professor anwar sheikha md, frcp, frcpath., fcap, frcpa, frcpi, facp senior consultant clinical...
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Professor
Anwar SheikhaAnwar SheikhaMD, FRCP, FRCPath., FCAP, FRCPA, FRCPI, FACP
Senior Consultant Clinical & Lab. Hematologist
Clinical Professor of HematologyUniversity of Mississippi Medical Center, Jackson,
Mississippi
C.E.O., Raziana Company for Health Services, Hawler, IRAQ
Anemias
Reduction in the concentration of Hb below what is normal for age and sex
? ↓ RCCIs a Hb of 12 g/dL anemia?
Hb(g/dL)
Male Female Neonate 2-3 month13-17 12-15 13.5-19.5 9.5-13.5
Anemias
REDISTRIBUTION 2,3 DPG
C.O. PLASMA
Anemia
HYPOXIA
COMPENSATORYMECHANISMS
C.O.PATHOPHYSIOLOGY
OF ANEMAIS
Anemias TIREDNESS
LASSITUDE
EASYFATIGUABILITY
MUSCLE WEAKNESS
CLINICAL FEATURES
PALLORGI
GUS CVSCNS
Anemias
Etiological Morphological
Classification
AnemiasETIOLOGIC
Classification
BLOODLOSS
IMPAIREDRED CELL
FORMATION
INCREASEDRED CELL
DESTRUCTION
I
II III
AnemiasETIOLOGIC
Classification
BLOODLOSS
IMPAIREDRED CELL
FORMATIONHEMOLYTICANEMIAS
I
II III
CHRONICACUTE
DEFICIENCYNON
DEFICIENCY
RBCABNORMALITIES
RBC ENVIRONMENTABNORMALITIES
AnemiasDEFICIENCY ANEMIAS
ANEMIAS DUE TO DEFICIENCY OF SUBSTANCES ESSENTIAL FOR ERYTHROPOIESIS
IRONDEFICIENCYANEMAIS
MEGALOBLASTICANEMAIS
AnemiasNON
DEFICIENCY ANEMIAS
ANEMIAS NOT DUE TO DEFICIENCY OF SUBSTANCES ESSENTIAL FOR ERYTHROPOIESIS
APLASTICANEMIA
ACDANEMIA
OFCHRONIC
DISORDERS
ANEMIAOF
BONE MARROWINFILTRATION
AnemiasNON
DEFICIENCY ANEMIAS
ANEMIAS NOT DUE TO DEFICIENCY OF SUBSTANCES ESSENTIAL FOR ERYTHROPOIESIS
AAACDBM
INFILTRATION
INFECTION
COLLAGEN DISEASES
RENAL FAILURE
LIVER FAILURE
MALIGNANCY
LEUKEMIAS
LYMPHOMAS
MYELOMA
MYELOFIBROSIS
AnemiasOTHERNON
DEFICIENCY ANEMIAS
SIDEROBLASTIC ANEMIAS
CONGENITALDYSERYTHROPOIETIC
ANEMIAS
AnemiasMORPHOLOGIC
Classification
IIHYPOCHROMIC
MICROCYTIC
IIIMACROCYTIC
ANEMIAS
INORMOCYTIC
NORMOCHROMIC
Iron DeficiencyThalassemias
ACD
Megaloblastic
Macrocytosis
Megaloblastic AlcoholismLiver Diseases
“Alcoholic”
Reticulocytosis Hypothyroidism Chemotherapy
Sideroblastic Anemia LEA Paraproteinemias
Leukemias MDS 5q- Syndrome
MPDNewborn Pregnancy
Chronic Respiratory Failure
Iron Deficiency Anemias
IRON
4% of Earth’s Crust
3 to 5 grams in Adult Human
Hb1.5 to 3.0
gm
Storage1.2 to 2.0
gm
Essential Plasma
0.3gm
3 to 4mg
Hemosiderin
Ferritin
Iron Metabolism
Bone Marrow RES
Circulating RBC
PlasmaAbsorption Excretion1 mg 1 mg
30 mg
23 mg23 mg
30 mg
7 mg
AnemiasDAILY IRON LOSSES & REQUIREMTNS
Daily Loss
Menses
Growth
TotalLoss
INFANTS: 0- 4 INFANTS: 0- 4 mm
5-12 5-12 mm
0.50.5
0.50.5 0.50.50.50.5
1.01.0
CHILDCHILD 0.50.5 0.50.5 1.01.0
ADOLESCENT MALEADOLESCENT MALE 0.90.9 0.90.9 1.81.8ADOLESCENT ADOLESCENT FEMALEFEMALE
0.90.9 1.01.0 0.50.5 2.42.4MENSTRUATING MENSTRUATING
FEMALEFEMALE0.90.9 1.91.9 2.82.8
