ANEMIAS

AHMAD MAGABLEH.MD

ANEMIA
Anemia: Is defined as a reduction in one
or more of major RBC measurements.
HGB.
HTC.
RBC count .
Anemia is not a disease by itself but is one
of the major signs of disease.
May be the first manifestation of a
systemic disease,along with other
nonspecific complaints such as
fever,weight loss,anorexia.

HGB Concentration:measures the

major oxygen-carrying pigment in
whole blood.
Values are expressed as grams of
HGB per dL of whole blood(g/dL).
Normal range: M 13-16,5 g/dL
F 12-15,5 g/dL

Hematocrit (HTC):Is the percent of a

volume of whole blood occupied by
intact RBCs.
Values are expressed as a percentage.
Normal range: M 41-51%.
F 37-47%.

RBC Count: Is the number of RBCs

contained in a unit of whole blood.
Values are expressed as millions of
cells per uL of whole blood.
Normal range: M 4,5-6,5
F 3,8-5,8

VOLUME STATUS
The three measurements are all
concentrations.
As such they are dependent upon both the
RBC mass and the plasma volume.
1.In acute bleeding anemia develops only
after 36-48 hours.
2.Pregnancy:RBC mass is increased by
25% and plasma is increased by
50%.Normal values in pregnancy are
diffirent.
3.Dehydration.

SPECIAL POPULATIONS
1.Living at high altutute.
2.Smoking and air pollution.
3.African-Americanslower values.
4.Populations with a high incidence of
ch.diseases.
5.Athletes.
6.The elderly:should not have a lower
normal range for fear of missing a
serious underlying disorder.

ERYTHROPOESIS -1
Erythropoesis takes place in adults within
the BM under the influence of the stromal
framework,a number of cytokines,and the
eryrhroid specific growth
factor,erythropoietin(EPO).
EPO is a true endocrine hormone produced
in the kidney.
EPO enhances the growth and
differentiation of the 2 erythroid
progenitors.
1.Burst Forming Units-erythroid/BFU-E/.
2.Colony Forming Units-erythroid/CFU-E/.

ERYTHROPOESIS-2
The rate of RBC production equals the
rate of RBC destruction.
Approximately 1% of RBCs is removed
from the circulation daily.
The rate of RBC production can
increase markedly under the
influence of high levels of EPO.5-7
folds.

CLINICAL CONSEQUENCES
OF ANEMIA
The signs and symptoms induced by
anemia are dependent upon the
degree of anemia as well as the rate
at which the anemia has evolved.
Symptoms of anemia can result from
two factors:
1.Decreased O2 delivery to tissues.
2.Hypovolemia/acute bl.loss/.

COMPENSATORY
MECHANISMS
Signs and symptoms depend also on the

Signs and symptoms depend also on the

compensatory mechanisms.
1.Extraction of O2 by the tissues can increase
from 25% to 60%.
2.Cardiac compensation:stroke volume and heart
rate/cardiac output/.
Thus normal O2 delivery can be maintained by
1and 2 at rest at HBG as low as
5g/dL,assuming that the intravasc.volume is
maintained.
Thus symptoms will develop when HBG falls
below this level at rest or at higher HBG during
exersion or when cardiac compensation is
impaired.

SYMPTOMS AND SIGNS

Symptom:is a sensation or change in
health function experienced by the
patient.It is a subjective report.
Fatigue/tiredness
Pain.
Nausea.
Dizziness.

Sign:is an objective evidence of the

presence of a disease or disorder
.Signs are discovered and reported
by
the physician,not by the patient.
Elevated BP.
Skin rash.
Tachypnea.

