Anemia. Greek Anaimia from: an + haima No Blood. Y. Haroon Ahmad, MD Arizona Oncology Associates. Presenter: Y. Haroon Ahmad, MD
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1 Presenter: Y. Haroon Ahmad, MD Anemia Greek Anaimia from: an + haima No Blood Y. Haroon Ahmad, MD Arizona Oncology Associates
2 Conflict of Interest I have nothing to disclose
3 Learning Objectives Discuss the causes for Anemia. Discuss optimal therapies for Anemia. Discuss failure of therapy in Anemia and its management.
4 UpToDate
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6 Anemia RBC Mass Therefore O 2 carrying capacity Decrease in concentration of red cells or hemoglobin Presenter: Y. Haroon Ahmad, MD
7 Presenter: Y. Haroon Ahmad, MD
8 Presenter: Y. Haroon Ahmad, MD Signs and Symptoms 1 Symptoms affected by speed of onset Asymptomatic in mild cases Fatigue, dyspnea especially after exercise Angina, TIA unmasked by anemia Hgb < 7.5 g% results in increased cardiac output leading to palpitations and cardiac failure in pts with poor cardiac reserve
9 Signs and Symptoms 2 Dizziness and headache Difficulty in concentrating Feeling cold because of decreased blood flow to the skin Restless Leg Syndrome Abnormal menstruation Presenter: Y. Haroon Ahmad, MD
10 Presenter: Y. Haroon Ahmad, MD Physical Examination Pallor conjunctival or palmar Tachycardia Hyperdynamic precordium Systolic murmur Venous hum over neck vessels Icterus Splenomegaly Leg ulcers
11 Presenter: Y. Haroon Ahmad, MD
12 Approach to patient with anemia 1 Family history eg SCD, Thalassemia, Spherocytosis Physical Examination Presenter: Y. Haroon Ahmad, MD
13 Approach to patient with anemia 2 The Big Question: 1. Do we have decreased production of RBC? or 2. Enhanced destruction of RBC? or 3. Blood loss? Presenter: Y. Haroon Ahmad, MD
14 Approach to patient with anemia 3 CHECK STOOL FOR OCCULT BLOOD LOSS CBC MCV incredibly important and useful Will help distinguish between Microcytic, Macrocytic and Normocytic Anemias Presenter: Y. Haroon Ahmad, MD
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16 UpToDate
17 Microcytic Anemias Iron deficiency Thalassemia Sideroblastic anemia Presenter: Y. Haroon Ahmad, MD
18 Presenter: Y. Haroon Ahmad, MD Macrocytic Anemia Megablastic anemias - deficiencies of Vit B12 and/or Folate Liver disease particularly alcohol use Hypothyroidism Aplastic anemia Myelodysplastic syndromes HEMOLYTIC ANEMIAS -?? Reticulocyte count
19 Normocytic Anemia 1 A. Secondary to other underlying diseases Anemia of chronic disease Infection Autoimmune diseases (RA) Malignancy Anemia of Uremia (CKD) Anemia of Liver Disease Anemia of Endocrinopathy Presenter: Y. Haroon Ahmad, MD
20 Normocytic Anemia 2 B. Intrinsic bone marrow pathology Myelodysplastic syndromes Myeloid metaplasia Myelophthisic anemia Aplastic anemia Usually bone marrow biopsy required for diagnosis, particularly when more than one cell line is abnormal. Presenter: Y. Haroon Ahmad, MD
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22 Presenter: Y. Haroon Ahmad, MD Hemolytic Anemias Immunohemolytic anemias Coomb s test Microangiopathic hemolytic anemia DIC TTP/HUS Sickle Cell & Thalassemia syndromes Membrane pathology eg Spherocytosis Enzyme pathology eg G6PD deficiency
23 Iron Deficiency Anemia 1 Adult male and non-menstruating female WITH LOW MCV Presenter: Y. Haroon Ahmad, MD
24 Presenter: Y. Haroon Ahmad, MD
25 Iron Deficiency Anemia 2??? IRON STATUS??? Presenter: Y. Haroon Ahmad, MD
26 Iron Deficiency Anemia 3 Iron saturation beware of low TIBC Ferritin Iron stains on bone marrow aspirate Presenter: Y. Haroon Ahmad, MD
27 Iron Deficiency Anemia 4 Pica Ice pagophagia Starch amylophagia Clay geophagia Presenter: Y. Haroon Ahmad, MD
28 Iron Deficiency Anemia 5 If iron deficiency found, endoscopic examination is OBLIGATORY!!! Presenter: Y. Haroon Ahmad, MD
29 Iron Deficiency Anemia 6 Malignancy colon or gastric Menorrhagia BARIATRIC SURGERY Peptic Ulcer Disease Celiac Disease Angiodysplasia Blood donation Vegans Presenter: Y. Haroon Ahmad, MD
30 Presenter: Y. Haroon Ahmad, MD
31 Iron Deficiency Anemia 7 Increased Fe utilization eg pregnancy and rapid growth Hemodialysis Hematuria Chronic hemoglobinuria mechanical heart valves and PNH Presenter: Y. Haroon Ahmad, MD
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34 Treatment of Iron Deficiency Oral iron Fe sulfate vs gluconate Problems with P.O. Iron Side effects and absorption Parenteral iron Indications Administration
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37 Megaloblastic Anemia 1 Macrocytosis Anemia - MCV or MCV if also iron deficient Neuropsychiatric symptoms Peripheral Neuropathy Spinal cord degeneration Memory loss
38 Megaloblastic Anemia 2 Infertility and fetal loss Glossitis Methylmalonic acid & hemocysteine Hypersegmented neutrophils (5-6 lobes) Anti-Intrinsic Factor Antibodies Achlorhydria EGD?
