Haematology - Anaemia Flashcards by Annie Rees

Which investigations would you do for microcytic anaemia?

Peripheral Blood Smear + Iron Studies

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Which investigations would you do for macrocytic anaemia?

Peripheral Blood Smear + LFTs + TFTs

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Which investigations would you do for normocytic anaemia?

Peripheral Blood Smear + Direct Antiglobulin Test + CRP + ESR

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What are three causes of anaemia?

Reduced production of RBCs
Increased loss of RBCs (haemolytic anaemias)
Increased plasma volume/dilution (pregnancy)

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What are some symptoms of anaemia?

Fatigue
Dyspnoea
Faintness
Palpitations
Headache
Tinnitus
Anorexia

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What are some signs of anaemia?

Pallor

In severe anaemia (Hb <80g/L):
- Tachycardia
- Flow murmurs (ejection-systolic loudest over apex)
- Heart Failure

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What is a high MCV?

> 100fL
Decreased production of RBCs

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What is a low MCV?

<80fL
Normal number of RBCs (most of the time), but not much to go in them

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Define anaemia

A condition in which the number of RBCs or the haemoglobin in them is lower than normal.

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What are some causes of a microcytic anaemia?

FAST:
F - (Fe) Iron-deficiency anaemia
A - Anaemia of chronic disease
S - Sideroblastic anaemia
T - Thalassaemia (may not be anaemic if mild)

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What are some causes of normocytic anaemia?

All Hoes Fuck Prostitutes:
All - Anaemia of chronic disease
Hoes - Haemorrhage, Hypothyroidism, Haemolysis
Fuck - Failure (renal + bone marrow)
Prostitutes: Pregnancy

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What are some causes of macrocytic anaemia:

FAT RBC
F - Foetus (pregnancy)
A - Antifolates (e.g. phenytoin)
T - Thyroid (hypothyroidism)
R - Reticulocytosis (release of larger immature cells e.g. with haemolysis)
B - B12/folate deficiency
C - Cirrhosis (alcohol excess or liver disease)

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What are some signs of IDA?

Koilonychia
Atrophic Glossitis
Angular Cheilosis
Post-cricoid webs (PLUMMER-VINSON SYNDROME)
Brittle hair + nails

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What are signs of IDA on a blood film?

Microcytic
Hypochromic
Ansiocytes
Poikilocytosis
PENCIL CELLS

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How does IDA present with on iron studies?

Decreased Iron
Decreased Ferritin
Increased Transferrin
Decreased Transferrin Saturation
Increased TIBC

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What is the commonest cause of IDA?

Bleeding (commonest cause)
Menorrhagia in young women

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Name four causes of IDA

Blood loss = Gi loss (e.g. peptic ulcers, Meckel’s diverticulum, menorrhagia etc.)
Increased utilisation = pregnancy/lactation or growth in children
Decreased uptake = prematurity/suboptimal diet
Decreased absorption = coeliac/post-gastric surgery (decreased acid which helps Fe absorption)
Intravascular haemolysis = MAHA/PNH (chronic loss of Fe in urine)

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What investigations would youo do for IDA?

IF no obvious cause = OGD + colonoscopy, urine dip, ceolia investigations

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What is the treatment of IDA?

Treat Cause
Oral Iron
IV Iron (e.g. Ferrinject/Monofer - anaphylaxis risk)
Blood transfusion in SEPSIS (iron will not absorb well)

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What are some side effcts of oral iron supplements?

Nausea
Abdominal discomfort
Diarrhoea/constipation
Black stools

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What are the indications for IV iron?

Poor oral absorption
Failure of oral iron trial
Need for rapid rise (e.g. imminent major surgery)

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What is Anaemia of Chronic Disease?

Cytokine driven inhibition of red cell production

EXCEPT in renal failure: it’s due to erythropoeitin (EPO) deficiency which is made by the kidney

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What are the causes of ACD?

Chronic infection (e.g. TB/osteomyelitis)
Vasculitis (inflammation)
Rheumatoid arthritis
Malignancy

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What would iron studies show for ACD?

Normal Iron
Increased Ferritin
Decreased Transferrin
Decreased TIBC

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Why is Ferritin high in ACD?

Iron is sequestered in macrophage to depreive invasding bacteria of iron

What causes reduced EPO synthesis by the kidneys in renal failure-causing ACD?

Inflammatory markers (e.g. IFNs, TNF, IL1) reduce receptor production and therefore synthesis

Why is iron metabolism dysregualted in ACD?

IL6 and LPS stimulate liver to make hepcidin, which decreases iron absorption from the gut (by inhibiting transferrin) and causes iron accumulation in macrophages

How would you manage ACD?

Treat underlying cause

What are the iron studies of sideroblastic anaemia?

Increased Iron Increased Ferritin Decreased Transferin Decreased TIBC

What would be seen on the blood film of sideroblastic anaemia?

