Haem Flashcards
What are the risk factors for DVT?
- immobility
- recent surgery
- long haul flights
- pregnancy
- hormone therapy with oestrogen
- malignancy
- polycythaemia
- SLE
- thrombophilia
Examples of thrombophilia
- antiphospholipid syndrome
- antithrombin deficiency
- protein C or S deficiency
- factor V Leiden
How and when do we give DVT prophylaxis?
- all patients are assessed for their risk
- low molecular weight heparin e.g
enoxaparin - contraindication with active bleeding or existing anti coagulation
- anti-embolic stockings unless they have peripheral arterial disease
DVT presentation
Usually unilateral
Calf or leg swelling
Tenderness to the calf
Oedema
Colour changes to the leg
More than 3cm difference in circumference between legs (10cm below tibial tuberosity)
What is the Wells Score?
Risk of a patient with symptoms actually having a DVT or pulmonary embolism.
Takes into account risk factors and clinical findings
How is DVT diagnosed?
- D-dimer is a sensitive test, so good to exclude DVT.
- US Doppler
- CT angiogram for PE
In what conditions is D dimer raised?
DVT Pneumonia Malignancy Heart failure Surgery Pregnancy
Management of DVT
- Initial - LMWH even before confirmation of diagnosis e.g enoxaparin, dalteparin
- Long-term use warfarin, DOAC or LMWH
- IVC filter is a sieve that collects clots in the IVC - used it unsuitable for anti coagulation and have recurrent PEs
When does each type of leukaemia usually present?
ALL CELL MATES HAVE COMMON AMBITIONS
- ALL = less than 5 or over 45
- CLL = over 55
- CML = over 65
- AML = over 75
How does leukaemia present?
fatigue, fever, pallor, petechiae, abnormal bruising, abnormal bleeding, lymphadenopathy, hepatosplenomegaly
What causes petechiae?
thrombocytopenia
Caused by: leukaemia, meningococcal septicaemia, vasculitis, Henoch-Schonlein purpura, idiopathic thrombocytopenia, non-accidental injury
How is leukaemia diagnosed?
petechiae + hepatosplenomegaly = urgent referral
blood film
raised LDH
bone marrow biopsy
LP to check to CNS involvement
CT, MRI, PET for staging and assessing
What are the 2 types of bone marrow biopsy?
Aspiration - liquid, quicker
Trephine - solid, slower, better to see cells
What causes ALL and what is it associated with?
Malignant change in a lymphocyte precursor cells
- acute proliferation, usually B lymphocytes
- film shows blast cells
- associated with DOWNS SYNDROME
- Philadelphia chromosome 9:22 translocation
What causes CLL and what is it associated with?
- chronic proliferation of a well-differentiated lymphocyte
- usually a B lymphocyte
- often asymptomatic but can present with anaemia, bleeding and weight loss
- warm autoimmune haemolytic anaemia
- can transform into a high-grade lymphoma
- film shows smear or smudge cells
CLL can transform into _____
high-grade lymphoma
What cause AML and what is it associated with?
- most common acute leukaemia in adults
- transformation of myeloproliferative disorder e.g. polycythaemia vera or myelofibrosis
- film shows blast cells with rods (auer rods)
What causes CML and what is it associated with?
- chronic, accelerated and blast phases
- raised WBC (asymptomatic) to anaemia, thrombocytopenia and immunocompromised to severe symptoms (fatal)
- philadelphia chromosome
How is leukaemia managed? Side effects?
Chemo and steroids are primary
radiotherapy, bone marrow, surgery
But can chemo can cause: stunted growth, infections, neurotoxicity, infertility, cardiotoxicity
What is tumour lysis syndrome?
release of uric acid from killed tumour cells
- forms crystals in interstitial tissue and tubules of kidneys causing an AKI
- use allopurinol or rasburicane to reduce uric acid
- potassium and phosphate can also rise to monitor calcium levels
What is lymphoma?
group of cancers that affect the lymphocytes inside the lymphatic system.
When does Hodgkin’s Lymphoma present?
peaks around 20 and 75
Risk factors for Hodgkin’s lymphoma
HIV
EBV
Autoimmune conditions such as RA and sarcoidosis
Family history
How does Hodgkin’s lymphoma present?
