1. Anaemia
For 2nd year (ish)

2. What is it? Reduced haemoglobin (Hb)concentration
 <13.5g/dL in males
 <11.5g/dL in females
But consider: age, sex, clinical context
Not really a diagnosis in itself  find the cause!
3 broad reasons:
increased RBC destruction
decreased RBC production
blood loss

3. Erythropoeisis Lasts around 4 days
Factors stimulating: Common denominator is hypoxia  haemorrhage, damage to bone marrow, high altitude, exercise, haemolytic disease
Mature RBC’s survive for around 120 days
RBC breakdown – engulfed by phagocytic macrophages -- 90% by liver/spleen, 10% haemolyses in circulation

4. Hb Breakdown Globin chains amino acids
utilised by phagocytes or released into circulation
Haem
(macrophages convert haem) biliverdin – bilirubin
complexes with albumin
hepatocytes conjugate bilirubin + glucuronic acid
Conjugated (water soluble) bilirubin
Stored and concentrated in gallbladder
Excreted in bile
Excess congegated/ uncongegated = jaundice
Excreted in stool/ urine

5. Signs and Symptoms
Generally related to lack of O2/decreased BP/the underlying cause of the anaemia
Signs Koilonychia, angular stomatosis, pale conjunctivae, pale skin, jaundice, rapid pulse
Symptoms Most common = fatigue/TATT. Also SOB/SOBOE, chest pain, headaches, palpitations, dizziness
Anaemia can worsen existing conditions e.g HIV/AIDS, angina, COPD

7. Tests for Anaemia FBC Hb MCV (Mean Corpuscular Volume)
Haematocrit (% of a blood sample occupied by intact RBCs )
Blood Film: Hypo/Normo/Hyperchromic and abnormal cells
Haematinics - Iron, folate, B12
Serum Iron, ferritin, TIBC
Parietal Cell Antibody, Intrinsic factor antibody
EPO
Differentials - TFT, BM/urine dip, U and E’s, CRP,

8. More terminology... Anisocytosis – unequal size of RBC’s
Poikilocytosis –abnormal shaped RBC’s eg cigar in iron deficit anemia
Reticulocytes - slightly immature RBC’s characterised by network of filaments and granules. Normally 1% total RBC count – increased if body compensating for some anaemias

9. Using MCV to Classify Anaemia ...and starting to find the cause

10. Microcytic Anaemia MCV < 80 femtolitres
Mostly Iron deficiency Anaemia, can be haemolytic
i.e cells smaller and poorly filled with Hb
Also haemolytic anaemia
Causes
Generally associated to causes of chronic bleeding
 Malabsorption condition reducing iron absorption, post gastric bypass, diet (vegetarian, anorexia nervosa), pregnancy,
 low Hb, low MCV, hypochromic on film/ low MCH, with anisocytosis and poikilocytosis, low iron, low ferritin (with caution), raised TIBC

12. Haemolytic Anaemia
Bone Marrow cannot compensate for increased RBC loss – DIFFERENT TO HAEMOLYTIC DISEASE!
Most Common Cause is extravascular  RBC’s removed from circulation by mononuclear phagocytic system as intrinsically defective/presence of bound Ig’s
Findings: increased reticulocytes (count or film)/sickle cells/fragmented RBC’s on film/jaundice/gallstones and Fam/Med Hx
 Consider areas of prevalence for 2 main haemolytic diseases  SC and thalassaemias

14. Normocytic Anaemia MCV 80-100
Generally anaemia of chronic disease – pathology not certain – inflammatory cytokine related
Normochromic
Normal or Reduced Reticulocyte Count
Infection, inflammation, malignancy  e.g?
Acute blood loss
Physiological (pregnancy)

15. Macrocytic Anaemia MCV > 96 Megaloblastic and Non megaloblastic
Megaloblastic  Presence of megaloblasts on blood film – delayed nucleus maturation due to defective DNA synthesis - B12/folate deficit e.g malabsorption, methotrexate
Most Common: Pernicious Anaemia  tends to be disease of the elderly
Non Megaloblastic  Alcohol Abuse most common, liver disease

16. Key History Points
PC – ?
HPC - Any bleeding noted by P, weight loss, dyspepsia,
PMHx – Menorrhagia, GI ulcers, anaemia, alcohol abuse
PSHx – Recent surgeries
Meds - NSAIDS, steroids, MTX,
FamHx – haematological disorders, malabsorption disorders, anaemias, cancers
Social – diet, stress, travel
ROS – missing symptoms/assess severity of ?anaemia

17. The Dr will see you now...
Mrs. Baxter is a 38 y/o come to GP feeling TATT and is complaining of heavy periods – her main I/C/E is the tiredness as all her family have heavy periods so that doesn’t bother her.
Any other Questions?
What tests do you want to run in GP

18. Results FBC and blood film reveal:  Hb 9.8 g/Dl  MCV 70
 Hypochromic RBC’s
 Cigar shaped RBC’s

19. Meanwhile, at the Royal...
52 y/o male staggers in to A and E feeling SOB and dizzy – he says he has been for a while but it’s gotten worse, then vomits. He is clearly intoxicated and you note his yellow sclera
In addition to his deranged LFT’s, you note his FBC results below
Hb 9.5 g/Dl
MCV 108
What do you initially suspect? What additional test do you need for your differential?

20. During a home visit...
You go to visit 60 y/o Deloris Evans in her care home to review her medication for her RA and various other conditions. Generally it is well controlled. Her daughter tells you that quite recently her mother has become very SOB on minimal exertion and is having to use her GTN far more frequently. On further questioning Deloris says she has been feeling much more tired lately and at times a little dizzy but thought this was just down to old age......

21. You check Deloris’ FBC results from a recent hospital visit:
Hb 8.6 g/Dl
MCV 108
Blood Film reveals presence of megaloblasts
What specific test would be useful in this scenario given the patients age and presentation?

22. Treatments – Briefly!
Microcytic  Iron deficiency  Why are they deficient?
Dietary advice/Iron supplements/control bleeding
Normocytic  Anaemia of chronic disease
 limited options; disease control, EPO if renal involvement
Macrocytic Megaloblastic  b12/folate deficit  why are they deficient? Look at meds. B12 injections for PA
Macrocytic Non megaloblastic  generally think alcohol/liver disease  stop drinking, treat deficiency

23. SUMMARY 3 general causes of anaemia
Classify by MCV – micro/normo/macro
Not a diagnosis alone – find cause
Take into account Hx and clinical context
Investigations relevant to classify and find cause
Treat cause  Treat anaemia

24. Revision Cheese and Onion Meducation  handy guide to anaemia
Crash course in immunology and heamatology
Almost a Doctor
Don’t get too hung up on detail!