
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Approach to the Patient with ANEMIA. Lisa Mohr, MD Mike Tuggy, MD. Objectives. 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.

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Approach to the patient with anemia

Approach to the Patient with ANEMIA

Lisa Mohr, MD

Mike Tuggy, MD


Objectives

Objectives

  • 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


Rbc the important players

RBC-The important players

  • Hemoglobin

    • reversibly binds and transports 02 from lungs to tissues

    • 4 globin chains & iron


Rbc the important players 2

RBC-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*


Definitions

Definitions

  • Anemia-values of hemoglobin, hematocrit or RBC counts which are more than 2 standard deviations below the mean

    • HGB<13.5 g/dL (men)<12 (women)

    • HCT<41% (men)<36 (women)


Approach to the patient with anemia

CASE

  • 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??


Evaluation of the patient

Evaluation 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


Evaluation of the patient 2

Evaluation 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


Evaluation of the patient 3

Evaluation of the Patient (3)

PHYSICAL EXAM

•Stable or Unstable?

-ABCs

-Vitals

•Pallor

•Jaundice

-hemolysis

•Lymphadenopathy

•Hepatosplenomegally

•Bony Pain

•Petechiae

•Rectal-? Occult blood


Laboratory evaluation

Laboratory Evaluation

  • Initial Testing

    • CBC w/ differential (includes RBC indices)

    • Reticulocyte count

    • Peripheral blood smear


Laboratory evaluation 2

Laboratory 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


Differential diagnosis

Differential Diagnosis

  • Classification by Pathophysiology

    • Blood Loss

    • Decreased Production

    • Increased Destruction

  • Classification by Morphology

    • Normocytic

    • Microcytic

    • Macrocytic


Blood loss

Blood Loss

  • Acute

    • Traumatic

    • Variety of sources

      • Melena, hematemesis, menometrorrhagia

  • Chronic

    • Occult bleeding

      • Colonic polyp/carcinonma


Decreased production

Decreased Production

  • Infectious

  • Neoplastic

  • Endocrine

  • Nutritional Deficiency

  • Anemia of Chronic Disease


Decreased production infectious

Decreased ProductionINFECTIOUS

  • Bacterial

    • Tuberculosis

    • MAI

  • Viral

    • HIV

    • Parvovirus


Decreased production neoplastic

Decreased ProductionNEOPLASTIC

  • Leukemia

  • Lymphoma/Myeloma

  • Myeloproliferative Syndromes

  • Myelodysplasia


Decreased production endocrine

Decreased ProductionENDOCRINE

  • Thyroid Dysfunction

    • Hypothyroidism

  • Erythropoietin Deficiency

    • Renal Failure


Decreased production nutritional deficiency

Decreased ProductionNUTRITIONAL DEFICIENCY

  • Iron

  • B12

  • Folate


Macrocytic anemia

Macrocytic Anemia

  • MCV > 100

  • Megaloblastic:Abnormalities in nucleic acid metabolism

    • B12, Folate

  • Non-megaloblastic:Abnormal RBC maturation

    • Myelodysplasia

  • ETOH, liver dz, hypothryroidism, chemotherapy/drugs


Microcytic anemia

Microcytic Anemia

  • MCV <80

  • Reduced iron availability

  • Reduced heme synthesis

  • Reduced globin production


Microcytic anemia reduced iron availabilty

Microcytic 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


Microcytic anemia reduced heme synthesis

Microcytic AnemiaREDUCED HEME SYNTHESIS

  • Lead poisoning

  • Acquired or congenital sideroblastic anemia

  • Characteristic smear finding: Basophylic stippling


Microcytic anemia reduced globin production

Microcytic AnemiaREDUCED GLOBIN PRODUCTION

  • Thalassemias

  • Smear Characteristics

    • Hypochromia

    • Microcytosis

    • Target Cells

    • Tear Drops


Lab tests of iron deficiency of increased severity

Lab tests of iron deficiency of increased severity


Differential diagnosis revisited

Differential Diagnosis-Revisited

  • Classification by Pathophysiology

    • Blood Loss

    • Decreased Production

    • Increased Destruction


Increased destruction

INCREASED DESTRUCTION

  • Immune Mediated

  • Non-immune Mediated


Increased destruction immune mediated

Increased DestructionIMMUNE MEDIATED

  • Cold Agglutinin

    • Paroxysmal nocturnal hemoglobinuria

    • Post mycoplasmal hemolytic anemia

  • Warm Agglutinin

    • Drug induced

    • Autoimmune hemolytic anemia

    • Transfusion reaction


Increased destruction non immune mediated

Increased 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)


Back to m l you appropriately decide to obtain more history

Back to M.L.-You appropriately decide to obtain more history!

  • HPI: “I’ve been a little more tired than usual, but I’ve been busy at work. I’m 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

  • ROS:+fatigue, +urine seems a little darker lately


More on m l

More 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


M l s initial labs

M.L.’s Initial Labs

  • Only a CBC w/ diff was obtained:

    • WBC: 8.2, HCT 32.2, MCV 79, Platelets 221, differential - normal


Initial thoughts

Initial Thoughts?

  • Blood loss?

    • Age places him at risk for colon CA

  • Decreased Production?

    • Alcohol use, Iron deficiency

  • Increased Destruction?

    • “Darker urine” lately


Further work up

Further Work-up

  • CAGE questions

  • Peripheral Blood Smear

  • Reticulocyte count

  • Iron Studies

    • Ferritin

    • TIBC

    • % Saturation

  • Urinalysis

  • FOBT or colonoscopy referal


More results

More 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


What s next

What’s 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


Diagnosis

Diagnosis

  • 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”!


References

References

  • 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


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