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Medicine year 3 ANNA > Anaemia > Flashcards

Anaemia Flashcards

1
Q

What are the main categories of anaemia?

A
  1. Microcytic <80fL
  2. Normocytic 80-100fL
  3. Macrocytic >100fL
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2
Q

What are the common causes of microcytic anaemia?

A

Causes of microcytic anaemia (<80fL):

  • Iron deficiency
  • Anaemia of chronic disease
  • Sideroblastic anaemia
  • Thalassaemia
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3
Q

What are the main causes of normocytic anaemia?

A

Causes of normocytic anaemia:

  • Acute blood loss (though not always immediate drop in Hb as it is a concentration)
  • Chronic kidney disease / ESRF (deficiency of EPO)
  • Aplastic anaemia (pancytopenia)
  • Haemolytic anaemia (↑ reticulocytes)
  • Anaemia of chronic disease
  • Sickle Cell anaemia
  • Thalassaemia
  • Connective tissue disease
  • Marrow infiltration / fibrosis
  • Endocrine
    • hypothyroidism
    • hypoaldrenalism
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4
Q

What are the main causes of Macrocytic anaemia?

A

Main causes of Macrocytic anaemia:

  1. With megoblastic changes:
    • B12/ folate deficiency
    • pernicious anaemia
  2. Without megoblastic changes:
    • alcohol
    • liver disease
    • hypothyroidism
    • pregnancy
    • reticulocytosis
    • myelodysplasia
    • drugs: cytotoxics
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5
Q

What are the causes of iron deficiency anaemia?

A
  1. Poor intake
    • Dietary (low in red meat / dark greens)
  2. Malabsorption
    • CRC
    • Coeliac
    • Bowel ressection
    • Gut absorption e.g. IBD
  3. Losses
    • GI bleed
      • peptic ulcer
      • diverticulitis
      • CRC
    • Parasitic (hookworm, Africa)
    • Menorrhagia
    • Haematuria
    • Medication (blood thinners)
    • Pregnancy (↑ demands)
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6
Q

How do you treat iron deficiency anaemia?

A
  1. Treat underlying cause
  2. Iron replacement:
    • 100-200mg / day of elemental iron
    • Treat until Hb is normal, then + 3 months (to replace stores)
    • e.g. ferrous sulphate (SE constipation)
    • The reticulocyte count should peak at 1 to 2 weeks and haemoglobin should show improvement at 3 to 4 weeks (20 g/L per month) with normalisation of haemoglobin after 2 to 4 months and replacement of iron stores after 6 months.
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7
Q

What is a normal range of Hb for:

  1. Male
  2. Female
A
  1. Male: 130-180 g/L
  2. Female: 120-160 g/L
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8
Q

What are the side effects of oral iron replacement?

A

GI side effects:

  • Nausea (dose-related)
  • Stomach pain (dose-related)
  • Constipation / diarrhoea (not dose related)
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9
Q

What are the counselling points of iron replacement therapy?

A
  • Black poo!
  • Side effects can be reduces by changing preparation (GI: nausea, stomach pain, diarrhoea or constipation)
  • Avoid taking with food (reduces absorption) unless nauseous
  • Avoid taking with:
    • tea
    • coffee
    • milk
    • eggs
  • But can take with OJ (acid helps absorption)
  • Will take a few months before benefit is felt
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10
Q

When should iron replacement be used with caution/ not be given?

A
  • May exacerbate symptoms of
    • IBD
    • diverticular disease
    • intestinal strictures
  • Can reduce absorption of
    • Levothyroxine
    • bisphosphonates
  • Stop 7 days before colonoscopy (black sticky stools makes hard to visualise)
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11
Q

What should you do with a patient with new iron deficiency anaemia, >60yrs?

A

Refer for 2ww

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12
Q

What questions must you ask every anaemic patient?

A

Red Flag Qs:

  • Any recent weight loss?
  • Change in bowel habit?
  • Bleeding?
    • nose
    • vomiting
    • stool
    • urine
    • heavy periods
    • self harm
  • Medication history - blood thinners
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13
Q

What is pernicious anamia?

