Clinical Approach To Anemia: Fakultas Kedokteran Universitas Prima Indonesia

CLINICAL APPROACH TO ANEMIA
FAKULTAS KEDOKTERAN
UNIVERSITAS PRIMA INDONESIA
ANEMIA
• Anemia is not a disease, but rather the expression of an
underlying disorder or disease.
• Anaemia is defined as haemoglobin concentration less than the
normal reference range according to age and sex.
• Cut off point anaemia in Indonesia :
- Pre school age 11 g/dL
- School age 12 g/dL
- Pregnant women 11 g/dL
- 3 month post partum 12 g/dL
- Female 12 g/dL
- Male 13 g/dL
Prevalence
• Anaemia is thought to affect 1.62 billion people on a

daily basis (WHO); this is 24% of the world’s
population.
• Anaemia affects both developing and developed

nations.
• Women (both pregnant and non-pregnant) and

children suffer most from the condition.
Cause of Anemia
 Decreased RBC production :
- Insufficient production
- Inefficient production (erythropoiesis)
 Increased RBC loss or destruction exceeds the maximal

capacity of bone marrow RBC production :
- Reduced RBC lifespan
- Excessive Loss of RBC
Signs and symptoms of anemia
Central nervous system Immune system
 Debilitating fatigue  Impaired T-cell and
 Dizziness, vertigo macrophage function
 Depression
 Impaired cognitive function Cardiorespiratory system
 Exertional dyspnoea
 Tachycardia, palpitations
Gastro-intestinal system  Cardiac enlargement,
 Anorexia hypertrophy
 Nausea  Increased pulse pressure,
systolic ejection murmur
 Risk of life-threatening cardiac
Vascular system
 Low skin temperature failure
 Pallor of skin, mucous
Genital tract
membranes and conjunctivae  Menstrual problems
 Loss of libido
Adapted from Ludwig H. Semin Oncol. 1998;25(suppl 7):2-6.

6
Signs and symptoms of anemia
The signs and symptoms of anemia range from slight

fatigue to life threatening reactions depending upon :
– Rate of onset
– Severity
– Ability of the body to adaptive
Diagnosis of Anemia
1. Patient history
2. Patient physical examination
3. Hematologic laboratory findings
Identification of the cause of anemia is important so

that appropriate therapy is used to treat the anemia.
Diagnosis of Anemia
1. History
- Symptoms of anemia (Acute vs. Chronic)
- The severity of cerebral and circulatory symptoms relative to
the severity of anemia.
- The possibility of chronic blood loss (GI, Gynecological).
- The possibility of episodes of hemolysis.
- The presence of neurological symptoms.
- Prior therapy of anemia.
- Use of other medications and exposure to toxins.
- Dietary history.
- Family history.
- Social history
- Underlying disease.
- Effect of symptoms (Quality of Life)
History
 Poorly nourished patient on insufficient diets

 Jaundice : haemolytic anaemia, malaria
 Ingestion of certain drugs, chemicals exposure
 Preexisting of renal diseases
 Bleeding : gynaecologic, GI iron deficiency anaemia
 Ethnic, geographical consideration, genetic back
grounds
 Diet
 Infectious disease problems.
Diagnosis of Anemia
2. Clinical Presentation and Physical Examination
• General findings might include
– Skin pallor
– Hepato or splenomegaly
– Heart abnormalities
•Specific findings may help to establish the underlying
cause:
– In vitamin B12 deficiency there may be signs of
malnutrition and neurological changes
– In iron deficiency there may be severe pallor, a smooth
tongue, and esophageal webs
– In hemolytic anemias there may be jaundice due to the
increased levels of bilirubin from increased RBC
destruction
Physical examination
 Pallor, bruising , shock

 Organomegaly : spleen, liver, lymph nodes
 Jaundice
 Leg ulcer in HbS anaemia / thalassaemia
 Neurological abnormalities : vit B12 deficiency
 Koilonychia, angular cheilosis
Angular cheilosis Koilonychia
Leg ulcer (HbSS)

Diagnosis of Anemia
3. Laboratory Investigations
 Initial Tests :
- CBC (Hb, RBC indices, RDW, WBC, Platelets)
- Reticulocyte count
- Peripheral blood smear (PBS)
 Specific Tests :
- Iron Studies (s-ferretin, iron profile).
- Vitamin B12 and Folate levels.
- Hemoglobin electrophoresis.
- Work up for hemolysis.
- Renal Function Test.
- Liver Function Test.
- Endocrine Evaluation.
- Bone marrow examination.
HYPOCHROMIC, MICROCYTIC ANEMIAS
DIAGNOSIS OF HYPOCHROMIC MICROCYTIC
ANAEMIA
LABORATORY TEST INTERPRETATION
Peripheral Hypochromic & microcytic
smear anaemia
Iron Absent Increased

(Bone marrow)
Ringed sideroblasts
Haemoglobin Normal Abnormal Normal

electrophoresis
Iron Thalassaemia Sideroblastic

Diagnosis deficiency haemoglobino anaemia
anaemia -pathies
SI/TIBC, PERRITIN
NORMOCHROMIC, NORMOCYTIC ANEMIAS
MACROCYTIC ANEMIAS
DIAGNOSIS OF MACROCYTIC ANAEMIA
LABORATORY TEST INTERPRETATION
Peripheral smear Macrocytic anaemia
Bone marrow Megaloblastic No megaloblastic

examination changes changes
Reticulocyte Low High Low

count
Therapeutic Responds Responds to Probable Possible liver

response to vit B12 folic acid haemolytic disease
anaemia (evaluate liver
(continue function tests)
Diagnosis Vit B12 Folic acid workup)
deficiency deficiency
(determine if
dietary or
abnormal
absorption
Macrocytic Microcytic hypochromic
Normocytic normochromic
Hypersegmentation Macro ovalocyte with cabot
ring inclusion
MORPHOLOGICAL CLASSIFICATION OF ANEMIAS
Treatment of Anemia
 Specific treatment of underlying disorder caused anemia.
 Replacement of missing factors (iron, vitamin B12, folate, Epo)
 In many chronic anemias regular blood transfusions are needed

(thalassemia, myelodysplastic syndrome)
 Blood transfusion is usually needed in acute blood loss or if the

patient has severe symptoms or in heart failure
 Blood transfusion

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CLINICAL APPROACH TO ANEMIA

• Anaemia is thought to affect 1.62 billion people on a

• Anaemia affects both developing and developed

• Women (both pregnant and non-pregnant) and

 Increased RBC loss or destruction exceeds the maximal

Adapted from Ludwig H. Semin Oncol. 1998;25(suppl 7):2-6.

The signs and symptoms of anemia range from slight

Identification of the cause of anemia is important so

 Poorly nourished patient on insufficient diets

 Pallor, bruising , shock

Leg ulcer (HbSS)

Iron Absent Increased

Haemoglobin Normal Abnormal Normal

Iron Thalassaemia Sideroblastic

Peripheral smear Macrocytic anaemia

Bone marrow Megaloblastic No megaloblastic

Reticulocyte Low High Low

Therapeutic Responds Responds to Probable Possible liver

 Specific treatment of underlying disorder caused anemia.

 Replacement of missing factors (iron, vitamin B12, folate, Epo)

 In many chronic anemias regular blood transfusions are needed

 Blood transfusion is usually needed in acute blood loss or if the

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