Abnormal FBC Results Guidance

This guidance has been developed from published guidance, in

collaboration with local Haematologists and Gastroenterology, in
response to frequently asked questions on interpreting FBCs.

This guidance is to assist GPs in decision making and is not intended to

replace clinical judgment.

You may also want to seek further specific guidance using the ‘Advice
and Guidance’ service.

Abnormal FBC in Adults

Haemoglobin White Cell Count Platelets

Anaemia Neutrophils

Polycythaemia Lymphocytes

Eosinophils

Monocytes

NB – Abnormalities affecting more than one cell type are more likely to be due to bone marrow causes rather than reactive .
Always consider earlier referral when the patient is unwell.

Pathway created by Sarah Morgan & Alex Warner

and approved by Camden PEC March 2013
Produced in collaboration with local Haematologists and Gastroenterology
Updated by Craig Seymour June 2015
Contact for this pathway: sarah.morgan1@nhs.net
Review due June 2018
V1.16 for new GP website Feb 2016
 NB Mixed deficiency
Anaemia Monitor FBC for
Look at the whole picture Hb <130 g/L men evidence of
<115 g/L non-pregnant women progression over time

MCV
Low (<76) Normal ( 76-96 ) High (>96)
Check Ferritin + Consider Hb electrophoresis Anaemia of Chronic Disease? Review history:
(NB can be raised in (if no previous) Mixed Haematinic Deficiency? Duration, Symptoms, Bleeding,
inflammation/infection) Recent blood loss? Diet, Medication, Alcohol,
Family Hx, Recent transfusion?

< 15 > 15
Low Normal / Raised Check ESR,
LFT (+ GGT),B12, Folate, TFT, Renal

Iron NB Ferritin Anaemia of Beta Thal trait Blood Film, Reticulocyte Count
Deficiency acute phase Chronic ( HbA2)
Anaemia reactant Disease? Myeloma screen
Chk serum Alpha Thal trait if suspicion of malignancy
(difficult to diagnose Spherocytes
iron/TIBC (+Serum & Urine electrophoresis, on blood film (?Haemolysis)
as no specific test) Immunoglobulins, Bone profile)
Upper GI symptoms Coeliac DAT test
Serology (tTG) tTG +ve Counselling /
+ Reticulocyte count
Info leaflets Associated FBC abnormalities
or Normal Retic:
Abnormal cell shapes on blood film (men 28-105, women 25-92)
Refer / discuss with
Unexplained Heavy menstrual
bleeding pathway haematology as Persistent Unexplained Anaemia,
Hb < 110 Men DAT +ve/
clinically appropriate raised MCV (>100) or B12 deficiency
Hb <100 Raised Retic
Non-menstruating Dietary history
Women
Urine dip ?blood Anaemia of Chronic Disease Refer to haematologist
Urgent referral
Consider stool Refer gastroenterology Chronic Inflammation
(2wk) for upper &
parasitology (eg. TB,SLE, RA, Malignancy)
lower GI endoscopy Urgently refer
Endocrine
(eg. Hypothyroidism, Addisons, to haematology:
Family history Oral iron replacement Not iron replete Hypopituitarism)
Ferrous Fumarate (& not due to menstrual loss) Other Leucoerythroblastic
colorectal cancer
Start OD and increase as (eg. CKD, Liver disease, Malnutrition) anaemia on blood film
(2x1st deg relatives
tolerated to BD
or 1x1st deg age <50)
+ Consider Laxative Myelodysplastic syndromes (lone Unexplained progressive
NB Iron Absorption better Recheck symptomatic anaemia
Urgent referral unexplained persistent anaemia)
with food, orange juice/Vit C
(2wk) for lower GI Hb / Ferritin
Reduced by tea/coffee
at 3 months Consider haemochromatosis where Associated splenomegaly,
endoscopy Dietary advice
Consider alternative oral Ferritin raised lymphadenopathy or other
preparation if not tolerated cytopenias

