Anaemia Flashcards
why is anaemia under diagnosed
- symptoms of the anaemia is often of gradual onset - both patients and clinicians may attribute the symptoms of anaemia to the ageing process
what does unexplained profound iron deficiency anaemia may mean
- it may mean that there is an undiagnosed hiding tumour even when an initial colonoscopy has been clear
How do patients with chronic kidney disease show iron deficiency anaemia
- they may have a normal or even high ferritin even in the presence of iron deficiency
what do you have to consider when a patient lacks consent
- lack of capacity permanent or temporary
- emergency or non-emergency situation
what do you do for a patient that lacks consent permanently
- doing what is best for the patient and acting in there best interest
- support there autonomy
- maybe go for the less invasive test
- figure out if the test will change the course of treatment
What is the most common cause of anaemia in elderly people
- chronic disease
Name in order the most common causes of anaemia in elderly people
- chronic disease
- iron deficiency anaemia
- Vitamin B12 deficiency and folate deficiency
why is the MCV unhelpful in elderly people
- MCV drifts upwards in older age so an older people with iron deficiency may not always have the classic finding of microcytosis
what combination of MCV and … can be helpful in the diagnosis of elderly people with anaemia
MCV and red cell distribution width (RDW) is often the most helpful in elderly people with anaemia
what does it suggest if the RDW is raised
- if the red cell distribution width is raised this suggests that there is anisocytosis (red blood cells of unequal size)
- the presence of anisocytosis suggests that there are microcytes and microcytes in combination
what does anaemia of chronic disease be caused by
- any chronic inflammatory condition or chronic co-morbditiy
- causes mild to moderate anaemia
The extent of anaemia ….
correlates with the severity of the underlying disease.
what type of anaemia is caused by anaemia of chronic disease
- usually normochromic normocytic anaemia but 30% of elderly patients with anaemia of chronic disease have microcytosis
how do you distinguish between iron deficiency and anaemia of chronic disease
- serum ferritin - it is low in patients with iron deficiency anaemia and normal in patients with anaemia of chronic disease
- in some patients with iron deficiency anaemia who have an inflammatory condition the serum ferritin can be raised so its not ideal but the best
How is transferrin saturation affected by patients with anaemia of chronic disease and iron deficiency anaemia
Transferrin saturation is low in patients with anaemia of chronic disease and in patients with iron deficiency anaemia
How is serum iron affected by patients with anaemia of chronic disease and iron deficiency anaemia
Serum iron is low in patients with anaemia of chronic disease and in patients with iron deficiency anaemia
How are ferritin values related to the amount of iron present in reticuloendothelial stores
Around 1 µg/l in serum corresponds to 8 mg in the stores.
when is normocytic anaemia commonly found in
- Anaemia of chronic disease
- haemolytic anaemia
when is microcytic anaemia found
- iron deficiency
- anaemia of chronic disease
- thalassaemia minor
When is a microcytic anaemia found
- vitamin B12 deficiency
- folate efficiency
- myelodysplastic disorder
- chronic liver disease
- alcohol excess
what does haemolytic anaemia
- increase number of reticulocytes
- direct Coombs test will be positive in autoimmune haemolytic anaemia
What can help anaemia of chronic disease that occurs in patients with renal failure
Erythropoietin
What are the side effects of erythropoietin
- dose-dependent rise in blood pressure
- hypertensive crisis - symptoms suggestive of encephalopathy and seizures that require hospital admission
- hyperkalemia
- pure red cell aphasia
- Steven-johnson syndrome
- toxic epidermal necrolysis
when should Erythropoietins be given
Overcorrection of haemoglobin in patients with chronic kidney disease may increase the risk of death and serious cardiovascular events, and so the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK advise that patients should not be treated with erythropoietins for the licenced indications in chronic kidney disease (and cancer) unless they have symptomatic anaemia
- patients haemoglobin should not go above 12g/decilitre during treatment
What degree of anaemia warrants urgent action in older age
urgent 2 week referral
- all patients aged 60 and over with iron deficiency anaemia (haemoglobin of less than 12g/Decilitire or less for men and 11g/decilitre or less for women)
- all patients aged under 50 with rectal bleeding and unexplained iron deficiency anaemia (haemoglobin of 12 g/decilitre or less for men and 11 g/decilitre or less for women)
what is iron deficiency anaemia in elderly people due to
Iron deficiency anaemia in elderly people is due to gastrointestinal blood loss until proven otherwise
where is the blood loss usually in the GI tract
- Upper gastrointestinal tract in 20-40% of patients
- Lower gastrointestinal tract in 15-30% of patients
- Upper and lower gastrointestinal tract in 1-15% of patients.
How does carcinoma of the caecum present
Carcinoma of the caecum may present as iron deficiency anaemia without there being any bowel symptoms whatsoever.
