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Haematology- Investigation of Anaemia

Haematology- Investigation of Anaemia. By Nikki Barnett. A few pointers. WHO Anaemia <13 for males <12 for females Key indices- MCV Time course of anaemia

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Haematology- Investigation of Anaemia

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  1. Haematology- Investigation of Anaemia By Nikki Barnett

  2. A few pointers... • WHO • Anaemia • <13 for males • <12 for females • Key indices- • MCV • Time course of anaemia • The WCC, white cell differential and platelet count are significant if abnormal- increase the probability of an underlying bone marrow problem • Early forms of any anaemia may start out as normocytic

  3. Question 1 • A 74 year old woman comes to see you because she feels tired all the time. She has a haemoglobin level of 8 g/l. Her serum ferritin is 5 µg/l. What is the most likely diagnosis? • a. Iron deficiency • b. Anaemia of chronic disease • c. Vitamin B12 deficiency • d. Folate deficiency

  4. Koilonychia – spoon shaped nails

  5. Iron deficiency • In the elderly- IDA is due to GI blood loss until proved otherwise. In premenopausal women it is menorrhagia. • Upper and lower GI Inx should be considered in all PM women and all men where ID confirmed, unless there is an overt non GI blood loss. • All pts should be screened for coeliac disease. • British Soc. Of Gastro Guideline 2005 • Urgent referral – IDA at any age with Hb < 11 (m) <10 (f) • NICE 2005 • In 10-40% of patients the source of blood loss is never found.

  6. Causes of Iron deficiency • blood loss: • Gastrointestinal – ulcers , polyps, angiodysplasia, malignancy • Uterine e.g. menorrhagia • Urinary tract • increased demands: • pregnancy • prematurity • growth • others: • Malabsorption e.g. gastrectomy, coeliac disease • dietary iron deficiency

  7. Investigation of Iron deficiency • Ferritin – • low level is diagnostic • Is an acute phase protein – raised in infection, inflammation, malignancy • Fasting serum iron & transferrin (aka TIBC) • If ferritin not diagnostic • Upper and lower GI investigations • Coeliac screen

  8. Treatment of Iron deficiency • Iron supplements • Common ferrous sulphate 200mg TDS • SE- indigestion, constipation, diarrhoea and black stools • Minimised by starting OD and building up • Syntron- (liquid option) • IV for the minority - • cont for 3m after normalisation of Hb • Hb to raise by 1- 1.5 g/L per month

  9. Question 2 • A 27 year old male is a new patient at your surgery- he has just come from the middle east- his FBC shows the following: • Hb 12 • MCV 72 • You get his old records and note that he had a similar FBC 3 years ago. • What is the likely diagnosis? • A- Iron deficiency • B- Anaemia of chronic disease • C Thalassemia trait • D Sickle Cell

  10. Thalassaemia • Often lifelong low or v low MCV and MCH with a normal/near normal Hb • Disproportionate microcytosis • Sickle cell – often moderate anaemia

  11. Question 3 • A 79 year old man presents with tiredness. His haemoglobin is 8 g/l and his MCV is 110 fl. He has a poor diet and eats some meat but few vegetables. Which one of the following conditions should you suspect most strongly? • a. Iron deficiency • b. Anaemia of chronic disease • c. Vitamin B12 deficiency • d. Folate deficiency • e. Myelodysplastic syndrome

  12. Folate Deficiency • The body stores little folic acid - only enough for 6m. • Folic acid predominantly in green vegetables. • ~ 25% of elderly pts with folate def. have a normocytic anaemia. • Red cell folate is more reliable than serum folate • (measure of folate over last 3 months) • Vit B12 required for folate metabolism • If both low- tx vit b12 first • ? Subacute combined degeneration of the cord • Treatment is with 5mg folic acid for at least 4m.

  13. Vit B 12 deficiency • Lower level not well defined. • Eg if lower limit 180, levels down to 160 – doubtful clinical significance unless macrocytosis or peripheral neuropathy • Lower levels should be tx • Tx – hydroxycobalamin 1mg x3/wk for 2/52 then 3m. • If symptomatic prior to 3m – reasonable to give sooner • No need to recheck vit b12

  14. Question 4 • A 70 year old woman presents with tiredness. Blood tests reveal a macrocytic anaemia and very low vitamin B12 levels. Which one of the following is the most likely cause? • b. Transcobalamin II deficiency • c. Fish tapeworm infestation • d. Pernicious anaemia • e. Previous gastrectomy

  15. Pernicious Anaemia • W:M 3:2 • Usually > 60yrs • autoimmune disease of the stomach and gastric parietal cells. • Intrinsic Factor deficiency- leads to malabsorption of Vit B12 (in term ileum) • Other causes of Vit B12 – • Previous gastrectomy • Crohn’s • rarely the result of a poor diet, except in people who are strict vegans. • What’s the relevance of the cat?

  16. Macrocytosis Investigations • Vit B12/ folate • TFT • LFT • Gamma GT • reticulocytes • Blood film Causes • Vit B12/ folate • Hypothyroidism • Excess alcohol • reticulocytosis • liver disease • myeloproliferative disease • myelodysplastic disease • Drugs- eg azothioprine, methotrexate

  17. Haemolytic Anaemia • ↑bili and reticulocytosis - ? Haemolytic anaemia • ‘any cause of shortened red cell lifespan due to red cell breakdown • Commonest = HS and AIHA • HS – should have folate supplements • At risk of aplastic crisis – due to Parvovirus B19 • Refer any new onset jaundice and anaemia to haematology. Urgent if Hb < 10

  18. Question 5 • A 78 year old male • Hb 12.8 • MCV 107 • WCC and platelet normal • Other tests NAD • What would you do? • A Refer urgently • B Refer routine • C Repeat tests • D Nothing

  19. Mylodysplasia • ? Macrocytic or neutropenia or thrombocytopenia or a combination • Look for a progressive change months/years • Incidence raises with age • 1/3000 per year over 70 • Mild macrocytosis or anaemia – monitor • Neutropenia or pancytopenia – refer

  20. Normocytic Anaemia ? CXR- malignancy and other pulmonary lesions ? USS- splenomegaly, renal lesions, liver abnormalities, unsuspected malignancy and mets.

  21. Clinical assessment of pt Other comorbidities Consider time and course GI Investigations Menorrhagia ? Coeliac disease Microcytic anaemia Gradual fall in Hb & MCV Iron deficiency Lifelong norm/borderline Hb Low / v low MCV Thalassemia trait Normocytic anaemia Tests: Haematinics, ESR, Reticulocytes PSA Serum Electrophoresis Chest xray Chronic Anaemia of chronic disease Renal impairment Malignancy Myeloma Sudden Acute blood loss Macrocytic anaemia Tests: Haematinics, ESR, Reticulocytes PSA Serum Electrophoresis Chest xray B12/folate Haemolytic anaemia Myelodysplasia (may also have neutro-/thrombopenia Macrocytic w/o anaemia Ask about alcohol Drugs. Bld tests. B12/folate, reticulocytes, LFTs GGT

  22. More Confused?- InnovAit – March 2009- ‘Investigation of Anaemia’GP notebookBMJ learning- anaemia of the elderlyAny Questions?

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