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Sites of
absorption
of iron and
vitamin B12
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)
Anemia is a laboratory diagnosis
Men Women
Hemoglobin (g/dL) 14-17.4 12.3-15.3
Hematocrit (%) 42-50% 36-44%
RBC Count (106/mm3) 4.5-5.9 4.1-5.1
Reticulocytes 1.6 0.5% 1.4 0.5%
WBC (cells/mm3) ~4,000-11,000
MCV (fL) 80-96
MCH (pg/RBC) 30.4 2.8
MCHC (g/dL of RBC) 34.4 1.1
RDW (%) 11.7-14.5%
Erythrocytes - less informative index
of anemia than the level of
hemoglobin therefore, in the
general practice the basic criterion
of severity is precisely Hb:
Light degree of anemia - Hb 11-9
g/dl,
The average degree of severity - Hb
9-7 g/dl,
Severe anemia - Hb below 7 g/dl
Anemia adalah suatu keadaan dimana
kadar hemoglobin lebih rendah dari
kadar hemoglobin terendah pada umur
dan jenis kelaminnya.
Pada wanita hamil nilainya lebih rendah
dari wanita tidak hamil.
9
Hemoglobin normal:
WHO Group of Experts on Nutritional Anaemias, menentukan Hb
normal berdasarkan umur dan jenis kelamin:
Kelompok Kadar Hb
10
Tanda-tanda anemia:
A. Tanda-tanda umum :
Pucat.
Takikardia.
Tekanan nadi yang lebar.
Tanda hiperdinamik di precordial.
Desah sistolik didaerah pulmoner.
11
Gejala anemia:
A. Anemia akut:
1. Serebral: oyong kalau berdiri, vertigo, tinnitus,
sinkope, bintik didepan mata.
2. Sirkulasi: palpitasi, sesak nafas kalau bekerja, lelah,
angina, klaudikasio.
3. Demam : tanda infeksi, bisa juga ok proses penyakit
darah.
4. Lain-lain : hipersesitif thd dingin, anorexia, gangguan
pencernaan, haid tidak teratur, impotensi, libido hilang.
B. Anemia kronik:
Tubuh dapat menyesuaikan dengan anemia yang terjadi
lambat
Gejalanya ringan, kadang-kadang hanya rasa lelah.
12
Presentation/history
Mild anemia:
few or no symptoms; may be discovered
accidentally on lab test
May complain of:
Fatigue, decr. exercise tolerance, SOB,
palpitations, CP, lightheadedness on arising
Sore tongue (glossitis), cracking mouth corners
(angular cheilitis), peripheral paresthesias
(numb toes, etc.)
Hx:
EtOH use, FH anemia, pica, vegetarian diet,
melena/hematochezia, malabsorption
syndromes, Crohns disease
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)
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)
PHYSICAL EXAM
Stable or Unstable?
-ABCs
-Vitals
Pallor
Jaundice
-hemolysis
Lymphadenopathy
Hepatosplenomegally
Bony Pain
Petechiae
Rectal-? Occult blood
Anemia: Special Populations
Higher Hb/HCT:
Patients living at high altitudes
Smokers and patients living in air pollution
areas
Endurance athletes have increased HCT
Lower Hb/HCT:
African-Americans have 0.5 to 1 g/dl lower Hb
than do Caucasians
Elderly (slowed erythropoiesis)
Pregnant women (hemodilution)
Differential diagnosis
Consider:
Anemia
Hypothyroidism
Depression
Cardiac (congestive heart failure, aortic
stenosis)
Pulmonary causes of SOB/DOE
Chronic fatigue syndrome, others
Physical examination
Pallor (may be jaundiced think hemolytic)
Tachycardia, bounding pulses
Systolic flow murmur
Glossitis
Angular cheilosis
Decreased vibratory sense/ joint position
sense (B12 deficiency, w/ or w/o hematologic
changes)
Ataxia, positive Romberg sign (severe
B12/folate deficiency)
Pemeriksaan awal anemia:
A. Kuantitatif:
Hb
Ht
Hitung eritrosit
MCH
MCV
MCHC
Hitung retikulosit
Hitung lekosit
Hitung trombosit
LED.
20
Pemeriksaan awal anemia:
Kualitatif:
Gambaran morfologi darah tepi dg pengecatan
Wright: hipokromik, polikromasia, normokromik.
Besar sel : mikrositer, makrositer, anisositosis.
Bentuk sel : poikilositosis, sferositosis, sel oval dan
tear drops, fragmented cells, ghost cells, dll.
Badan-badan intraseluler: eritrosit berinti, badan
Howell-Jolly, siderosit, badan Papenheimer, badan
Heinz dan malaria.
21
Pemeriksaan lanjutan:
Bilirubin
Besi serum (SI)
TIBC
Transferrin
BMP
Hemoglobin elektroforesis
Coombs test
G6PD
Vit B12
Asam folat
22
Anemia AETIOLOGICAL CLASSIFICATION
I- Decrease red cell production.