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40 Gastric atrophy/achlorhydria (Pernicious anemia classic picture) Bariatric surgery Gastrectomy Megaloblastic Anemia 3 Ileal resection Crohn s Disease
41 Megaloblastic Anemia 4 Bacterial overgrowth Zollinger-Ellison Syndrome Pancreatic insufficiency Megadoses Vit C & PPI Pregnancy Nitrous Oxide Vegans ph
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43 Treatment of Vit B12 deficiency IM shots daily weekly monthly (neuro symptoms) P.O. vs sublingual Treat with B12 before folate to avoid masking B12 deficiency by folate (folate will not treat neuro symptoms)
44 Macrocytosis Anemia Folic Acid Deficiency MCV or normal if Fe deficient Serum level vs RBC level Similar neuropsychiatric symptoms to B12 deficiency Infertility and fetal loss
45 Causes of Folic Acid Deficiency 1 Lack of fresh vegetables (Dr. Victor Herbert) Ethanol Celiac Disease Small bowel resections Crohn s Disease Cytotoxic chemotherapy eg MTX
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47 Causes of Folic Acid Deficiency 2 Antibiotics Trimethoprim Diuretic Triamterene Anticonvulsant Phenytoin, Carbamazepine Increased Utilization Pregnancy Chronic hemolysis (SCD) Hemodialysis
48 Treatment Daily Folate 1 mg
49 Hemolytic Anemias 1 History (especially family history) Fatigue Jaundice Abdominal pain, gallstones (chronic hemolysis) Meds Travel (infection)
50 Hemolytic Anemias 2 Vascular/Cardiac surgery Discolored urine FH Jaundice/ gallbladder disease/ splenectomy/ hereditary anemia
51 Hemolytic Anemias Physcial Exam Pallor Tachycardia Jaundice Mechanical heart valve click Splenomegaly
52 Hemolytic Anemias Intrinsic Causes Abnormal hemoglobin SCD Thalassemia Unstable hemoglobin Abnormal membranes Spherocytosis Elliptocytosis Hemolytic uremic syndrome PNH Abnormal enzymes G6PD deficiency Pyruvate kinase
53 Hemolytic Anemias Extrinsic Causes 1 Immune Autoimmune syndromes Transfusion induced alloantibodies
54 Hemolytic Anemias Extrinsic Causes 2 Fragmentation/Physical Damage Heart valves DIC TTP HUS Hemodialysis Malignancy Burns Marathon/march hemoglobinuria Vasculitis Malignant HTN AV malformation
55 Hemolytic Anemias Extrinsic Causes 3 Infections Malaria Babesiosis Bartonella Closridium Chemicals Oxidants with G6PD def Insect and snake venom Lead Other causes Hypersplenism Liver disease
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63 Approach to Hemolytic Anemias 1 History and Physical Exam Labs CBC smear Retic count (corrected) haptoglobin LDH indirect Bilirubin Coomb s test PNH screen Hemoglobin electrophoresis
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65 Approach to Hemolytic Anemias 2 Physical damage Schistocytes Plasma Hgb Urine hemosiderin Infection Membrane and enzyme defects measure RBC enzymes and provocative tests
66 Treatment of Hemolytic Anemias Immunohemolytic anemias Steroids Gammaglobulin Rituximab Chemotherapy Therapies for other hemolytic anemias directed toward their individual causes
67 Hemolytic Anemias Intrinsic Causes Abnormal hemoglobin SCD Thalassemia Unstable hemoglobin Abnormal membranes Spherocytosis Elliptocytosis Hemolytic uremic syndrome PNH Abnormal enzymes G6PD deficiency Pyruvate kinase
68 Hemolytic Anemias Extrinsic Causes 2 Fragmentation/Physical Damage Heart valves DIC TTP HUS Hemodialysis Malignancy Burns Marathon/march hemoglobinuria Vasculitis Malignant HTN AV malformation
69 Hemolytic Anemias Extrinsic Causes 3 Infections Malaria Babesiosis Bartonella Closridium Chemicals Oxidants with G6PD def Insect and snake venom Lead Other causes Hypersplenism Liver disease
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72 Contact information Cell Day or Night 24/7 Call for anything (except pizza)
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