Professional Documents
Culture Documents
HematologicDisorders:TheAnemias
HematologicDisorders:TheAnemias
DefinitionofAnemia
Adecreaseinhemoglobin(orhematocrit)levelfromanindividualsbaselinevalue.
Reductionintheredcellmassorthebloodhemoglobinconcentration
Hemoglobinlevellessthanthelowerrangevalueforage(Ingeneralnormalhemoglobinlevelsare12
g/dLlowerinwomenandAfricanAmericanmenthaninwhitemen)
ClassificationofAnemia:
Physiologicclassificationleadstotreatment
Morphologicclassificationleadstodiagnosis
Typesofdisorders
Typesofanemia
Disordersofredcellproduction
Hypochromicmicrocytic
Disordersofredcellmaturation
Macrocytic
Disordersofredcelldestruction
Normochromicnormocytic
History&Physical
Historicalfactorsinevaluatingpatientwithanemia
Age
Sex
Race
Diet
Neonatal
Infection
Hepatitisinducedaplasticanemia
Infectioninducedredcellaplasiaorhemolyticanemia
Inheritance
Diarrhea(SuspectsmallboweldiseasewithmalabsorptionoffolateorB12,suspectbloodloss)
FamilyHistory
Anemia
gallbladderdisease
jaundice
sicklecellorthalassemia
splenomegaly
bleedingtendencies
NutritionalHistory
Dietaryintakeofironsources,vitamins,milk,andmeat
drug/toxinexposures
bonemarrowfailure
chronicillness
24hourdietaryrecall
Historyofpica
Picaisaneatingdisordertypicallydefinedasthepersistenteatingofnonnutritivesubstancesforaperiodof
atleast1monthatanageinwhichthisbehaviorisdevelopmentallyinappropriate(eg,>1824mo).The
substancesincludesuchthingsasclay,dirt,sand,stones,pebbles,hair,lead,plastic,ice,paper,paintchips,
coal,chalk,wood,andplaster.
Reviewofsystems
http://my.ilstu.edu/~ddwilso2/nur475/Anemia_Notes.htm
1/7
11/3/2016
Jaundice
Extremitypain
Abdominalpain
Bloodloss
Weightloss
PhysicalExamination
Pallor
Jaundice
Petechiae
Fundalhemorrhages
HematologicDisorders:TheAnemias
Recentinfections
Drugexposures
Travel
Behavioralchanges
Pallor
Petechiae,ecchymoses
Adenopathy
GIandGUdisorders
ChangesinstoolindicatingGI
bleeding
Excessivebruising
Mucousmembranebleeding
Jointorextremitypain
Heartmurmursandsignsof
CHF
Hepatosplenomegaly
Congenitalanomalies
Lymphadenopathy
Frontalbossing
DiagnosisofAnemia
LaboratoryAssessment
Completebloodcount:
Hemoglobin,hematocrit,RBCcount
RBCindices(MCV,MCH,MCHC,RDW)
WBCcountanddifferential
Plateletcount
Redcellmorphology(descriptionofblood
smear)
Reticulocyteproductionindex
Serumiron,TIBC,serumferritin
Bonemarrowaspiration/biopsy
RBCIndices
LookatH&Hfirst,then
MCV(meancorpuscularvolume)
75100mcg3
Decreased:microcytic(Irondeficiency)
Increased:macrocytic(Folicaciddeficiency,VitaminB12deficiency)
Normal:normocytic
MCH(meancorpuscularhemoglobin)
2333pg/cell
Decreased:hypochromicanemia(Irondeficiency)
Normal:normochromic
Increased:hyperchromicorpolychromic(macrocyticanemiassuchasperniciousanemia)
RDW(RBCdistributionwidth)
Normal:11.514.5%
CalculatedfromtheMCVandtheRBCcount
Quantitativemeasureofanisocytosis(RBCsunequalinsize)
Assistsindistinguishingirondeficiencyanemiafromthalassemia
BothconditionshavelowMCV
IrondeficiencyanemiahashighRDW
ThalassemiahasanormalRDW
TheRDWmaybecomeabnormalbeforetheanemiaoccurs.
http://my.ilstu.edu/~ddwilso2/nur475/Anemia_Notes.htm
2/7
11/3/2016
HematologicDisorders:TheAnemias
HypochromicMicrocyticAnemia
Decreasediron,increasedTIBC,increasedFEPandnormalHgbelectrophoresisindicateirondeficiency
anemia
Iflabstudiescontinuetoshowirondeficiency,considermalabsorption,noncompliance,inadequatedose
NormalTIBCwithhighHgbAorHgbFindicateThalassemiaMinor
AnemiaClassification
Microcytic(MCVlow)
irondeficiencyanemia(late)
anemiaofchronicdisease(late)
leadtoxicity(rare)
sideroblasticanemia(asfromchronicalcoholism,leadpoisoning,preleukemicmyelodysplasia,
pyridoxine[B6]deficiency)
IronDeficiencyAnemia
MostprevalentnutritionaldisorderintheUnitedStates
Prominentinagegroupsexperiencingratesofrapidgrowth:
toddlers
adolescents
pregnantandlactatingwomen
Almostalwaysduetobloodloss
So:Teststoolsforoccultblood/GIreferral
Alsodueto:
dietaryinsufficiency
decreasedabsorptionduetogastricsurgeryorheavyantaciduse
Threestagesofirondeficiencyanemia
Stage1ferritinandhemosiderinstoresdepleted
Stage2serumirondecreased,ironbindingcapacityincreased
Stage3Hemoglobindecreased,irondeficiencyaffectshemesynthesis
Clinicalmanifestations
Thin/chubby
Historyofpica
Behavioralchanges
Pale
Tachycardia
Mildsystolicejectionmurmur
Treatment
http://my.ilstu.edu/~ddwilso2/nur475/Anemia_Notes.htm
3/7
11/3/2016
HematologicDisorders:TheAnemias
Ferroussulfate325mgPOtid
ContinueuntilHgbreturntonormal
Then36monthsofbiddosingtoreplenishferritinstores.
