Approach to

Patients with

Anemia
Prof. Dr / Nabil Lymon
Blood Cells
and
Hemoglobin
structure
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 :Definitions
: Anemia -
is defined as the lowering of hemoglobin
concentration below the established normal
:levels
.In male < 13.5 gm/dl & In female < 11.5 gm / dl
Anemia is a clinical sign not a diagnostic -
.entity

:)Hematocrit )Hct -
is the proportion, by volume, of the blood
occupied by red blood cells. The hematocrit
(Hct) is expressed as a percentage, normal
: levels are
in Adult male & 0.37 - 0.47 in Adult 0.54 - 0.4
 :Definitions
Red Cell Indices
Are measurements that indicate the size
:and hemoglobin content of red cells
)M.C.V )Mean Corpuscular Volume

M.C.H )Mean Corpuscular

)Hemoglobin

M.C.H.C)Mean Corpuscular Hemoglobin

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)Concentration
 M.C.V:))Mean Corpuscular Volume
Referred to the average volume of red cells , normally = 76 -
96 fl
It can be calculated from an independently-measured red
:blood cell count and hematocrit

MCV  )femtoliters) = 10 x HCT)percent) ÷ RBC

))millions/µL

 : MICROCYTOSIS & MACROCYTOSIS

By definition, microcytosis is taken to mean the presence of
RBCs with a MCV less than normal, while macrocytosis
means the presence of RBCs with an MCV greater than
.normal
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 M.C.H)Mean Corpuscular
:)Hemoglobin

or "mean cell hemoglobin" (MCH), is a measure of the

mass of hemoglobin contained by a red blood cell.
It is diminished in microcytic anemias, and
increased in macrocytic anemias. It is calculated
by dividing the total mass of hemoglobin by the
-: RBC count
MCH=Hb/RBC
A normal value in humans is 27 to 32 picograms/cell

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 M.C.H.C
Mean Corpuscular Hemoglobin)
:)Concentration

is a measure of the concentration of hemoglobin in a

.given volume of packed red blood cell
It is diminished)"hypochromic") in microcytic
anemias, and normal)"normochromic") in
macrocytic anemias (due to larger cell size, though
the hemoglobin amount or MCH is high, the
.(concentration remains normal
It is calculated by dividing the hemoglobin by the
:hematocrit
 Signs &Symptoms of
Anemia
: Cardiovascular -
E xertional DyspneaP alpitations
Orthopnea
T achycardiaA ngina
Claudications
C ardiomegallyBounding
peripheral Pulses
M urmursV ascular bruits
Pedal edema

: Neurological -
H eadacheT innitus
Dizziness
 Signs &Symptoms of
Anemia
: Skin -
P.allor of skin , mucous membranes, nail beds and palms
: Gastrointestinal -
A norexiaN ausea
Constipation
Diarrhea
: Respiratory -
Increased Respiratory Rates
: Genitourinary -
M enstrual irregularityA menorrhea
Menorrhagia
Loss of libido or potency
: Fundus Examination -
Is the patient Anemic or
not ?
Anemic means single or
total decrease in :
- Hb
- Hct
- RBCscount
in?…But
millions

?..What Type of Anemia

This depends on the RBCs
indices
 Red Cell Indices
According to MCV & MCH
Normal Decreased

Normocytic Microcytic
Normochro
mic Anemia Increased Hypochromi
c Anemia
Macrocytic

Anemia
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 Anemia
It may be due to :
- Acute Blood Loss

- Aplastic Anemia
- Hemolytic Anemia ( Except
Thalasemia)
- A.O.C.D (Anemia Of Chronic
Which of
(Diseases
Which ….?
Do Reticulocytic Count
Normal Low or High
A.O.C.D Absent Acute Blood -
:.e.g B.M.F Loss
TB, SLE, Aplastic“ search for )
Malignancy, Rh. evidence of
Arthritis ”Anemia
(the cause

:Note BM biopsy or BM
Evidence of the - aspiration Hemolytic -
cause : show
 - low Hb &/or Hct & /or RBCs count
- Normal RBCs indices
- Reticulocytosis

Do Indirect Serum Billirubin

Unconjugated Hyper-
billirubinemia
“
jaundice”

Other Evidences of Hemolysis e.g.:-

- Hemoglobinuria - Hemoglobinemia
(increased free Hb)
- Decreased Haptoglobin.