Consider referral for Refer to appropriate

parenteral iron if oral specialty as necessary
iron not tolerated
 Polycythaemia Eosinophilia
Men: Hb > 185 Hct > 0.52 > 0.44 x109/L
Women: Hb > 160 Hct > 0.48

Check history:
Drugs, Travel, Atopy
May be associated Causes of Polycythaemia
with increased WCC & Platelets normal Repeat FBC + Blood Film
WCC & Platelets Apparent within 1-2wks
+ Basophils
Reduced plasma volume Consider:
Common in obese men, associated Probable secondary ESR,CRP, IgE, ANA,
Probable primary with smoking, diuretics, alcohol, polycythaemia Chest X-Ray
polycythaemia hypertension, stress, dehydration (Ferritin usually normal)
(Ferritin usually low) At risk of occlusive vascular episodes Stool for OCP
Modify known
Absolute associated lifestyle Serology for Discussion with
factors Strongyloides + relevant
+ Monitor FBC microbiology / ID
1° Polycythaemia (Rubra Vera) to travel history as appropriate
(92% are JAK2 +ve) (eg Schistosomiasis)

2° Polycythaemia Eosinophils >1.5

Hypoxia persisting >3mths
(COPD,Heart disease, smoking) Refer to
or rising without haematologist
Abnormal EPO production obvious cause
(Renal & liver tumours, fibroids)

Eosinophilia causes to consider:

Refer if:
Asthma / allergic disorders
Raised Hct >0.52 males + Past history of arterial or venous thrombosis
>0.48 females Splenomegaly, Pruritus, Elevated WCC or Platelets
Infections
(uncuffed blood samples)
(esp. Parasitic eg. Schisto, also malaria, TB, fungal,
recovery from any infection)
Or if persistent, unexplained raised Hct above these levels on at least 2
occasions over 4 weeks apart.
Drugs (eg. Penicillin, Allopurinol, Amitriptylline, Carbamazepine)
Smoking
Urgently Refer: (2wks) Connective tissue disorders (eg. RA, PAN, Churg-Strauss)
Hb >200 g/l / Hct > 0.60 (in absence of chronic hypoxia)
Endocrine (eg. Addison’s)
Raised Hb in association with: Recent arterial or venous thrombosis
Neurological Symptoms Skin disease (Eczema, psoriasis, dermatitis herpetiformis,
Visual Loss erythema multiforme)
Abnormal bleeding
Malignancy (eg. Lymphoma, Leukaemia, CA lung/stomach)

Löffler’s syndrome, Endocarditis, Post-splenectomy, Irradiation

 Lymphocytes Neutrophils
If features of viral
Normal 1.3 – 3.5 x109/L illness & Normal 2.0 – 7.5 x109/L
20-45% otherwise well, 40 - 75 %
Repeat once
Low Raised resolved 4-6wks Low Raised

Lymphopenia Lymphocytosis Neutropenia Neutrophilia

(Isolated neutropenia is v.common)

