Anemia

Mike Clark, M.D.

Anemia is a decrease in the normal number of red blood cells (RBCs) or less than the normal quantity of hemoglobin in the blood. However, it can include decreased oxygen-binding ability of each hemoglobin molecule due to deformity or lack in numerical development as in some other types of hemoglobin deficiency.

Because anemia has multiple causes (etiologies)

a work-up must be performed to identify the specific cause or in some cases causes.

Symptoms Most commonly, people with anemia report non-

specific symptoms of a feeling of weakness, or fatigue, general malaise and sometimes poor concentration. They may also report shortness of breath, dyspnea, on exertion. In very severe anemia, the body may compensate for the lack of oxygen carrying capability of the blood by increasing cardiac output. The patient may have symptoms related to this, such as palpitations, angina (if preexisting heart disease is present), intermittent claudication of the legs, and symptoms of heart failure

Signs• On examination, the signs exhibited may

include pallor (pale skin, mucosal linings and nail beds) but this is not a reliable sign. There may be signs of specific causes of anemia, e.g., koilonychia (in iron deficiency), jaundice (when anemia results from abnormal break down of red blood cells — in hemolytic anemia), bone deformities (found in thalassemia major) or leg ulcers (seen in sickle cell disease).

Pallor

koilonychia

History and Physical• As a result of the non-specific signs and

symptoms a history and physical examination is performed.

Lab Tests

CBC Values

• If you wish to understand the meaning of each value on a CBC go to my MS-Word Document:

CBC Explanation of Values

Two main causes of anemia• Decreased Production of red blood cells

and/or hemoglobin• Increased destruction of red blood cells

and/or hemoglobin• Main test to distinguish the difference is the

reticulocyte count. Normal count is .5 – 2%• Generally a low normal to low reticulocyte

count is caused by decreased production and high one is caused by increased destruction

Anemia

Increased Peripheral Destruction

Decreased Production

The red blood cells are producedand released from the bone marrow correctly, but they are destroyed for some reason outside the bone marrow.

The bone marrow is not producing red blood cells effectively and/or not releasing them sufficiently.

Hemorrhage Splenomegalyhemolytic

Iron DeficiencyVitamin B12 Deficiency

Normal to increased reticulocyte count

Normal to decreased reticulocyte count

Anemia

Increased Peripheral Destruction

Decreased Production

Size and rbc color OK

Normocytic -Normochromic

Hemorrhage Splenomegalyhemolytic

Bone marrow problemStem Cell Problem

Hormone problemIron DeficiencyVitamin B12 Deficiency

Normal to increased reticulocyte count

Normal to decreased reticulocyte count

Decreased Production Causes • Reduction in red blood cells or subnormal level of

hemoglobin• Inadequate production of red cells• Insufficient raw materials– Iron deficiency– Vitamin B12 deficiency– Folic acid deficiency

• Inability to deliver adequate red cells into circulation due to marrow damage or destruction (aplastic anemia), replacement of marrow by foreign or abnormal cells

Increased Destruction Causes• Excessive loss of red cells– External blood loss (hemorrhage)– Shortened survival of red cells in circulation–Defective red cells: hereditary hemolytic

anemia–Accelerated destruction of cells from

antibodies to red blood cell or by mechanical trauma to circulating red cells

Diagnostic Evaluation of Anemia• 1. History and physical examination• 2. Complete blood count: to assess degree of anemia,

leukopenia, and thrombocytopenia• 3. Blood smear: determine if normocytic, macrocytic,

or hypochromic microcytic• 4. Reticulocyte count: assess rate of production of new

red cells• 5. Lab tests: determine iron, B12, folic acid• 6. Bone marrow study: study characteristic

abnormalities in marrow cells• 7. Evaluation of blood loss from gastrointestinal tract to

localize site of bleeding

CBC indices regarding red blood cells

• Red Blood Cell Count - 4.8 – 5.4 million per microliter• Hematocrit ( 30 – 60) generally 45% to 52% for men and 37% to

48% for women• Hemoglobin ( 13 to 18 grams per deciliter for men and 12 to 16

for women) • MCV (Mean Corpuscular Volume) - 80 to 100 • MCH (Mean Corpuscular Hemoglobin) –this is the average amount

of Hgb. in a the typical red blood cell. 27 to 32 picograms• MCHC (Mean Corpuscular Hemoglobin Conc.) - the average

concentration of hemoglobin in a given volume of red cells (32 – 36%)

• RDW – (Red Cell Distribution Width) – a measurement of the variability of red cell size and shape. Higher numbers indicate greater variation in size 11 - 15

Peripheral Smear• Look at size – 6 – 9 micromillimeters • Too small – microcytic• Too big – macrocytic• Normal size – normocytic

• Look at color• Too pale – hypochromic• Too dark – hyperchromic• Normal color - normochromic

Anemia: Morphologic Classification

• Classification based on red cell appearance suggests the etiology of the anemia:– Normocytic anemia: normal size and appearance– Macrocytic anemia: cells larger than normal

• Folic acid deficiency• Vitamin B12 deficiency

– Microcytic anemia: cells smaller than normal

Anemia: Morphologic Classification

• Hypochromic anemia: reduced hemoglobin content

• Hypochromic microcytic anemia: smaller than normal and reduced hemoglobin content

Increased Destruction (Peripheral)

• Too extensive destruction after cells have been formed and released from bone marrow

• Generally find a high reticulocyte count – because more and more immature red blood cells are being released from bone marrow to compensate for the shortage in the peripheral circulation