Initiatingtherapywithonceadaydosing(325mg)andgraduallytitratingupwardmayhelpminimizeGI
intolerance
Lowerdosesmaybeusedtodecreaseconstipation.
AddingvitaminCpotentiatesironabsorption
Reticulocytecount12aftertherapyifanemiaissevereorbonemarrowactivityisinquestion
ReassessHgbafter34weekstodocumentimprovement
Hgbshouldreturntonormalin68weeks
Therapyshouldcontinuewithbiddosinguntilferritinstoresarereplenished(36months).
FailureofHgbtorespondtotreatment:
misdiagnosisnoncompliance
malabsorptionunrelentingbloodloss
Refernonresponderstoaphysician.
MacrocyticAnemias
MCVhigh
B12deficiency
Folatedeficiency
chemotherapyandothermeds
liverdisease
myelodysplasia
thyroiddisease
Mostcommoncause:alcoholabuse
B12andfolatedeficiency=1/3ofallmacrocyticanemias.
Physicianconsultationiswarrantedinallcases.
VitaminB12Deficiency
Mostcommoncauseisperniciousanemia,achronic,progressive,macrocyticanemiacausedbyadeficiency
inintrinsicfactor(substancenecessaryforB12absorptionintheGItract).
Autoimmunedisease
mostcommoninwomenage3560ofNorthernorEasternEuropeanancestry
LesscommoncausesofB12deficiency:
gastricsurgery(gastrectomy,ilealresection)
Crohnsdisease
pancreaticinsufficiency
dietaryinsufficiency(uncommonfoundprimarilyinthosewhoconsumenoanimalordairyproducts)
http://my.ilstu.edu/~ddwilso2/nur475/Anemia_Notes.htm
4/7
11/3/2016
HematologicDisorders:TheAnemias
AssessmentofVitaminB12Deficiency
S:changeintaste,anorexia,mouthsoreness,N,bowelchanges,irritability,memorychanges,moodswings,
paresthesias
O:Neurologicabnormalitiesandglossitis
Labs:NormalorelevatedMCV,slightlyelevatedbilirubin,decreasedreticcount.
Schillingtestcanbeusedtodifferentiateperniciousanemiafromothercauses
Treatment
Initiatedwith100mcgofB12IMonadailybasisfor1week,thenweeklydosefor1month,thenamonthly
doseforlife
Firstfewdaysoftreatment:olderadultatriskforCHFandhypokalemia
WHY???
Mayhavetosupplementfolateandironstores.
FolicAcidDeficiency
Causes
Inadequateintake(commoninelderlyalcoholics)
chronicingestionofovercookedfoods
increasedbodyrequirements(malignancy,hemolyticanemia,severeexfoliativepsoriasis)
Medications(phenytoin,methotrexate,triamterene,trimethoprim)
Presentswithmacrocyticanemiaandlowserumfolatelevels.
B12shouldalwaysbeassessedinpresenceoffolatedeficiency
Folatereplacementwillmaskhematologicfindingsbutnotpreventneurologicalsequelaecausedby
coexistentB12deficiency
Treatunderlyingcauseandsupplementfolicacid(usually1mgPOqd)untilresolved.
NormocyticAnemias
MCVnormal
irondeficiencyanemia(early)
anemiaofchronicdisease(early)
hemolyticanemia
irondeficiency+B12deficiency
renalorthyroiddisease
AnemiaofChronicDisease(ACD)
Anemiaoftenaccompanieschronicinflammationormalignancydueto:
decreasedRBClongevity
decreasederythropoiesis
Maybecomehypochromicormicrocyticovertime
http://my.ilstu.edu/~ddwilso2/nur475/Anemia_Notes.htm
5/7
11/3/2016
HematologicDisorders:TheAnemias
RarelycausesdropofHgb<9orHct<25unlessaccompaniedbycoexistingpathology
IrondeficiencyfrequentlycoexistswithACD.
Labs:
Likeirondeficiency:serumironandtransferrinsaturationlow
Unlikeirondeficiency:ferritinisnormalorincreasedandTIBCislow
Causes
Autoimmunedisease
Chronicinfection(TB,HIV,endocarditis)
Malignancy
Liverdisease
Chronicrenalfailure
Treatment
Aimedatunderlyingdiseaseprocess.
IfHgb<9,Hct<25,lookforcoexistingpathology(B12,irondeficiency,multiplemyeloma)
Ifrenalfailure:erythropoietin,Vit.C,E,iron
Empirictrialofirontotreatanycoexistentirondeficiency
DisordersofRBCproduction
Examples
aplasticanemia
Anemiasecondarytomalignanciesand/orchronicdisease
Intervention
BloodreplacementwithpackedRBCtransfusions
DisordersofRBCmaturation
Examples
Irondeficiency
Leadpoisoning
Thalassemiasyndromes
Interventions
Irontherapy
Nutritionalcounseling
Promotecompliance
Leadremoval
Chelationtherapy
Geneticcounseling
DisordersofRBCdestruction
Examples
Sicklecellanemia
G6PDdeficiency
http://my.ilstu.edu/~ddwilso2/nur475/Anemia_Notes.htm
6/7
11/3/2016
HematologicDisorders:TheAnemias
Pyruvatekinasedeficiency
Hereditaryspherocytosis
http://my.ilstu.edu/~ddwilso2/nur475/Anemia_Notes.htm
7/7