Causes of Lymphopenia If > 20 x 109/L <1.0 x 109/L 1–1.5 x 109/L >7.5 x 109/L
Drugs or
(eg. Steroids) Lymphadenopathy
Infection – postviral common Splenomegaly
(exclude HIV, Legionella) Anaemia
Malignancy Other cytopenia Well and afebrile. Infection most
(Marrow infiltration, post Unwell, Febrile or on Do blood film. Check blood Refer if
Weight loss, night common cause
chemo/radiotherapy, ChemoRx If normal: film > 15 x 109/L
sweats, PUO
myeloma – consider v urgent Lymphadenopathy, +/- Or associated
Repeat FBC
protein electrophoresis and splenomegaly, other Repeat FBC & B12,Folate, splenomegaly
Refer urgently 4-6wks with
BJP if suggestive sx) cytopenia blood film in 1 Ferritin, ANA Or other FBC
inflammatory
Renal or hepatic impairment week abnormalities
markers
Connective tissue
(eg. RA, SLE, Sarcoid) Otherwise
Anorexia Nervosa check IM
screen and Emergency Refer urgently if Repeat FBC
Primary immune deficiency Referral persists 4 – 6 wks Refer if
repeat 4 – 6
weeks Cause unclear
Unable to manage in
Causes of Neutropenia primary care
Refer if persists and Neutrophilia persists
Refer to haematologist Infection (EBV, Hep B,C, HIV)
Refer for treatment of unexplained
underlying cause If persisting Or if other fbc
Ethnic variation common
Or if remains low on repeat abnormalities
Afro-Caribbean, SE Asian
testing Or if history of
Causes of Lymphocytosis recurrent infections/ Causes of Neutrophilia
Drugs (eg. Phenytoin, Carbimazole, Infection
Infection eg EBV, CMV, ulcers
Antipsychotics, Clotrimoxazole) (Bacterial, some viral eg
Pertussis, Mumps, Rubella
Stress VZV,HSV, some fungal &
Monocytosis Endocrine (eg. thyroid) parasitic)
Vigorous exercise
Monocyte count Post splenectomy Drugs (eg. Steroids)
> 0.8 x 109/L Malignancy Malignancy
Haem Malignancies
(marrow infiltration, chemo/radiotherapy, (eg.Carcinoma,Lymphoma
eg ALL, CLL, NHL
Raised in malaria, myeloma – consider v urgent serum Leukaemia)
typhoid, TB, MDS, electro and urine BJP if suggestive sx) Connective tissue
CMML(persistently >1.5) (eg. RA, Gout)
Connective tissue (eg. RA, Gout) Haemorrhage, Haemolyis,
Repeat and Refer if Autoimmune Hypoxia, tissue damage,
persists B12, Folate, Iron deficiency infarction
Excess alcohol
Liver disease (Cirrhosis)
 Check history: travel, drugs, alcohol

Ask about bleeding history:

Spontaneous skin/mucosal bleeding,
bruising, GI bleeding, epistaxis, gums,
menorrhagia. Platelets
Post dental / surgical haemorrhage
Haemarthoses / muscle haematomas Normal 150 - 400 x109/L

Thrombocytopenia Urgently Refer:

< 150 > 400 Thrombocytosis Abnormal Bleeding
Often artefact Neurological symptoms
Repeat with blood Plt > 1000 x109/L
film Check for
hepato/splenomegaly or Or > 600 x109/L
neuro symptoms with recent thrombosis or at
high risk thromboembolism or
Check CRP, Blood film, CVD
Ferritin
< 50 x109/L 50-100 x109/L 100-150 x109/L Or Splenomegaly
If asymptomatic Other symptoms suggestive
repeat after 4-6 wks malignancy
Repeat monthly Other significantly abnormal
Urgent Outpatient If other cytopenia, FBC indices
splenomegaly, & Refer if
Referral
lymphadenopathy, progressive
pregnancy, decrease, other
If < 20 x109/L or any
Otherwise Refer upcoming surgery FBC abnormalities < 450 x109/L >450 x109/L
bleeding
If persists > 4-6 Urgent Outpatient or if unwell
Refer for same day
assessment weeks and Referral
unexplained Thrombocytosis

No further 1° - Myeloproliferative Treat 2° causes

Thrombocytopenia action required (likely if splenomegaly and
plt >1000) Check Hb/Ferritin
(Polycythaemia?)
Viral infection including EBV
(usually resolves within few weeks) 2° - More common
Also HIV, Malaria, TB Reactive
(Infection, inflammation
Drugs haemorrhage, exercise, Refer haematology if
(NSAIDs, Heparin, Digoxin, Quinine, tissue damage, post- persistent unexplained
anti-epileptics, antipsychotics, PPIs) surgery, haemolysis) > 600 x109/L
Alcohol Malignancy on at least 2 occasions
Hyposplenism/Splenectomy 4-6 weeks apart
Malignancy Iron deficiency
Liver & Renal disease Or 450-600 x109/L
in association with other
Aplastic anaemias, FBC abnormalities
B12/Folate deficiency
Autoimmune / ITP / SLE