Possible Causes of Increased Destruction

• Acquired hemolytic anemia– Normal red cells but unable to survive due to a

“hostile environment”– Attacked and destroyed by antibodies– Destruction of red cells by mechanical trauma– Passing through enlarged spleen (splenomegaly)– In contact with some part of artificial heart valve

Possible Causes of Increased Destruction Hemolytic Anemia (Genetic)

• Hereditary hemolytic anemia– Genetic abnormality prevent normal survival

• 1. Abnormal shape: hereditary spherocytosis• 2. Abnormal hemoglobin: hemoglobin S (sickle

hemoglobin); hemoglobin C; both found predominantly in persons of African descent

• 3. Defective hemoglobin synthesis: thalassemia minor and major; globin chains are normal but synthesis is defective (Greek and Italian ancestry)

• 4. Enzyme defects: glucose-6-phosphatase dehydrogenase deficiency predisposes to episodes of acute hemolysis

Distortion of red cells containing sickle hemoglobin when incubated under reduced oxygen tension.

Distortion of red calls containing sickle hemoglobin when incubated under reduced oxygen tension. Higher

magnification view.

Decreased Production• Something is causing red blood cells not to be

produced fast enough

• Generally the reticulocyte count is low or low normal. The reason is that if production is bad –reticulocytes (immature red blood cells) also cannot be produced adequately.

Classification of anemia based on the “bone marrow factory” concept

Iron-Deficiency Anemia• Characteristic laboratory profile– Low serum ferritin and serum iron– Higher than normal serum iron-binding protein– Lower than normal percent iron saturation

• Treatment– Primary focus: learn cause of anemia– Direct treatment towards cause than symptoms– Administer supplementary iron

• Examples– Infant with a history of poor diet– Adults: common cause is chronic blood loss from GIT (bleeding

ulcer or ulcerated colon carcinoma)– Women: excessive menstrual blood loss– Too-frequent blood donations

Normal red cells

Cells of hypochromic microcytic anemia

Vitamin B12 Deficiency Anemia

• Vitamin B12: meat, liver, and foods rich in animal protein• Folic acid: green leafy vegetables and animal protein

foods– Both required for normal hematopoiesis and normal

maturation of many other types of cells– Vitamin B12: for structural and functional integrity of nervous

system; deficiency may lead to neurologic disturbances

Vitamin B12 Deficiency Anemia

• Absence or deficiency of vitamin B12 or folic acid– Abnormal red cell maturation or megaloblastic

erythropoiesis with formation of large cells called megaloblasts

– Mature red cells formed are larger than normal or macrocytes; corresponding anemia is called macrocytic anemia

– Abnormal development of white cell precursors and megakaryocytes: leukopenia, thrombocytopenia

Most vitamin B12 deficiency symptoms are actually folate deficiency symptoms, since they include all the effects of pernicious anemia and megaloblastosis, which are due to poor synthesis of DNA when the body does not have a proper supply of folic acid for the production of thymine. When sufficient folic acid is available, all known B12 related deficiency syndromes normalize, save those narrowly connected with the vitamin B12-dependent enzymes

The total amount of vitamin B12 stored in body is about 2–5 mg in adults. Around 50% of this is stored in the liver. Approximately 0.1% of this is lost per day by secretions into the gut as not all these secretions are reabsorbed. Bile is the main form of B12 excretion, however, most of the B12 that is secreted in the bile is recycled via enterohepatic circulation

Macrocytic Cells

Pernicious Anemia• Lack of intrinsic factor results in macrocytic anemia– Vitamin B12 in food combines with intrinsic factor in gastric

juice– Vitamin B12 intrinsic factor complex absorbed in ileum

• Causes– Gastric mucosal atrophy; also causes lack of secretion of acid

and digestive enzymes– Gastric resection and bypass: vitamin B12 not absorbed– Distal bowel resection or disease: impaired absorption of

vitamin B12 intrinsic factor complex– May develop among middle-aged and elderly– Associated with autoantibodies against gastric mucosal cells

and intrinsic factor

Figure 23.14a

CardiaEsophagus

Pyloric sphincter(valve) at pylorus

Pyloriccanal

Pyloricantrum

Rugae ofmucosa

Body

Lumen

Serosa

Fundus

Lessercurvature

Greatercurvature

Muscularisexterna • Longitudinal layer • Circular layer • Oblique layer

(a)

Duodenum

Figure 23.15b

(b) Enlarged view of gastric pits and gastric glands

Mucous neck cellsParietal cell

Surface epithelium(mucous cells)

Gastric pits

Chief cell

Enteroendocrine cell

Gastric pit

Gastric gland

Folic Acid Deficiency Anemia• Relatively common• The body has very limited stores, which rapidly

become depleted if not replenished continually• Pathogenesis– Inadequate diet: encountered frequently in chronic

alcoholics– Poor absorption caused by intestinal disease– Occasionally occurs in pregnancy with increased demand

for folic acid

Polycythemia• Secondary polycythemia– Reduced arterial O2 saturation leads to compensatory

increase in red blood cells (increased erythropoietin production)

– Emphysema, pulmonary fibrosis, congenital heart disease; increased erythropoietin production by renal tumor

• Primary/Polycythemia vera– Manifestation of diffuse marrow hyperplasia of unknown

etiology– Overproduction of red cells, white cells, and platelets– Some cases evolve into granulocytic leukemia

Polycythemia

• Complications– Clot formation due to increased blood viscosity and platelet

count• Treatment– Primary polycythemia: treated by drugs that suppress

marrow function– Secondary polycythemia: periodic removal of excess blood