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Sites of
absorption
of iron and
vitamin B12
Definitions
Anemia-values of hemoglobin,
hematocrit or RBC counts which are
more than 2 standard deviations
below the mean
HGB<13.5 g/dL (men) <12 (women)
HCT<41% (men) <36 (women)
Anemia is a laboratory diagnosis
Men Women
Hemoglobin (g/dL) 14-17.4 12.3-15.3
Hematocrit (%) 42-50% 36-44%
RBC Count (106/mm3) 4.5-5.9 4.1-5.1
Reticulocytes 1.6 0.5% 1.4 0.5%
WBC (cells/mm3) ~4,000-11,000
MCV (fL) 80-96
MCH (pg/RBC) 30.4 2.8
MCHC (g/dL of RBC) 34.4 1.1
RDW (%) 11.7-14.5%
Erythrocytes - less informative index
of anemia than the level of
hemoglobin therefore, in the
general practice the basic criterion
of severity is precisely Hb:
Light degree of anemia - Hb 11-9
g/dl,
The average degree of severity - Hb
9-7 g/dl,
Severe anemia - Hb below 7 g/dl
Anemia adalah suatu keadaan dimana
kadar hemoglobin lebih rendah dari
kadar hemoglobin terendah pada umur
dan jenis kelaminnya.
Pada wanita hamil nilainya lebih rendah
dari wanita tidak hamil.
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Hemoglobin normal:
WHO Group of Experts on Nutritional Anaemias, menentukan Hb
normal berdasarkan umur dan jenis kelamin:
Kelompok Kadar Hb
10
Tanda-tanda anemia:
A. Tanda-tanda umum :
Pucat.
Takikardia.
Tekanan nadi yang lebar.
Tanda hiperdinamik di precordial.
Desah sistolik didaerah pulmoner.
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Gejala anemia:
A. Anemia akut:
1. Serebral: oyong kalau berdiri, vertigo, tinnitus,
sinkope, bintik didepan mata.
2. Sirkulasi: palpitasi, sesak nafas kalau bekerja,
lelah, angina, klaudikasio.
3. Demam : tanda infeksi, bisa juga ok proses
penyakit darah.
4. Lain-lain : hipersensitif thd dingin, anorexia,
gangguan pencernaan, haid tidak teratur,
impotensi, libido hilang.
B. Anemia kronik:
Tubuh dapat menyesuaikan dengan anemia yang
terjadi lambat
Gejalanya ringan, kadang-kadang hanya rasa lelah.
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Presentation/history
Mild anemia:
few or no symptoms; may be discovered
accidentally on lab test
May complain of:
Fatigue, decr. exercise tolerance, SOB,
palpitations, CP, lightheadedness on arising
Sore tongue (glossitis), cracking mouth
corners (angular cheilitis), peripheral
paresthesias (numb toes, etc.)
Hx:
EtOH use, FH anemia, pica, vegetarian diet,
melena/hematochezia, malabsorption
syndromes, Crohns disease
Evaluation of the Patient
HISTORY
Is the patient bleeding?
Actively? In past?
Is there evidence for increased RBC
destruction?
Is the bone marrow suppressed?
Is the patient nutritionally deficient?
Pica?
PMH including medication review, toxin
exposure
Evaluation of the Patient (2)
REVIW OF SYMPTOMS
Decreased oxygen delivery to tissues
Exertional dyspnea
Dyspnea at rest
Fatigue
Signs and symptoms of hyperdynamic state
Bounding pulses
Palpitations
Life threatening: heart failure, angina,
myocardial infarction
Hypovolemia
Fatiguablitiy, postural dizziness, lethargy,
hypotension, shock and death
Evaluation of the Patient (3)
PHYSICAL EXAM
Stable or Unstable?
-ABCs
-Vitals
Pallor
Jaundice
-hemolysis
Lymphadenopathy
Hepatosplenomegally
Bony Pain
Petechiae
Rectal-? Occult blood
Anemia: Special Populations
Higher Hb/HCT:
Patients living at high altitudes
Smokers and patients living in air pollution
areas
Endurance athletes have increased HCT
Lower Hb/HCT:
African-Americans have 0.5 to 1 g/dl lower Hb
than do Caucasians
Elderly (slowed erythropoiesis)
Pregnant women (hemodilution)
Differential diagnosis
Consider:
Anemia
Hypothyroidism
Depression
Cardiac (congestive heart failure, aortic
stenosis)
Pulmonary causes of SOB/DOE
Chronic fatigue syndrome, others
Physical examination
Pallor (may be jaundiced think
hemolytic)
Tachycardia, bounding pulses
Systolic flow murmur
Glossitis
Angular cheilosis
Decreased vibratory sense/ joint position
sense (B12 deficiency, w/ or w/o
hematologic changes)
Ataxia, positive Romberg sign (severe
B12/folate deficiency)
Pemeriksaan awal anemia:
A. Kuantitatif:
Hb
Ht
Hitung eritrosit
MCH
MCV
MCHC
Hitung retikulosit
Hitung lekosit
Hitung trombosit
LED.
