Macrocytic anaemia

Question 1

An 87 year old man is fatigued and pale. His FBC shows Hb 78 g/L (>130), MCV 108 (80-100), platelets 168 (>140). How would you assess and manage him?

Answer 1

Impression
Given sx of pallor and fatigue in setting of FBC findings, this is a presentation of macrocytic anaemia. Consider megaloblastic (B12/folate deficiency - pernicious anaemia) and non-megaloblastic causes (liver disease). Given patients age, would also want to rule out malignancy as potential cause.

• rule out acute bleeding as a cause of the anaemia (most common is bowel bleeding in elderly patients)

Goals

• undertake thorough H/E/I to determine underlying cause for anaemia
• rule out red flag differentials
• initiate appropriate acute and ongoing management

Question 2

Macrocytic anaemia - Assessment

Answer 2

Assessment
would start initially with ABCDE assessment to ensure haemdynamic stability.
Given Hb of 78, if symptomatic/unstable would consider immediate RBC transfusion with packed RBCs.

Question 3

Macrocytic anaemia - History

Answer 3

History

• sx: fatigue, SOB, chest pain, pica, pallor
• REDF: haematochezia, malena, fevers, night sweats, weight loss, neurological deficits, peripheral neuropathy
• PMHx: autoimmune disease, alcoholism/substance use (quantify intake), chronic liver/kidney disease
• SNAP

Question 4

Macrocytic anaemia - Examination

Answer 4

Examination

• General inspection: Pallor (conjunctival, palmar crease), cap refill, beefy tongue, skin rashes
• Cardiorespiratory examination: murmurs
• Haematological examination: spleen, bone pain, etc

Question 5

Macrocytic anaemia - Investigations

Answer 5

Investigations

• Bedside: vitals
• Bloods: FBC, peripheral blood smear, B12/Folate level, anti-parietal cell antibodies, anti-intrinsic factor antibodies (if suspicious), UEC, LFT, CMP, TFT, iron studies, Group + cross-match for transfusion
• Imaging: nil indicated. Otherwise diagnostic/staging imaging for haematological malignancy.
• Other: bone-marrow biopsy if suspicious, upper & lower endoscopy for ?bowel malignancy

Question 6

Macrocytic anaemia - Management

Answer 6

Management
Acute
- blood transfusion if symptomatic
- haematology referral if no cause identified
- gastro referral for further investigation

Ongoing

• B12/Folate replacement (loading doses every second day x 3 then every 3-6 monthly, folate is oral tablet
• Alcohol counselling and cessation advice (if relevant)
• Treat underlying comorbid conditions (liver disease, etc)
• Dietician review