What drugs can contribute to iron deficiency anaemia
Aspirin and NSAIDS
Assuming there is no blood loss how quickly do you except the haemoglobin level to rise after being prescribed iron
By 2 g/decilitre per month
What is the treatment of iron deficiency
oral iron
who should blood transfusions be reserved for in iron deficiency
blood transfusions should be reserved for patients with symptomatic anaemia in spite of iron therapy, or for those at risk of cardiovascular instability because of the extent of their anaemia, particularly if they are due to undergo endoscopy before you expect to see a response to oral iron treatment
What is the aim of blood transfusion in iron deficiency
- haemoglobin has to be restored to a safe rather than necessarily a normal level and that transfusions should be followed with a course of oral iron to replenish iron stores
who should be offered upper and lower GI investigations for people with unexplained iron deficiency anaemia
- all men and postmenopausal women with unexplained iron efficiency
- endoscopy
- if contradicted then CT colonography or barium enema
- screening for coeliac disease either with antibody testing or with examination of a duodenal biopsy specimen
- if respond well to oral iron treatment then further imaging not needed
- NSAIDS and Aspirin should be stoped
- dietary deficiency corrected
what happens if the patient doesn’t respond well to oral iron in iron deficiency anaemia a
- video capsule endoscopy or CT/MRI of the small bowel, a repeat gastroscopy, and helicobacter pylori testing
- an advantage of CT scanning is that it may identify pathology outside the GI tract such as renal tumours
what is useful when patients cannot tolerate absorbed oral iron
- parenteral iron can be useful when patients cannot tolerate or absorb iron
what environment should parenteral iron be given in
- only in environments where patients can be adequately monitored and where cardiopulmonary resuscitation equipment is available
- anaphylactic reactions can occur when patients are given parenteral iron
- need to be given in a hospital setting
when the haemoglobin returns to normal after taking iron how long should you continue the oral iron medication
- when her haemoglobin level returns to the normal range you should continue treatment for another three months to replenish the body’s iron stores
what treatment is used for iron deficiency anaemia
ferrous sulphate is probably the most effective treatment for iron deficiency
what does a 200mg of ferrous sulphate contain
- 65mg of elemental iron
How much iron does a western diet contain
15-20mg of iron per day
what is total body iron
Total body iron is about 4 g of which around 75% is present within the red blood cells as haemoglobin
if a patient has macrocytic anaemia and a poor diet what is the likely cause of it
folate deficiency
around 25% of elderly patients with folate deficiency have a…
Normocytic anaemia
why should you not give folic acid straight away
In a patient with both B12 and folate deficiency, correction of the folate alone may precipitate subacute combined degeneration of the spinal cord, and so you should never treat patients with megaloblastic anaemia with folic acid unless you know that the serum vitamin B12 level is normal.
What drugs can folate deficiency lead to
- phenytoin
- methotrexate
How should you treat folate deficiency
You should treat patients who have megaloblastic anaemia secondary to folate deficiency with a daily dose of folic acid (5 mg/day) for at least four months
What are myelodysplastic syndrome
Myelodysplastic syndromes (MDS) are conditions that can occur when the blood-forming cells in the bone marrow become abnormal. This leads to low numbers of one or more types of blood cells.
what are the spectrum of presentation of myelodysplastic syndromes
- Mild macrocytic anaemia requiring occasional monitoring of her full blood count - this is the stage of disease that Mrs Berry has at present
- Worsening anaemia which may require occasional or regular blood transfusions
- Pancytopenia putting the patient at risk of infection and/or bleeding
- Very occasionally, transformation to an acute leukaemia.
What does a patient need to have capacity
- Understand the question
- Retain the information
- Weigh up the risks and benefits of any given issue
- Communicate the decision (either verbally, or non verbally).
What is pernicious anaemia
Pernicious anaemia is an autoimmune disease of the stomach and gastric parietal cells. This leads to loss of intrinsic factor from the stomach and, as a result, failure of vitamin B12 absorption from the terminal ileum.
Who is pernicious anaemia common in
- common in people with other autoimmune disorders such as autoimmune hypothyroidism
Where is B12 absorbed
- absorption occurs in the terminal ileum
what can also lead to macrocytosis
- untreated hypothyroidism
- chronic liver disease
- excess alcohol consumption
- myelodyplastic syndrome
What is the treatment for pernicious anaemia
- IM injections of hydroxocobalamin = alternate days for two weeks and then every three months for the rest of your life
what can treatment of pernicious anaemia result in
- In patients with severe vitamin B12 deficiency, replacement of vitamin B12 can cause a marked reticulocytosis. The reticulocytes can start to use up all the available potassium and as a result hypokalaemia can occur.
- Another cause of an incomplete response to vitamin B12 replacement would be coexisting untreated or undertreated hypothyroidism
what are loose stools suggestive of
Loose stools which take a couple of flushes to flush away are suggestive of steatorrheoa. Steatorrhoea and weight loss despite a normal appetite point to a diagnosis of malabsorption.
How important is conjunctival pallor in determining the presence of anaemia
The presence of conjunctival pallor, without other information suggesting anaemia, is reason enough to perform a haemoglobin determination. The absence of conjunctival pallor is not likely to be of use in ruling out severe anaemia