A
  • Autoimmune condition where there is atrophy of the gastric mucosa, with failure of Intrinsic Factor (and acid production)→ B12↓ absorption
  • caused by antibodies to gastric parietal cells or intrinsic factor
    • usually older people,
    • ↑common in women, fair hair blue eyes.
    • Associated with other autoimmune conditions e.g.
      • Thyroid
      • Vitiligo
      • Addisons
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14
Q

What are the clinical features of pernicious anaemia?

A
  • General:
    • Glossitis
    • Angular stomatitis
    • Mild jaundice
    • weakness + tiredness
    • Dysponea
    • Diarrhoea
    • Premature grey hair
    • Mild Splenomegaly
    • Fever
  • Neurological
    • fits with very low levels of B12
  • Polyneuropathy
    • weakness, ataxia, paraplegia
  • Optic atrophy
    • dementia, visual disturbances.
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15
Q

What are the causes of B12 deficiency?

A
  1. Poor intake
    • Vegan diet
  2. Malabsorption
    • Pernicious anaemia
    • Gastrectomy (no IF from terminal ileum),
    • Illeal disease/resection,
    • coeliac disease.
  3. Losses
    • Cancer
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16
Q

What are the causes of folate deficiency?

A
  1. Poor Intake
    • old age
    • poverty
    • alcohol excess (though beer is a good source!)
    • anorexia
  2. Malabsorption
    • coeliac disease
    • tropical sprue
  3. Excess utilization
    • pregnancy, lacatation, prematurity
    • chronic haemolytic anaemia, malignant and inflammatory diseases,
    • dialysis
  4. Drugs:
    • Methotrexate
    • anticonvulsants
17
Q

What are the signs of iron deficiency anaemia?

A
  • Brittle hair + nails
  • Atrophic glossitis
  • Angular stomatitis
  • Koilonychia
18
Q

What is the treatment for B12 deficiency?

A
  1. Treat underlying cause
  2. B12 injections (hydroxocobalamin)
    1. every other day for 2 weeks
    2. then every 3 months
19
Q

Folic acid replaecement:

A
  • Never give alone in undiagnosed anaemias (can exacerbate neuropathies) - give with B12
  • In true folate deficiency give 5mg daily for 4 months
20
Q

What blood markers are raised in haemolytic anaemia?

A
  • FBC: Reticulocytes
  • U+Es: Bilirubin
  • Lactate dehydrogenase
    • LDH is abundant in red blood cells and can function as a marker for hemolysis
21
Q

What is Coomb’s test?

aka direct antiglobulin test

A
  • Direct Coombs’ tests a sample of red blood cells, and identifies RBCs coated with antibody/complement. A positive result ususally indicates an immune cause
  • Indirect Coombs test is done on a sample of serum. It detects antibodies that are present in the bloodstream and could bind to certain red blood cells, leading to problems if blood mixing occurs (e.g. pregnancy)
22
Q

What is Autoimmune haemolytic anaemia (AIHA)?

A
  • AIHA is characterised by a positive direct antiglobulin test (Coombs’ test)
  • AIHA may be divided in to ‘warm’ and ‘cold’ types, according to at what temperature the antibodies best cause haemolysis.
    • Warm
      • IgG antibody
      • causes haemolysis best at body temperature
      • haemolysis tends to occur in extravascular sites, for example the spleen.
      • Management options include steroids, immunosuppression and splenectomy
      • Causes:
        • autoimmune disease: e.g. systemic lupus erythematosus
        • neoplasia: e.g. lymphoma, CLL
        • drugs: e.g. methyldopa
    • Cold
      • IgM
      • Haemolysis is mediated by complement and is more commonly intravascular.
      • Features may include symptoms of Raynaud’s and acrocynaosis.
      • Patients respond less well to steroids
      • Causes of cold AIHA
        • neoplasia: e.g. lymphoma
        • infections: e.g. mycoplasma, EBV
23
Q

What is hereditary spherocytosis?

A
  • An inherited abnormality of the red blood cell, caused by defects in structural membrane proteins.
  • It is the most common form of inherited haemolytic anaemia in the US and northern Europe.
  • Autosomal dominant
  • Presents w neonatal jaundice
  • Treatment:
    • Folic acid
    • Splenectomy
  • EMA tests for specific binding
  • Triangle of:
    • Palor / anaemia
    • Jaundice
    • Splenomegaly
24
Q

What is SLE?

A

Systemic lupus erythematosus (SLE) is a chronic multi-system disorder that most commonly affects women during their reproductive years. It is characterised by the presence of antinuclear antibodies.