What is the Further

?..………Step Coombs Test
 Coombs Test
Positive Negative
Immune Non-immune
Hemolytic Hemolytic
:Anemia :Anemia
: May be due to
e.g.Membrane Defect -
Spherocytosis (lab
Iso immune - show increased O.F.) &
P.N.H
Auto immune - Enzyme Defect -
(e.g. G6PD (lab : Enz. assay
Hb Defect -
((Hemoglobinopathy
 Red Cell Indices
According to MCV & MCH
Decreased

Microcytic

Increased Hypochromi
c Anemia
Macrocytic

Anemia
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Microcytic Hypochromic
Anemia
- The Commonest Cause is:
Iron Deficiency Anemia
-Other Causes: - Thalasemias
- Sedroplastic Anemia
- Lead Poisoning
- A.O.C.D
Which of Which ….?
:Do Iron Studies
Serum Iron -
Serum Ferritin -
(Total Iron Binding T.I.B.C -
(Capacity
Transferrin Saturation -
 According to Iron Studies
Iron Thalasse Sideropla A.C.O.D
Deficienc mia stic
y Anemia Anemia
Serum
Fe
Serum Normal N or
Ferritin
T.I.B.C Normal

Transferr
in
Saturatio
Iron Deficiency Anemia
Iron Deficiency Anemia
Iron :Notes
Studies Search For The -
Serum Fe :Cause
:.e.g
Serum Chronic Blood Loss
Ferritin
Ankylostoma
T.I.B.C
Cancer Colon
Nutritional causes
Transferri
n Severe Aniso-cytosis -
Saturatio :and Poikilo-cytosis
n Increased R.D.W(N ≤
(13%
 Anisocytosis with
hypochromia and
microcytes((IDA

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Spoon Nails:
If nails look scooped out, like a
spoon, it could be a sign of iron-
.deficiency anemia
Plummer Vinson Syndrome
Left : Spoon shaped finger nails
Right :Showing angular cheilitis, and
dry skin
Plummer Vinson
Syndrome
Iron Deficiency Anemia
 Thalassemia
Iron :Notes
Studies Hb Electrophoresis -
Serum Fe :will show
Persistence of
Serum ]Hb]f
Ferritin
Specific Clinical -
T.I.B.C Features of
:Thalasemia
Transferri
Huge Spleen
n
Saturatio Mongoloid Faces
n Hemosedrosis
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Thalassemia minor
is an inherited form of hemolytic anemia that
is less severe than thalassemia major .This
blood smear from an individual with
thalassemia shows small(microcytic), pale
(hypochromic), variously-shaped
(poikilocytosis )red blood cells .These small
red blood cells(RBCs )are able to carry less
oxygen than normal RBCs
Thalassemia, being a genetic disease, runs in
a family .Most are silent carriers or suffer
mild anemia .Severe cases such as the
Hemoglobin H disease with enlarged spleen,
small body and malnourished look shows
more prominent symptoms .[Pic below:
[Enlargement of spleen, small body
 Sideroplastic Anemia
Iron :Notes
Studies Sedroplastic Anemia
Serum Fe :is due to
B6 Deficiency -
Serum Norma Drugs e.g.: INH -
Ferritin l Inherited -
T.I.B.C Norma
:Blood film show
l
Transferri RBCs contain Iron
n Granules
Saturatio :Treated by
n B6 supply
Many rounded sideroblasts are present
in this field .This is the hallmark
feature ofsideroblastic anemia

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 Lead Poisoning
:Notes
.History is Suggestive -
.Elevated Serum Lead level -
Purely Motor Neuropathy (foot and -
(wrist drop
:Blood Film show -
Basophilic Stippling of RBCs
Basophilic Stippling of
RBCs
Basophilic stippling appears as round, dark-
blue granules in red blood cells on smears
stained with supra vital stains such as
brilliant cresyl blue.
They may be observed inlead poisoning,
exposure to some drugs, severe burns,
anemia, or septicemia. The granules are
precipitated ribosomes and mitochondria
 Red Cell Indices
According to MCV & MCH

Increased

Macrocytic

Anemia
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Macrocytic
Anemia
- In Which :
- low Hb &/or Hct & /or RBCs count
- Increased RBCs indices
- Causes :
# Folic Acid Deficiency # B12 Deficiency

- Search For The Cause:

# Pregnancy # Mal-absorption
Syndrome
# Chronic Gastritis # Atrophic Gastritis
# Cancer Stomach # Iliac Resection
# Drugs: Methotrexate / Metformin / Epanutin

- To be sure do the following tests:

Serum Folic Acid / Serum B12 /
Schilling test / FIGLU test
Schilling
Test
The Schilling test is
performed to evaluate
vitamin B12 absorption.
B12 helps in the
formation of red blood
cells, the maintenance of
the central nervous
system, and is important
for metabolism.
Normally, ingested
vitamin B12 combines
with intrinsic factor,
which is produced by
cells in the stomach.
Intrinsic factor is
necessary for vitamin
B12 to be absorbed in
the small intestine.
Certain diseases, such as
pernicious anemia, can
result when absorption
of vitamin B12 is
FIGLU test
a test of vitamin b12 deficiency,
folic acid deficiency, liver disease,
or genetic deficiency of glutamate
formimino-transferase, based on
urinary excretion offormimino-
glutamic acid (figlu), an
intermediate metabolite in
histidine catabolism in the
conversion of histidine to glutamic
acid, with the formimino group
being transferred to
.tetrahydrofolic acid
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