ADULT MALEADULT MALE 0.90.9 0.90.9POST-POST-MENAPAUSALMENAPAUSAL
0.90.9 0.90.9
AnemiasFACTORS AFFECTING IRON ABSORPTION
Favored By: Organ meat & Hem
iron Ferrous form Acid pH (e.g., Gastric
HCL) Vitamin C Low M.Wt. Chelate
(Sugar) Iron Deficiency Increased
Erythropoiesis Pregnancy
Reduced By:Reduced Animal FoodFerric formAlkalies (Pancreatic
secretion)
TeaIron overloadDecreased ErythrpoiesisAcute or Chronic
inflammation
Anemias
PALLOR
AnemiasGLOSSITIS
Anemias
DYSPHAGIA
AnemiasMARROW IRON STORES
AnemiasIRON DEFICIENT MARROW
Anemias
IRON DEFICIENT ERYTHROPOIESIS
Anemias
Ancylostoma
Anemias
Ca Colon
Causes of Iron deficiency Anemias
BLOODBLOODLOSSLOSS
MALABSORPTION
DIETARY
Causes of Iron deficiency Anemias
BLOODBLOODLOSSLOSS
MALABSORPTION DIETARY
UTERINE
Menorrhagia
Pregnancy
Post-Menopausal
Bleeding
GITEsophageal varices
Hiatus HerniaPU
AspirinHookworm
HHT
Cancer (Stomach; Colon)
Ulcerative Colitis
Meckle’s
Piles
RENAL
Hematuria
Hb-uria
LUNGS
BLEEDING
SELF-INDUCED
20 mg of iron is lost with each menstrual period
Iron loss per pregnancy ranges from 500 to 1000 mg
During vaginal delivery about 500 ml of blood is lost
In pregnancy, plasma volume is increased by 50%,while red cell mass is only increased by 10%-20%
in women not receiving iron and by 30% in those taking iron
This disproportionate expansion of plasma relative to red cell mass creates a state of dilutional anemiawhich is called physiological anemia of pregnancy.
Women with a hemoglobin level of < 9 gm/dl or > 13 gm/dL have an increased risk of poor fetal outcome
P R
E G
N A
N C
Y &
I R O
N
Anemias
Causes of Iron deficiency Anemias
BLOODLOSS
MAL-ABSORPTION
CeliacGastrectomy
Atrophic GastritisClay Eating
DIETARY
HEPCIDINIRONABSORPTION
SEQUENCE OF
EVENTS IN
IRON DEFICINCY
SEQUENCE OF EVENTS IN IRON DEFICINCY I
Hb 15 g/dL
RCC 5 million/ uL
MCH 30 pg Hct. 0.45
MCHC 35 g/dL
MCV 86 fL
Serum Iron UIBC
100 ug/dL 200 ug/dL
TIBC= 300 ug/dL
Saturation 33%
FERRITIN 150 ug/L
WBC7,500/uL
Platelet200,000/uL
SEQUENCE OF EVENTS IN IRON DEFICINCY II
BLEEDING
40 ml/ Day
20 mgIRON
Iron Absorption
up to5
mg/Day
Net Daily Loss= 20-5 = 15 mg
1500------ = 100 Days 15
Latent Iron
Deficiency
No Clinical FeaturesNormal Blood Values
Increased Iron Absorption↓Iron/ ↑TIBC/ ↓Ferritin
SEQUENCE OF EVENTS IN IRON DEFICINCY III
IRONDEFICIENCY
ANEMIA
↓ MCH
↓ MCHC
↓Iron ↑ TIBC
↓ Ferritin
APKHypochromiaMicrocytosisThrombocytosis
↓Hb ↓ MCV
↑ RDW
NAILPaleDryBrittleRidgesFlatKoilonychia
Glossitis
AngularStomatitis
DYSPHAGIAKelly
PatersonWhite
Syndrome
Pica
AtrophicGastritis
MANAGEMENT OF
IRON DEFICIECY ANEMIA
ORAL IRON THERAPY
Avoid giving iron blindly to all hypochromic microcytic anemias
Always evaluate iron status & look at blood smear
Thalassemia minor patients or sideroblastic anemia patients
do not need iron; they are already iron overloaded.