- lymphadenopathy is key
- non-tender and rubbery
- can be pain in nodes when they drink
- fever, night sweats, weight loss
- fatigue
- itching
- cough
- SOB
- abdominal pain
- recurrent infections
Investigations for Hodgkin’s lymphoma
raised LDH
lymph node biopsy is key
- Reed-Sternberg test = abnormally large B cells with multiple nuclei inside them
- CT, MRI and PET for staging
What is Ann Arbor Staging?
used for all lymphoma
puts importance on whether the affected nodes are above or below the diaphragm
Stage 1: confined to one region of lymph nodes
Stage 2: in more than one region but on the same side of the diaphragm
Stage 3: affects nodes above and below the diaphragm
Stage 4: widespread involvement including non-lymphatic organs such as the lungs or liver
How is Hodgkin’s lymphoma treated?
chemo and radio
can lead to leukaemia and infertility due to chemo
radio can lead to cancer, tissue damage and hypothyroidism
Give some examples of Non-Hodgkin Lymphomas and their associations
- Burkitt = EBV, malaria and HIV
- MALT = H.pylori
- Diffuse large B cell = rapidly growing mass in over 65s
Risk factors for non-Hodgkin’s
HIV EBV H pylori Hep B or C Exposure to trichloroethylene Family history
Treatment of non-Hodgkin’s lymphoma
- watchful waiting
- chemo
- rituximab
- radio
- stem cell transplant
What is anaemia?
low level of Hb in the blood as a result of an underlying disease
What are the 3 main categories of anaemia?
Microcytic, normocytic and macrocytic
What are the causes of microcytic anaemia?
TAILS
Thalassaemia Anaemia of chronic disease Iron deficiency anaemia Lead poisoning Sideroblastic anaemia
What are the causes of normocytic anaemia?
3As and 2Hs
Acute blood loss Anaemia of chronic disease Aplastic anaemia Haemolytic anaemia Hypothyroidism
What are the causes of macrocytic anaemia?
can be megaloblastic (due to impaired DNA synthesis) or normoblastic
Megaloblastic = B12 or folate deficiency
Normoblastic = alcohol, reticulocytosis, hypothyroidism, liver disease, azathioprine
Symptoms of anaemia
Signs on examination
- tiredness
- SOB
- headaches
- dizziness
- palpitations
- worsening of other conditions
- Pale skin
- conjunctival pallor
- tachycardia
- raised RR
- koilonychia (iron deficiency)
- angular chelitis (iron deficiency)
- atrophic glossitis
- jaundice (haemolytic)
What symptoms are specific to iron deficiency anaemia?
Pica (describes dietary changes for abnormal things such as dirt)
Hair loss
How should anaemia be investigated?
Hb, MCV, B12, folate, ferritin, blood film
OGD and colonoscopy to look for GI cause of unexplained iron deficiency anaemia
Bone marrow biopsy if the cause is unclear
In what broad scenarios can iron deficiency anaemia occur?
- insufficient dietary iron
- iron requirements increase (pregnancy)
- iron lost (slow bleeding)
- inadequate iron absorption
How can PPIs cause iron deficiency?
- reduces the stomach acid
- stomach acid is required to keep the iron soluble (Fe2+)
- Fe3+ is insoluble
Causes of iron deficiency anaemia?
- blood loss (menorrhagia or in GI tract, oesophagitis or gastritis)
- dietary insufficiency
- poor iron absorption (IBD, coeliac)
- increased requirements during pregnancy
What would a high/low ferritin level suggest?
Low suggests iron deficiency
High suggests inflammation
(can have normal ferritin level if you have both)
What does a high/low total iron binding capacity suggest?
- marker for how much transferrin is in the blood
- increases in iron deficiency
- decreases in iron overload
What does transferrin saturation tell us?
- total iron in the body
- normal is around 30%
- less iron in body = less saturation of transferrin
- more iron in body = more saturation of transferrin
What two things can increase the values of all the iron markers to suggest iron overload?
- supplementation
- acute liver damage
What is pernicious anaemia?
autoimmune condition where antibodies form against the parietal cells or intrinsic factor, preventing the absorption of vitamin B12
What antibodies can be investigated to diagnose pernicious anaemia?
- intrinsic factor antibody
- gastric parietal cell antibody
How can we treat pernicious anaemia/B12 deficiency?
- dietary deficiency can be treated with cyanocobalamin
- the anaemia can be treated with hydroxocobalamin to sort out the absorption
What should you treat first: B12 or folate deficiency?
- B12 because treating the folate first can lead to subacute combined degeneration of the cord
Haemophilia A is caused by a deficiency in factor ____
VIII
Haemophilia B is caused by a deficiency in factor
IX
Describe the inheritance pattern of haemophilia
X linked recessive
So men only need one abnormal X whereas women can be carrier
Almost exclusively affects males
Signs and symptoms of haemophilia
- spontaneous haemorrhage
- usually presents in neonates with intracranial haemorrhage, haematomas and cord bleeding.
- abnormal bleeding into joints and muscles are classic feature of severe haemophilia
- bleeding into gums, GI tract, urinary tract, intracranial, following procedures
How is haemophilia diagnosed?
based on bleeding scores, coagulation factor assays and genetic testing
How should haemophilia be managed
- by a specialist
- replace the relevant clotting factor by intravenous infusions, either prophylactic or in response to bleeding
Acute = infusions of factor, desmopressin to simulate VWF and antifibrinolytics (tranexamic acid)
Complication of haemophilia treatment
antibodies against clotting factor resulting in the treatment becoming ineffective