SYMPTOMS AND SIGNS OF

ANEMIA
Dyspnea/S.O.B.:on exersion/at rest.
Fatigue/tiredness.
Signs and symptoms of hyperkinetic state:
1.bounding pulses.
2.palpitations.
3.roaring in ears.
In more severe
anemia:Lethargy,confusion,CHF,angina,MI.
Pallor.
Headache.
Complications of extracellular volume depletion/in
acute bleeding/

CAUSES OF ANEMIA
There are 2 interrelated approaches
one can use to help identify the
cause of anemia.
1.Kinetic approach.
2.Morphologic approach.

KINETIC APPROACH
Anemia can be caused by one or more
of 3 independent mechanisms.
1.Decreased RBC production.
2.Increased RBC destruction.
3.RBC loss.

MORPHOLOGIC
APPROACH
According to RBC size.
Mean Corpuscular Volume /MCV/.
RBC size/MCV/ is 80-96 femtoliters(fL).
Microcyte.
Macrocyte.
Normocyte.

ANEMIAS ACCORDING TO
THE RBC SIZE
1.Microcytic anemia.
2.Macrocytic anemia.
3.Normocytic anemia.

MICROCYTIC ANEMIAS
Are associated with an MCV below 80
fL.
IDA
ACD
Thalassemias.

MACROCYTIC ANEMIAS
Are characterized by an MCV above
100 fL.
Reticulocytosis.
Vit.B12 def.
Folate def.
MDS.
Hypothyroidism

NORMOCYTIC ANEMIAS
By definition the MCV is normal.
ACD.
MDS.

EVALUATION OF THE
PATIENT WITH ANEMIA-1
Anemia is one of the major signs of
disease.
It is never normal and it`s cause should be
always be sought.
History.
Physical examination.
Simple lab.tests.
Are all useful in evaluating the anemic
patient.

EVALUATION OF THE
ANEMIC PATIENT-2
The workup should be directed towards
answering the following questions:
1.Is the patient bleeding(now or in the
past) ?.
2.Is there evidence of increased RBC
destruction?
3.Is the BM suppressed?.
4.Is the patient iron deficient?if so,why?.

HISTORY

Symptoms related to anemia

(melena,CRF,RA).
Duration of anemia (Recent origin,or
life-long).
Drug history (NSAIDs).
Family history.

PHYSICAL
EXAMINATION

Pallor.
Jaundice.
Tachycardia.
Lymphadenopathy.
Hepatosplenomegaly.
Bone tenderness.

LABORATORY
EVALUATION-1

Complete blood count (CBC):

HBG,HCT,
RBC count,RBC indices,and
WBC count.
WBC differential,PLT count,and
reticulocyte count.
Blood film (Blood smear).
Red cell distribution width.

LABORATORY
EVALUATION-2
Red cell indices:
1-Mean corpuscular volume.MCV 80-100
femtoliter.
2-Mean corpuscular hemoglobin.MCH
27,5-33,2 picograms of hemoglobin
per RBC.
3-Mean corpuscular hemoglobin
concentration.MCHC.33,4-35,5
grams of hemoglobin per dL of RBCs.

LABORATORY
EVALUATION-3
Reticulocyte count: helps to distinguish
among the different types of anemia.
0,5-1,5 percent of the RBCs count.
Absolute reticulocyte count.25,00075,000/uL.
Reticulocytes normally survive for 4 days,of which 3 days
in
the BM and one day in the peripheral
circulation.
White blood cell count (WBC count).
Platelet count (PLT count).

OTHER
INVESTIGATIONS

Bone marrow aspirate and trephine

biopsy.
Radiological studies.
Genetic studies.
Immunological studies.

BONE MARROW
EXAMINATION

BM examination generally offers little

additional diagnostic information in the
more common forms of anemia.
Although the absence of stainable iron in
BM is considered the gold standard
for the diagnosis of ID,this diagnosis
is usually established by lab.tests alone.

BONE MARROW
EXAMINATION-Contd

Indications for BM examination in

anemic
patients include:
1-Pancytopenia or bicytopenia.
2-The presence of abnormal cells
in the
circulation (blast forms).

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