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Approach to anaemia
1. Systematic Approach in Anemia Evaluation Dr .M.ASHOK. MD Consultant Physician & Assistant Professor of Medicine, Thanjavur medical college & hospital. Consultant : Vasan Medical Centre, Thiruverumbur
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18. Anemia Differential Dx by Flow Chart MCV/smear Micro Normo Macro Iron panel Retic Low Retic High High Low Iron/B12/Folate *Occult Blood Loss Yes No Coombs (+) Coombs (-) Go to *Occult Blood Loss B12/Folate B12 Low Folate/Low Normal MMA/Homocysteine MMA high – B12 Low Homocysteine high – Folate Low Normal – Go to ** **Normal Bone Marrow Bx Anemia of Chronic Dis.
19. First use size ( MCV ) to sort the Differential Dx MCV Micro Normo Macro
20. Macrocytic anemia Macro RPI >= 2 RPI < 2 Check Occult Blood Loss Check B12 and folate No Yes Coombs’ test
21. Macrocytic: RPI < 2 B12/Folate B12 Low Normal Folate Low MMA High MMA Homocysteine Normal Homocysteine High Consider Liver, Renal, Thyroid, Alcohol, Chronic dis. Consider Bone Marrow Bx
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23. Macrocytic: RPI >= 2 Occult Blood Loss? Yes No Investigate source Coombs’ (DAT) Check for Hemolysis Peripheral smear
24. Macrocytic: RPI >= 2 Hemolytic Anemia Coombs’ (DAT) Positive Negative Immune Hemolysis Drug related Hemolysis Transfusion, Infection, Cancer Hemoglobinopathy, G6PD, PK, Spherocytosis, Eliptocytosis, PNH, TTP, DIC
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41. Lab tests of iron deficiency of increased severity NORMAL Fe deficiency Without anemia Fe deficiency With mild anemia Fe deficiency With severe anemia Serum Iron 60-150 60-150 <60 <40 Iron Binding Capacity 300-360 300-390 350-400 >410 Saturation 20-50 30 <15 <10 Hemoglobin Normal Normal 9-12 6-7 Serum Ferritin 40-200 <20 <10 0-10
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Editor's Notes
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Limitations-1. Given that these ranges include 95% of the normal population, the 2.5% of normal subject with values which fall below the normal range will be arbitrarily depicted as being anemic 2. The normal range for HGB and HCT is so wide that, for example a male patient with a baseline HCT of 49% may lose up to 15% of his RBC mass through hemolysis or blood loss and still have a HCT within the normal range
CBC-red cell indices-size-micro,macro, normo, color(chromasia) WBC-leukopenia should alert to bone marrow suppression Differential-immature forms Retic count-high-indicates increased response to continued hemolysis or blood loss stable anemia w/ low retic is strong evidence for deficient production of RBCs (reduced marrow response) Smear-as above, nuceated RBCs hematologic dz(sickle, thal,hemolytic anemia), things missed by automated counters: schistocytes, RBC parasits, evidence for hemolysis
Primary Bone Marrow involvement Marrow dysfunction vs. Marrow infiltration
Note hypersegmented polys – B12 & folate deficiency
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