The incidence of clinically significant haemolytic anaemia (“warm” AIHA) has been described in up to 10% of patients with SLE.

25
Q

What is sickle cell disease?

A
  • an autosomal recessive condition that results for synthesis of an abnormal haemoglobin chain HbS.
  • SSickle-shaped red blood cells
  • Symptoms:
    • sickle cell crises, which can be very severe and can last up to a week
    • an increased risk of serious infections
    • anaemia→ tiredness and shortness of breath
  • Tests:
    • ↓ Hb
    • ↑ Reticulocyte count
    • Bilirubin may be raised
    • Blood film shows sickled erythrocytes
26
Q

What are the symptoms of a sickle cell crisis?

A

Thrombotic crises:

  • also known as painful crises or vaso-occlusive crises
  • precipitated by infection, dehydration, deoxygenation
  • infarcts occur in various organs including the bones (e.g. avascular necrosis of hip, hand-foot syndrome in children, lungs, spleen and brain):
    • extremely painful, bony infarcts e.g. in spine, ribs, limbs, hands and feet
    • difficulty breathing
    • headache / dizziness
    • jaundice
27
Q

When do you need an urgent x-ray in sickle cell patients?

A

Any respiratory symptoms or drop in O2 sats → could be ARDS due to sickling in lungs!

28
Q

What is the treatment for a sickle cell crisis?

A
  • admit to hospital
  • analgesia e.g. opiates within 30 mins of presentation to A&E
  • rehydrate (IV fluids)
  • oxygen
  • consider antibiotics if evidence of infection
  • blood transfusion
  • exchange transfusion: e.g. if neurological complications
29
Q

How are haemolytic anaemias classified?

A

Congenital vs Aquired

  1. Congenital:
    • Membrane (hereditary spherocytosis/elliptocytosis)
    • Enzyme (G6PD deficiency)
    • Hb disorders (sickle cell, thalassaemia)
  2. Aquired:
    • Immune
      • AIHA (autoimmune haemolytic anaemia)
      • alloimmune: transfusion reaction, haemolytic disease newborn
    • Non-immune
      • drug related
      • microangiopathic haemolytic anaemia (MAHA): TTP/HUS, DIC, malignancy, pre-eclampsia
      • infections (malaria)
      • copper deficiency (Wilson’s disease)
30
Q

what is the treatment for sickle cell disease?

A

hydroxycarbimide or methotrexate

31
Q

How do you approach treating anaemia?

A

The approach to any anaemia has four steps:

  1. Establish the type of anaemia
  2. Find the immediate cause of the anaemia
  3. Treat the anaemia
  4. Investigate and treat the underlying disease process that has caused the anaemia
32
Q

What are the main signs of anaemia?

A
  • Fatigue
  • Weakness
  • Pale or yellowish skin
  • Irregular heartbeats
  • Shortness of breath – worse if underlying respiratory or cardiac disease
  • Dizziness or light-headedness
  • Chest pain – worse if underlying arterial disease
  • Cold hands and feet
  • Headache
33
Q

What is the long-term management of sickle cell?

A
  • keep warm
  • keep hydrated
  • keep regular hours
  • eat well
  • take penecillin and folic acid
34
Q

What is ITP?

A

Immune thrombocytopenia

  • Immune thrombocytopenia (ITP) is an autoimmune bleeding disorder characterized by the abnormally low levels of platelets
  • uch symptoms may include:
    – Skin that bruises very easily and even spontaneously
    – A rash consisting of small red dots (petechiae) that represent small hemorrhages caused by broken blood vessels or leaks in a capillary wall
    – Bleeding from the gums
    – Frequent and long-lasting nose bleeds
    – Blood blisters on the inside of cheeks
    – Excessive and prolonged menstrual bleeding
    – Bleeding from any area of the body, e.g. in urine or feces
35
Q

What is Thalassemia?

A
  • Multiple gene defects → ↓ rate of production of one or more globin chains.
  • The imbalance of globin chain production leads precipitation of globin chains within red cells or precursors. This → cell damage, death of RBC precursors in the bone marrow and haemolysis.
    • – α thalassaemia: reduced α chain synthesis
    • – β thalassaemia: reduced β chain synthesis

Medicine year 3 ANNA (30 decks)

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