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Pemeriksaan awal anemia:
Kualitatif:
Gambaran morfologi darah tepi dg pengecatan
Wright: hipokromik, polikromasia, normokromik.
Besar sel : mikrositer, makrositer, anisositosis.
Bentuk sel : poikilositosis, sferositosis, sel oval dan
tear drops, fragmented cells, ghost cells, dll.
Badan-badan intraseluler: eritrosit berinti, badan
Howell-Jolly, siderosit, badan Papenheimer, badan
Heinz dan malaria.
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Pemeriksaan lanjutan:
Bilirubin
Besi serum (SI)
TIBC
Transferrin
BMP
Hemoglobin elektroforesis
Coombs test
G6PD
Vit B12
Asam folat
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Anemia AETIOLOGICAL CLASSIFICATION
I- Decrease red cell production.
A. Microcytic-hypochromic anaemias:
Thalassaemia.
Iron deficiency anaemia.
B-Normocytic-normochromic anaemias:
Acute post haemorrhagic anaemia.
Hemolytic anaemia.
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Decreased Production
NUTRITIONAL DEFICIENCY
Iron
B12
Folate
Anemia defisiensi
besi
40
Anemia defisiensi besi.
Tingkatannya:
1.deplesi besi: cadangan besi berkurang atau
tidak ada sama sekali, belum anemia.
2.defisiensi besi: cadangan besi berkurang
atau tidak ada + rendahnya besi serum dan
jenuh transferin, belum anemia.
3.anemia defisiensi besi: cadangan besi
berkurang atau tidak ada + rendahnya besi
serum dan jenuh transferin + Hb rendah dan
Ht rendah. Sudah anemia.
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Penyebab anemia defisiensi besi.
Perdarahan:
sal.urogenital,
sal.pencernaan,
sal.pernafasan.
Kebutuhan meningkat:
prematur,
hamil,
haid,
masa pertumbuhan.
Malabsorpsi.
Makanan kurang bergizi.
42
Fe++ deficiency anemia
Most commonly due to chronic
bleeding and erythropoiesis limited
by iron stores that have been
depleted
May be dietary (pica, lack of meat/
vegetables, other)
Iron balance is very close in
menstruating women, so Fe++
deficiency is not uncommon with no
other source of bleeding
Gambaran klinis:
Keluhan:
pucat,
lemah,
nyeri menelan,
pika,
nyeri epigastrik.
Tanda-tanda:
anemia,
glositis,
atrofi papil lidah,
koilonikia,
keluhan penyakit dasarnya.
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Physical Manifestation : Spoon
Nails in Iron Deficiency
Pemeriksaan
46
Labs
Iron and ferritin will be low
TIBC (total iron binding capacity) will be
high, since iron stores are not saturating
their binding sites on transferrin
Reduced RBC counts (definition of anemia)
Microcytosis & hypochromia are hallmarks,
but early Fe++ may be normocytic (
hypochromic)
Usually, MCH and MCHC will both be low
(whereas in macrocytic anemia, the MCH
may be normal while the MCHC is low,
because of the larger cell size)
Labs
Most practitioners would agree that if
a patient has microcytic hypochromic
anemia with a low reticulocyte count,
it would be reasonable to use a trial
of FeSO4 to diagnose
5-10 days after initiating therapy, a
robust rise in reticulocytes confirms
the diagnosis
LABORATORY DIAGNOSIS OF HYPOCHROMIC
MICROCYTIC ANAEMIA
LABORATORY TEST INTERPRETATION
Peripheral Hypochromic & microcytic
smear anaemia
Ringed sideroblasts
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Treatment
Iron, oral in most cases, parenteral
in cases of malabsorption
All forms of iron are constipating; the
amount of constipation directly
relates to the amount of elemental
iron delivered
If intolerant of FeSO4 (cheapest),
reduce the dose, rather than switching
form
Start 325 mg QD, increase slowly to TID
Follow up the cause of the iron
deficiency!
Treatment of Iron Deficiency Anemia
Diet: meat, liver, yeast, fish
Oral preparations: recovery rate Hb
Laboratory signs:
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Klasifikasi anemia megaloblastik
Defisiensi kobalamin
59
Defisiensi kobalamin
anemia pernisiosa,
paska gastrektomi
organisme intestinsal
abnormalitas ileum
nitrous oxide
60
History of
the Management of Anemia
Before 1980 Hb 10 g/dL
Hb 8 g/dL
Risks of transfusion
1980s infection
Transfusion guidelines
Moderate/severe anemia
Hb 8 g/dL
Klinis
Pemeriksaan penunjang
-darah perifer
-MCV>100 fl,
-MCV>110 fl sangkaan kuat
-defisiensi kadar kobalamin < 200 pg/ml (300-
900 pg/ml)
-defisiensi kadar asam folat <4 ng/ml (6-20
ng/ml)
Vit B12 N/
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Penatalaksanaan
Atasi penyebab
Defisiensi Kobalamin :
Kobalamin 1000 ug IM tiap minggu sd 8
minggu, lanjutkan kobalamin 1000 ug IM tiap
bulan
Vit B12 2 mg perhari
+ -
+ 1-2 g vit B12
reticulocyte response
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Thank You