MANAGEMENT OF IRON DEFICIECY ANEMIA
Treatment of theUnderlying Cause
(e.g., Colon Cancer)
Correction of theDeficiency withInorganic Iron
Blood Loss is the usual cause of Iron Deficiency
Whenever possible the site of blood loss must beidentified and the lesion treated
Always give iron since the deficiency cannot be corrected from normal diet for many years
Even in most severe iron deficiency anemia states, the amount of dietary iron absorbed cannot increase above 5 mg/day.
Likewise, no matter how much is the extent of iron overload, obligatory iron loss cannot exceed 5 mg/day.
In severe iron deficiency anemia, up to 30 mg of iron can be absorbed if 180 mg of elemental iron is prescribed.
ORAL IRON THERAPY
IRON SALTIRON SALT TABLET TABLET STRENGTHSTRENGTH
((mgmg))
ElementalElemental
Iron ContentIron Content
((mgmg))
Ferrous SulphateFerrous Sulphate 200200 6363
Ferrous Ferrous GluconateGluconate
300300 3535
Ferrous Ferrous SuccinateSuccinate
100100 3535
Ferrous Ferrous FumarateFumarate
200200 6565Adult: 100 to 200 mg of Elemental Iron/dayChildren: 1 mg/kg tid as Liquid Iron (Teeth Staining)Space the doses as absorption is impaired for 4 hrs > dose
SIDE EFFECTS OF ORAL IRON THERAPY
GIT Irritation Nausea
Epigastric PainConstipation
Diarrhea
Reduce Iron Dose
Change to Low Iron Tab
Take Iron with Meal
Avoid Enteric-Coated & Sustained Release tabletsas iron is released past sites of optimal absorption
Give Iron for 6 months to correct anemia & replenish stores
Correction of Ferritin is a good guide for adequate treatment. Ferritin should be donea week after stopping iron
Reticulocytosis starts > 3 days & lasts 3 weeks
Ideally expect Hemoglobin rise of 1 gm/dL/weekor at least 2 gm/3 weeks
ORAL IRON THERAPY
FAILURE OF RESPONSETO ORAL IRON THERAPY
*Continued hemorrhage*Intolerance to Oral Iron*Lack of Compliance*Malabsorption*Incorrect Diagnosis*ACD “Anemia of Chronic Disorders”*H. pylori
PARENTERAL IRON THERAPY
Usually unnecessary & misused
Unfortunately Kurdish patients seem to enjoy the pain!
Oral Iron can provide marrow with more iron than its capacity to produce red cells
Parenteral Iron does not rise Hemoglobin faster than oral iron
IRON MUST BE GIVEN BY DEEP DEEP INTRAMUSCULAR INJECTIONS
INDICATIONS FOR
PARENTERAL IRON THERAPY
•Genuine Iron Intolerance
•GIT Disorders (Ulcerative Colitis; Crohn’s Disease)
•Celiac Disease “occasionally”
•Rapid repletion of iron stores (late preganacy; pre-operative; continued bleeding)
TOTALDOSE
INFUSIONOF
IRON
PARENTERAL IRON PREPARATIONS
“Iron Dextran”“Iron Sucrose”
IMFERONi.v. i.m.
