cause of the anemia , clinical features and the managment

anemia , clinical features and management

1. APPROACH TO ANEMIA Presenter: Dr. Pradeep Bastola Moderator: Asso. Prof. Dr. Soniya Dulal

2. COntents Epidemiology Introduction Hematopoiesis Three point approach to anemia Case based approach

3. © UNICEF/Srijan Pun A female community health volunteer screens a woman in rural Nepal for anaemia by checking the lower eyelid for a pale colour .

4. Anaemia doesn’t just affect women and girls – it contributes to 40% of the world’s low birth weight cases and affects child growth and learning, particularly in poorer households. The economic toll is staggering:  anaemia costs South Asia an estimated $32.5 billion annually, perpetuating cycles of poverty and poor health . Yet, the condition is preventable and treatable. Reference: https://news.un.org/en/story/2025/07/1165350

5. DOI: 10.3126/jngmc.v16i1.24231

6. Published at : April 26, 2025 https://kathmandupost.com/health/2025/04/26/nepal-s-anaemia-fight-stalls-as-iron-and-folic-acid-supplies-run-out

7. Introduction According to the World Health Organization (WHO): Anemia: Hb levels <12.0 g/dL in women and <13.0 g/dL in men.

8. CASE A 68-year-old woman with a history of type 2 diabetes mellitus, hypertension, CAD on aspirin, repaired abdominal aortic aneurysm, hyperlipidemia, and osteoporosis was referred for evaluation of anemia. She denied fatigue but had reduced endurance evident by a new requirement to rest after a short walk. She had been transfused only once in her life (during the aneurysm repair 10 years ago) She had no family history of blood cancers.

9. History taking Demographic Details Age/Sex : Iron deficiency in young women; anemia of chronic disease in elderly; hemoglobinopathies in children. Occupation/Socioeconomic Status : May suggest nutritional deficiencies, parasitic infections, or exposure to toxins.

10. Clinical Presentation Chronic anemia: Lassitude, Fatigue, Exertional dyspnea Acute anemia: 10-15% loss: vascular instability >30% loss: postural hypotension and tachycardia >40% loss: hypovolemic shock: confusion, dyspnea, diaphoresis, hypotension, and tachycardia appear

11. Specific symptoms depending on cause : Iron deficiency : Pica (e.g., eating clay), brittle nails, glossitis B12/folate deficiency : Paresthesia, memory changes, ataxia, glossitis Hemolysis : Jaundice, dark urine, splenomegaly, gallstones Acute blood loss : Hematemesis, melena, menorrhagia, trauma

12. Past history: Chronic diseases: CKD, autoimmune diseases, infections (e.g., TB, HIV), cancer Prior anemia or transfusions Surgeries (e.g., gastrectomy → B12 deficiency) Family history: Hemoglobinopathies, hemolytic anemias, enzyme deficiency Drug history Dietary history: vegan, alcoholism, poor intake Menstrual history Travel history: Malaria endemic zone

13. CASE continued Laboratory review showed anemia emerged ∼3 years ago, with most recent hemoglobin of 13.5 g/dL, and an MCV of 89 fL during an annual physical examination 3 years ago. Her physician had initiated oral iron sulfate (65 mg of elemental iron), 1 tablet daily and she was compliant. However, Hemoglobin had declined since previous report. Her laboratory evaluation showed hemoglobin of 11.3 g/dL, MCV of 83 fL , retics count 2%, TLC and Platelets within normal limit.

14. Three point approach to anemia Are other cell lines affected? Is pancytopenia present? Is the anemia microcytic, macrocytic, or normocytic? Is the marrow response appropriate for the anemia as determined by the reticulocyte count? 

15. • Mean corpuscular volume (MCV): Average size of red blood cells Normal range: 80 to 100 femtoliters • Mean corpuscular hemoglobin (MCH): Amount (mass) of hemoglobin per red cell Usually reported in picograms (per cell) • Mean corpuscular Hgb concentration (MCHC): Concentration of Hgb in red cells Usually reported g/dL

16. CASE CONTINUED serum iron at 25 μg /dL, TIBC of 396 μg /dL, TSAT of 7%, and serum ferritin at 25 ng/ mL.

17. CASE CONTINUED SOBT was positive using 3 cards. She underwent an EGD and a colonoscopy and there was no obvious cause of bleeding found other than mild gastritis. She was negative for  Helicobacter pylori .

18. CASE MANAGEMENT She was treated with 1 dose of IV Ferrous carboxymaltose 500 mg. Her walking endurance improved, and she achieved a normal hemoglobin level. She continued oral ferrous sulfate every other day because of an ongoing need for aspirin for secondary prevention of CAD.

19. CASE CONCLUSION The patient had occult gastrointestinal bleeding from either gastritis or an occult source. Small-bowel interrogation is a consideration now or in the future. Recommendation: At least annual monitoring for development of new symptoms or recurrence of IDA.

20. Take home messages History and Physical Examination – Assess symptoms, bleeding, nutritional status, and look for clinical signs. Identify the Cause – Classify by MCV and retic count to determine etiology (e.g., iron deficiency, hemolysis, marrow failure). Diagnostic Tests – CBC with indices, reticulocyte count, peripheral smear, iron/B12/folate studies, hemolysis panel, bone marrow Treatment – Address the underlying cause with appropriate therapy (supplements, transfusion, disease-specific treatment). Monitoring and Follow-Up – Reassess hemoglobin, check response to treatment, manage complications, ensure long-term care.

21. References Harrison's Principles of Internal Medicine , 21 st Edition, McGraw-Hill Education, 2022 Davidson’s Principles and Practice of Medicine , 24 th Edition, Elsevier, 2022 Jeanna L. Welborn MD, Frederick J. Meyers MD & Richard B. Birrer MD (1991) A three-point approach to anemia, Postgraduate Medicine, 89:2, 179-186, DOI: 10.1080/00325481.1991.11700826 Oyedeji CI, Artz AS, Cohen HJ. How I treat anemia in older adults. Blood. 2024 Jan 18;143(3):205-213. doi : 10.1182/blood.2022017626. PMID: 36827619; PMCID: PMC10808247.

22. Thank you