CLINICAL APPROACH TO ANEMIA dr. T.

HARYANTO SURIJADI, SpPK

Anemia from the Greek (an-amia) meaning "without blood

Difinition

: Condition in which characterized Hb concentration decrease

below the normal value. Usually is followed by a :decrease in hematocrit value or erythrocyte count. Hb concentration depends on sex, age, altitude and method used for Hb determination.
CUT OFF POINT OF ANEMIA IN INDONESIA (Menkes 736 a/menkes 1989)

Pre school age School age Pregnant women : Adult woman Adult man

11 g/dL 12 g/dL 11 g/dL 12 g/dL 13 g/dL

Hemoglobin normally carries oxygen from the lungs to the tissues, anemia leads to hypoxia (lack of oxygen) in organs. Varying degrees of anemia can have a wide range of clinical consequences.

ETIOLOGI OF ANEMIA 1. BLOOD LOSS - ACUTELY ----- HEMORRHAGE

- CHRONICALLY ---- LOW-VOLUME LOSS

2.EXCESSIVE BLOOD CELL DESTRUCTION /HEMOLYSIS

a.Hereditary abnormalities : erythrocyte membrane, enzyme defect, hemoglobinopathy b.Aquired abnormalities : immuologic defect, obstetric infection, chemistry, physic, mechanic abnormality

3.DEFICIENT RED BLOOD CELL PRODUCTION (ineffective hematopoiesis).

a. Nutritrional anemia : protein, folic acid, Fe, vit B12 deff b. Bone marrow failure : aplastic anemia, anemia in malignancy

ANEMIA IS THE MOST COMMON DISORDER OF THE BLOOD.

DIAGNOSIS
LABORATORY EVALUATION :
Laboratory evaluation essential to definitive diagnosis and treatment Complete Blood Count : RBC number : Hb, Ht, RBC count, RBC indices : MCV , MCHC, MCH Platelet count WBC count , WBC diff Blood film morfology : cell size hemoglobinization, anisocytosis, poikilocytosis , polychromasia Reticulocyte count Marrow examination Marrow aspirate ( E/G RATIO, CELL MORF, IRON STAIN ) Marrow biopsy ( cellurality, morphology )

MCHC ( MEAN CORPUSCULAR HEMOGLOBIN CONCETRATION)

A MEASURE OF CONCENTRATION OF HEMOGLOBIN IN THE AVERAGE RED CELL. REPPORTED IN g/dL, N : 31 - 36 MCHC : Hemoblobin in g/ 100 mL X 100 Hematocrit , percent

MCH ( MEAN CORPUSCULAR HEMOGLOBIN )

A MEASURE OF HEMOGLOBIN CONTENT OF RED CORPSCLES . REPPORTED IN : pg (PICOGRAM) . N : 26 - 34
MCH : Hemoglobin in g/ 100 mL X 10 Red blood cell count , millions / uL

RETICULOCYTE COUNTS. * A reticulocyte count is a quantitative measure of the bone marrows production of new red blood cells. * The reticulocyte production index is a calculation of the ratio between the level of anemia and the extent to which the reticulocyte count has risen in response. (If the degree of anemia is significant, even a "normal" reticulocyte count actually may reflect an inadequate response). If an automated count is not available, a reticulocyte count can be done manually following special staining of the blood film.
Newly formed RBCs are usually slightly larger than older RBCs and show polychromasia. BONE MARROW EXAMINATION : TO KNOW ABOUT PRODUCTIVITY OF ERYTHROCYTE . TO KNOW CELLULARITY OF SOURCES.

RED BLOOD CELL SIZE MORPHOLOGICAL APPROACH ANEMIA IS CLASSIFIED BY THE SIZE OF RED BLOOD CELLS The size is reflected in the mean corpuscular volume(MCV). N : 80 100 fL MICROCYTIC If the cells are smaller than normal (under 80 fl),. NORMOCYTIC if they are normal size (80-100 fl). MACROCYTIC if they are larger than normal (over 100 fl). This scheme quickly exposes some of the most common causes of anemia; for example : microcytic anemia is often the result of iron deficiency. In clinical workup, the MCV will be one of the first pieces of information available.

MACROCYTIC ANEMIA
ETIOLOGI 1.Megaloblastic anemia, the most common cause of macrocytic anemia (due to a deficiency of either vitamin B12, folic acid (or both). Deficiency in folate and/or vitamin B12 (inadequate intake or insufficient absorption). Folate deficiency normally does not produce neurological symptoms, while B12 deficiency does. 2.Pernicious anemia is an autoimmune condition-- decrease intrinsic factor produced by the parietal cells of the stomach. Intrinsic factor is required to absorb vitamin B12 from food-- destruction of intrinsic factor --- poor absorption of vitamin B12. 3. Removal of the functional portion of the stomach--- during gastric bypass surgery, leading to reduced vit B12/folate absorption. 4. Hypothyroidism 5. Alcoholism , liver Disease coomonly causes a macrocytosis, although not specifically anemia. 6 Methotrexate, zidovudine, and other drugs that inhibit DNA replication.

Macrocytic anemia divided to 1.megaloblastic anemia 2.non-megaloblastic macrocytic anemia". The cause of megaloblastic anemia primarily a failure of DNA synthesis with preserved RNA synthesis, which result in restricted cell division of the progenitor cells. The megaloblastic anemias often present with neutrophil hypersegmentation (6-10 lobes). The non-megaloblastic macrocytic anemias have different etiologies (i.e. there is unimpaired DNA globin synthesis,) which occur, for example in alcoholism. Non-specific symptoms of anemia Specific features of vitamin B12 deficiency : 1.peripheral neuropathy and subacute combined degeneration of the cord with resulting balance difficulties from posterior column spinal cord pathology. 2.smooth, red tongue and glossitis.

To Raise Vitamin Or Iron Levels Vitamin.

Common vitamin supplements are vitamin B12 and folic acid/folate.

Iron.
Sources of iron to make hemoglobin 1.iron supplement 2. meat red meat, such as beef or liveras well as chicken, pork, fish, and shellfish. 3.Nonmeat foods sources of iron include: Spinach and other dark green leafy vegetables Peanuts, peanut butter, and almonds , Eggs ,Peas; lentils; and white, red, and baked beans . Vitamin C is sometimes given to help the body absorb iron.

The End