JECTOFERi.m.
Facilities for CPR should be at hand
Avoid in Allergic Disorders (Asthma; Eczema; Anaphylaxis)
Only give oral iron > 5 days from last injection
Fefol
Vitamin C
MEGALOBLASTIC ANEMIAS
MEGALOBLASTIC ANEMIAS
Distinctive morphology of developing red cells in the bone marrow
B12↓ Folate↓
Others
Pernicious Anemia is rare in Kurdistan & ME
MEGALOBLASTIC ANEMIAS
BB1212 FolateFolate
Content in Content in
FoodFoodMeat: Meat: RichRich
Veg. PoorVeg. PoorMeat: Meat: ModerateModerate
Veg. Veg. RichRich
Cooking EffectCooking Effect 10-30% Loss10-30% Loss 70-100% Loss70-100% Loss
Daily Daily RequirementRequirement
1 ugm1 ugm 100 ugm100 ugm
Daily IntakeDaily Intake 5-30 ugm5-30 ugm 500-800 ugm500-800 ugm
AbsorptionAbsorption Terminal Terminal
ileumileumDuodenum & Duodenum & JejunumJejunum
StoresStores 2-5 mg2-5 mg 5-10 mg5-10 mg
Serum LevelSerum Level 160-925 160-925 ng/Lng/L
3-15 ugm/L3-15 ugm/L
MEGALOBLASTIC ANEMIAS
Causes of Vitamin B12 Deficiency
•Nutritional Vegans•Malabsorption
• Gastric:• Pernicious Anemia• Gastrectomy
• Intestinal:• Stagnant Loop• Tropical sprue• Ileal Resection & Crohn’s Disease• Fish Tapeworm
MEGALOBLASTIC ANEMIAS
Causes of Folate Deficiency
Dietary: Old Age; Infancy; Poverty; Alcoholics; Chronically invalids
Malabsorption: Celiac; Tropical Spru
Excess Use: Physiological (Pregnancy; Lactation; Prematurity)
Pathological (HA; MF; Cancer; Inflam. Diseases)
MEGALOBLASTIC ANEMIAS
Pernicious Anemia
Severe lack of Intrinsic Factor from Gastric Atrophy
Common in Europe & America; rare in ME
Macrocytosis; Low B12; Positive Schilling Test
Dramatic response to treatment
MEGALOBLASTIC ANEMIAS
MEGALOBLASTIC ANEMIAS
MEGALOBLASTIC ANEMIAS
Clinical Features
Anemia symptoms
Low Platelet & WBC
PallorWith a tinge
OfJaundice
Bruises from Thrombocytopenia
GLOSSITIS
ANGULARSTOMATITIS
SUBACUTE
COMBINEDDEGENRATION
OFTHE
SPINAL CORD
Premature GreyingBlue EyesVitiligo
BONEMARROW
ASPIRATION
HYPERCELLULARFRAGMENTS
&TRAILS
MEGALO-BALSTIC
ERYTHRO-POIESIS
Late
Intermediate
Early Megaloblasts
MANAGEMENTOF
MEGALOBLASTIC ANEMIAS
R/ B12 1000 ugm i.m. every other day
for 6 doses every 3 month
Folate 5 mg daily
In undiagnosed megaloblastic anemiaReplenish B12 before giving Folate
otherwise neuropathy is precipitated
Give prophylactic Folate in Pregnancy, Prematurity & HA
ىژهروپ رازیانه كومبانياىه نجه خانه ىپنه خوشخانه و شير
كاتەميديا دروست د
له بریتیه پزيشکان ۲۰۰پروژهكه مالى كلينيكو كومهلگاى و نهخوش ژورى
MEDIA MEDICAL & CANCER CENTER
MEDIA MEDICAL & CANCER CENTER
A 200 BED HOSPITAL, MEDICAL OFFICE BUILDINGS & A RESIDENCE VILLAGE AT A COST OF ~ $50 MILLION
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