Anaemia

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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221 Anaemia

Patient 1

Instruction

Would you like to ask this anaemic patient a few questions?

Salient features

History

• Ask about the following:

• Blood loss such as bleeding per rectum, melaena, haematemesis
• Menstrual blood loss: duration of periods, the occurrence of clots and the number of sanitary towels or tampons used
• Drug history: NSAIDs, phenytoin, chloramphenicol
• Associated symptoms such as weight loss, shortness of breath, chronic diarrhoea
• Diet: in vegans, alcoholics, elderly patients
• Past history of gastrectomy
• Family history.

Diagnosis

This patient’s anaemia is caused by severe melaena, which indicates bleeding in the upper GI tract and is probably the result of peptic ulcer or bleeding varices (aetiology). The patient is currently receiving a blood transfusion, indicating that the anaemia was severe (functional status).

Patient 2

Instruction

Would you like to examine this anaemic patient?

Salient features

Examination

• Examine:

• nails for koilonychia or iron-deficiency anaemia and (rarely) for clubbing of infective endocarditis
• tongue for pallor, atrophic glossitis and angular stomatitis of vitamin B12 deficiency (Fig. 221.1)
• mouth for angular stomatitis of severe malnutrition and ulcers of neutropenia
• lymph nodes in the neck, axillae and groin (secondaries, lymphoproliferative disorders)
• skin for bruising associated with bone marrow depression, seen in leukaemia and aplastic anaemia
• abdomen for hepatomegaly, splenomegaly and other masses
• legs for ulcers seen in haemoglobinopathies.

• Comment on the pallor of the face and conjunctiva, looking for the lemon-yellow hue of pernicious anaemia.

• Comment on the ethnic origin (thalassaemia).

• Tell the examiner that you would like to:

• do a rectal examination and inspect the stool for occult blood
• do an FBC including a peripheral smear and ESR.
image

Fig. 221.1 Iron-deficiency anaemia leading to pallor of the face, lips and tongue plus atrophic glossitis and angular stomatitis.

(With permission from Forbes, Jackson 2003.)

Diagnosis

This patient has koilonychia and anaemia indicating an iron-deficiency anaemia. I would like to exclude a GI cause for the blood loss (aetiology).

Questions

Mention a few causes of anaemia

• With a low mean corpuscular volume (MCV):

• Iron-deficiency anaemia
• Thalassaemia
• Sideroblastic anaemia.

• With a high MCV:

• Vitamin B12 deficiency: pernicious anaemia, vegans, alcoholics, coeliac disease
• Folate deficiency: pregnancy, phenytoin, sprue, coeliac disease, malignancy, haemolysis
• Other: myxoedema, liver disease, alcoholics.

• With a normal MCV:

• Uraemia
• Malignancy
• Rheumatoid arthritis
• Aplastic anaemia: myelofibrosis, chloramphenicol, phenylbutazone, gold, anticancer drugs.

What do you know about the Paterson–Kelly syndrome?

It comprises iron-deficiency anaemia and dysphagia from oesophageal webs in middle-aged women. The clinical significance of this syndrome is uncertain. It is also known as Plummer–Vinson syndrome.

What are the common causes of iron-deficiency anaemia?

Occult GI bleeding from the following:

• Peptic ulcer

• Carcinoma located anywhere in the GI tract

• Excessive anticoagulation

• Hereditary haemorrhagic telangiectasia

• Angiodysplasia of the colon.

How would you investigate microcytic anaemia?

• FBC

• Serum ferritin

• Faecal occult blood

• Upper GI endoscopy

• Barium enema, colonoscopy

• International normalized ratio (INR), prothrombin time and platelet count

• Haemoglobin electrophoresis in susceptible ethnic groups (Asians, Afro-Caribbeans).

How would you investigate macrocytic anaemia?

• Peripheral smear

• Vitamin B12 and red-cell folate and serum folate concentrations

• Serum ferritin, plasma iron and total iron-binding capacity (for associated iron deficiency)

• Schilling test

• Gastric parietal cell and intrinsic factor antibodies

• Upper GI endoscopy

• Reticulocyte count (a high MCV could be present when the reticulocyte count is >50%)

• Bone marrow examination.

When is a peripheral smear useful in the evaluation of anaemia?

When there is suspicion of:

• Sickle cell disease: dactylitis or sudden splenic enlargement and pallor in a young child, or limb, abdominal or chest pain in an older child or adult

• Thrombocytopenia (e.g. petechiae or abnormal bruising) or neutropenia (e.g. unexpected or severe infection)

• Lymphoma or other lymphoproliferative disorder (lymphadenopathy, splenomegaly): enlargement of the thymus (a mediastinal mass on radiology) or other lymphoid organs, skin lesions suggestive of infiltration, bone pain and systemic symptoms such as fever, sweating, itching and weight loss

• Myeloproliferative disease: splenomegaly, plethora, itching or weight loss

• Disseminated non-haematopoietic cancer: weight loss, malaise, bone pain

• Disseminated intravascular coagulation

• Infectious mononucleosis or other viral infection or inflammatory or malignant disease: general ill health, often with malaise and fever

• Bacterial or parasitic disease

• Acute or recent-onset renal failure or unexplained renal enlargement

• Retinal examination reveals haemorrhages, exudates, signs of hyperviscosity, optic atrophy

• Unexplained jaundice, anaemia or both.

RF Schilling (b. 1919), Chairman of the Department of Medicine and haematologist at the University of Wisconsin.

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