Basophilic stippling

How is sideroblastic anaemia diagnosed?

Ring sideroblasts seen in marrow

What are ring sideroblasts?

Erythroid precursors with iron deposited in mitochrondria in a ring around the nucleus

What are some causes of sideroblastic anaemia?

Congenital or acquired Myelodysplastic disorders Post-chemo Irradiation ALCOHOL EXCESS lead excess Anti-TB drugs Myeloproliferative disease ?Lead poisoning

What is the management of sideroblastic anaemia?

- Remove cause - ?Pyridoxine (vitamin B6 promotes RBC production) - ?Giving EPO - Transfusions

What is sideroblastic anaemia?

Congenital or acquired anaemias of INEFFECTIVE ERYTHROPOEISIS leading to iron loading, causing haemosiderosis.

What is Transferrin saturation?

Serum Iron / TIBC IF <20% = IDA

What are the Iron studies for chronic haemolysis?

Increased Iron Decreased TIBC Increased Ferritin

What are the iron studies for haemachromatosis?

Increased Iron Low/Normal TIBC Increased Ferritin

What are the iron studies for pregnancy?

Increased Iron Increased TIBC Normal Ferritin

What is ferritin?

An acute phase protein that increases with inflammation.

What investigations would you do for pancytopenia?

- B12/Folate/Iron - Abdo exam (Splenomegaly = ?myelofibrosis) - Reticulocyte count (if low = bone marrow problem) - Blood Film for abnormal cells (?acute leukaemia) + dysplasia (?myelodysplasia) - Myeloma screen - Blood PCR for Parvovirus - ?check medications - Bone marrow UNLESS clear cause found from other tests

What are the megaloblastic causes of macrocytosis

- B12 deficiency - Folate deficiency - Cytotoxic drugs

What are the non-megaloblastic causes of macrocytosis

- Alcohol - Reticulocytosis - Liver disease - Hypothyroidism - Pregnancy

What is the most common cause of macrocytosis without anaemia?

Alcohol

What are other haematological diseases causing macrocytosis?

- Myelodysplasia - Myeloma - Myeloproliferative disorder - Aplastic anaemia

What are features of a megaloblastic blood film?

- Hypersegmented polymorphs - Leucopenia - Macrocytosis - Anaemia - Thrombocyopenia with megaloblasts

What are megaloblasts?

Red cell precursors with an immature nucleus and mature cytoplasm

What vitamin is required for nucelus maturation in megaloblasts?

B12 + Folate

What investigations would you do to assess for macrocytic anaemia?

- Peripheral blood smear - LFTs - TFTs

Where does Vitamin B12 come from?

Meat + dairy products

What are some causes of B12 deficiency?

- Diet (e.g. vegans) - Malabsorption (e.g. pernicious anaemia, post-gastrectomy, ileal resection, crohn's disease, bacterial overgrowth, tropical sprue + tapeworms)

What glycoprotein is required for the absorption of B12, where is it produced and where is B12 absorbed?

- Intrinsic Factor - Produced by gastric parietal cells - B12 absorbed in terminal ileum

What are the clinical features of B12 deficiency?

- Mouth: Glossitis, angular cheilosis - Neuropsychiatric: Irritability, depression, psychosis, dementia - Neurological: Paraesthesiae, peripheral neuropathy

Which carboxylic acid is elevated in B12 deficiency?

Serum Methylmalonic Acid (MMA)

What is the most common cause of macrocytic anaemia in Western countries?

Pernicious anaemia (Usually >40yrs)

What is pernicious anaemia?

A type of B12 anaemia - Autoimmune atroophic gastritis leading to achlorhydria and lack of gastric intrinsic factor Achlorhydria = condition where stomach does not produce hydrochloric acid

What are specific tests for pernicious anaemia?

- Parietal cell antibodies (90%) - Intrinsic factor antibodies (50%) - Schilling test (outdated - positive if B12 deficiency secondary to pernicious anaemia)

What is the treatment of B12 deficiency?

- Replenish stores with IM hydroxocobalamin (B12) - 6 injections over 2 weeks - Test for anti-parietla cell/ anti-intrinsic factor Abs as IF autoimmune cause then need 3-monthly injections

What are some sources of folate?

DIET - Green vegetables - Nuts - Yeast - Liver

What are some causes of folate deficiency?

- Poor diet - Increased demand (e.g. pregnancy) OR increased cell turnover (e.g. haemolysis, malignancy, inflammatory disease and renal dialysis) - Malabsorption (e.g. coeliac disease, tropical sprue) - Drugs (e.g. alcohol, anti-epileptics, phenytoin, methotrexate, trimethoprim)

How does phenytoin cause folate deficiency?

It inhibits folate absorption

What is the management of folate deficiency?

- Oral folic acid - Ensure B12 checked + replaced before folic acid as it may exacerbate neuropathy of B12 deficiency

Haematology - Anaemia Flashcards

(62 cards)