A. Microcytic-hypochromic anaemias:
Thalassaemia.
Iron deficiency anaemia.
B-Normocytic-normochromic anaemias:
Acute post haemorrhagic anaemia.
Hemolytic anaemia.
38
Decreased Production
NUTRITIONAL DEFICIENCY
Iron
B12
Folate
Anemia defisiensi
besi
40
Anemia defisiensi besi.
Tingkatannya:
1.deplesi besi: cadangan besi berkurang atau
tidak ada sama sekali, belum anemia.
2.defisiensi besi: cadangan besi berkurang
atau tidak ada + rendahnya besi serum dan
jenuh transferin, belum anemia.
3.anemia defisiensi besi: cadangan besi
berkurang atau tidak ada + rendahnya besi
serum dan jenuh transferin + Hb rendah dan
Ht rendah. Sudah anemia.
41
Penyebab anemia defisiensi besi.
Perdarahan:
sal.urogenital,
sal.pencernaan,
sal.pernafasan.
Kebutuhan meningkat:
prematur,
hamil,
haid,
masa pertumbuhan.
Malabsorpsi.
Makanan kurang bergizi.
42
Fe deficiency anemia
++
vegetables, other)
Iron balance is very close in
Keluhan:
pucat,
lemah,
nyeri menelan,
pika,
nyeri epigastrik.
Tanda-tanda:
anemia,
glositis,
atrofi papil lidah,
koilonikia,
keluhan penyakit dasarnya.
44
Physical Manifestation : Spoon
Nails in Iron Deficiency
Pemeriksaan
46
Labs
Iron and ferritin will be low
TIBC (total iron binding capacity) will be
high, since iron stores are not saturating
their binding sites on transferrin
Reduced RBC counts (definition of anemia)
Microcytosis & hypochromia are hallmarks,
but early Fe++ may be normocytic (
hypochromic)
Usually, MCH and MCHC will both be low
(whereas in macrocytic anemia, the MCH
may be normal while the MCHC is low,
because of the larger cell size)
Labs
Most practitioners would agree that if
a patient has microcytic hypochromic
anemia with a low reticulocyte count,
it would be reasonable to use a trial
of FeSO4 to diagnose
5-10 days after initiating therapy, a
50
Treatment
Iron, oral in most cases, parenteral in
cases of malabsorption
All forms of iron are constipating; the
Laboratory signs:
58
Klasifikasi anemia megaloblastik
Defisiensi kobalamin
59
Defisiensi kobalamin
anemia pernisiosa,
paska gastrektomi
organisme intestinsal
abnormalitas ileum
nitrous oxide
60
History of
the Management of Anemia
Before 1980 Hb 10 g/dL
Hb 8 g/dL
Risks of transfusion
1980s infection
Transfusion guidelines
Moderate/severe anemia
Hb 8 g/dL
62
Macrocytic anemia with ineffective
erythropoiesis
Low/normal reticulocyte count,
macrocytosis
Most common is folate/B12 deficiency
Dietary: folate far more common, B12 may occur
in strict vegans
Pernicious anemia: lack of B12 protection in
stomach and gut
Poor uptake in terminal ileum (e.g. in Crohns
disease)
B12 and folate are essential for cell maturation
and DNA synthesis, erythrocytes end up large,
usually normochromic, since iron is not lacking
Other: drugs, toxins, myelodysplasia
Folate deficiency
Folate intake is usually dietary, and
may be deficient with low fresh fruit
& vegetable intake
Folate supplementation of bread
severe deficiency
B12 deficiency
Less common, usually caused by absorption
problems, rather than dietary deficiency
B12 needs Intrinsic Factor for protection from
degradation in gut
Produced by parietal cells of stomach, protects
through gut for uptake at terminal ileum
Pernicious anemia from immune attack of IF
production
EtOH-related gastritis can affect IF production, and
liver disease may also contribute to macrocytosis
Neurological effects
Deficiency results in damage to
dorsal columns (sensory) and lateral
columns (motor) of spinal cord
Decreased vibration sense and
and dementia
Labs
Folate and B12 levels
Schilling test may be useful to establish
Bone Megaloblasti No
marrow c changes megaloblastic
examination changes
Klinis
Pemeriksaan penunjang
-darah perifer
-MCV>100 fl,
-MCV>110 fl sangkaan kuat
-defisiensi kadar kobalamin < 200 pg/ml (300-900
pg/ml)
-defisiensi kadar asam folat <4 ng/ml (6-20 ng/ml)
70
Deficiency Folic acid Serum
vit. B12
Serum RBC
Folic acid N
Vit B12 N/
Atasi penyebab
Defisiensi Kobalamin :
Kobalamin 1000 ug IM tiap minggu sd 8 minggu,
lanjutkan kobalamin 1000 ug IM tiap bulan
Vit B12 2 mg perhari
72
THERAPEUTIC TRIALS
Usual diet
+ -
+ 1-2 g vit
B12
73
Thank You