ANAEMIA

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ANAEMIA

Lately are you feeling tired, exhausted, fatigued, lethargic, giddy, dizzy, irritability or lack of concentration? You may be suffering from anaemia.

DEFINITION: (What is Anaemia)

Anaemia in Greek means No Blood (An=no, Haem=blood)

Anaemia is defined as the reduction in the concentration of Haemoglobin (Hb) and/ or RBC in the blood as per age, sex and geographical location.

          Normal: 14g to 16g /dl in Male and

                        13g to 15g /dl in Female

FUNCTION OF RBC:

RBC contains haemoglobin (Hb), which imparts red colour to blood. Hb is responsible for carrying Oxygen to different parts of the body and clearing the carbon dioxide. RBCs are formed in the Bone Marrow. Its life span is a little over 100 days. As a result about 1% of RBCs are destroyed daily in spleen, liver and other RE System.

Hb consists of Haem combined with Globin (a protein). Haem is Iron 'Protoporphyrin. After the breakdown of RBC, iron and protein are reutilized. The porphyrin is broken down to bilirubin (bile) and excreted as waste product.

INCIDENCE:

This is possibly the commonest disorder in human population. The incidence is higher among females. However  most of the anaemias are preventable, can be diagnosed easily and treated successfully. In a survey of 10,000 school children in Delhi 84% were found to be suffering from anaemia.               a

CAUSES OF ANAEMIA (ETIOLOGY):

It is not difficult to understand that anaemia can occur either by diminished formation or excessive destruction of RBCS.

A.      Diminished Formation (Dyshaemopoietic)

 1.      Nutritional

                   (a)     Iron Deficiency

                   (b)     Folic Acid/ Vit B₁₂  Deficiency

                   (c)     Protein Deficiency

          2.      Decreased Synthesis

                   (a)     Aplastic Anaemia

                   (b)     Replacement of BM (e.g. Leukaemia)

                   (c)     Thalassaemia

          3.      Chronic Disorder

                   (a)     Kidney Disease

                   (b)     Advanced Malignancy

                   (c)     Chronic Liver Disease

B.      Excessive Destruction

          1.      Post Haemorrhage

                   (a)     Acute Blood Loss

                   (b)     Ghronic Blood Loss

          2.      Excessive Haemolysis

                   (a)     Intracellular Defect (Defective RBC)

                             Thalassaemia

                             Haemoglobinopathies (Hb C/ E)

                             Sickle Cell Anaemia

                             Hereditary Spherocytosis

(b)            Extracellular Defect

Rh Incompatibility

Incompatible Blood Transfusion

Auto Immune Haemolytic Anaemia

Certain Snake Venom

The list is by no means exclusive. I have included only some common diseases to make the understanding clear.

CLASSIFICATION:

There are basically two ways to classify anaemia.

A.               Etiological (according to the cause)

It is the best way to delineate the exact disease and treat accordingly. However, if we start with the other classification, the diseases fall into certain groups and become easier to reach the definitive causes.

B.               Morphological (according to the size and Hb content of the RBCs)

Basically, all anaemias can be classified into three groups as per morphology of the RBCs.

          1.      Microcytic Hypochromic (RBCs are small in size and  less haemoglobinised)

                   (a)     Iron Deficiency Anaemia

                   (b)     Thalassaemia

          2.      Macrocytic normochromic (RBCs are large in size and normally haemoglobinised)

                   (a) Megaloblastic Anaemia due to Folate/B₁₂ deficiency

          3.      Normocytic Normochromic (RBCs are normal in size and normally haemoglobinised)

                   (a)     Haemolytic Anaemia

                   (b)     Post Haemorrhagic Anaemia

                             Internal Bleeding

                             Haemetemesis (blood vomiting)

                             Malaena (black tarry stool)

                             Haemoptysis (blood in sputum)

                             Street Accident

                             Bleeding during Operation

                             Post Partum Bleeding

(c)             Aplastic Anaemia

(d)            Leukaemia

(e)             Anaemia due to Renal Failure

SIGNS AND SYMPTOMS:

The signs and symptoms of acute anaemia in situation like massive haemorrhage, mismatched transfusion, acute leukaemias, the signs and symptoms of anaemia are masked by the gravity of the illness.

In chronic anaemias, the progression of the disease process is so slow that very often the signs and symptoms are often missed, ignored or neglected. The anaemia is discovered accidentally by blood examination for some other reason.

The followings are some of the signs and symptoms:

Moderate Anaemia

Fatigue

Lethargy

Irritability

Lack of Concentration

Giddiness

Dizziness

Difficulty in Breathing (Dyspnoea) on exertion

Pica (Craving for unusual food)

Severe Anaemia

Dyspnoea on mild exertion

Palpitation

Chest pain

Blackout (Transient loss of consciousness esp on standing)

Difficulty in swallowing esp in ladies

Signs:

Pallor:        Pallor is the most outstanding sign of anaemia. It is most pronounced in the conjunctiva, lip, tongue and nail beds. Skin becomes pale in case of severe anaemia.

Koilonychias (Concave shaped nails)

Pulse rate is raised in severe anaemia.

DIAGNOSTIC TESTS:

The diagnosis of anaemia is pretty simple. With a few additional tests, the cuse of most of the anaemias can be established. I am mentioning only some of the common laboratory tests.

Hb: Less than 13g/dl

TRBC: Less than 4.5 million / cubic centimeter

Packed Cell Volume (PCV): Less than 40%

Mean Corpuscular Volume (MCV):

          RBC size Less than 78 cubic micron ' Microcytic

                          Between 78 to 93 cubic micron ' Normocytic

                          More than 93 cubic micron ' Macrocytic

Mean Corpuscular Haemoglobin Concentration (MCHC)

          Between 27 to 32 % - Normochromic

          Less than 27 % - Hypochromic

Reticulocyte Count:

          Raised in Haemolytic Anaemia

          Low in Aplastic Anaemia

Peripheral Smear:

One can predict the type of anaemia. In addition the changes in WBCs and platelets give indication to the underlying disorder.

Bone Marrow Smear and Biopsy:

          Diagnostic of Aplastic Anaemia and Megaloblastic Anaemia

          Diagnose or exclude Leukaemia

          Iron staining shows the iron reserve

Serum Bilirubin:

          Raised in Haemolytic Anaemia

Hb Electrophoresis:

          Diagnostic of Haemoglobinopathies and Thalassaemia

Coombs Test:

          Positive in Auto Immune Haemolytic Anaemia

Serum Iron:

          Low in Iron Deficiency Anaemia

          High in Thalassaemia

Urine Urobilinogen:

          High in Haemolytic Anaemia

Stool Examination:

          For Ova of Hook Worm

          Occult Blood for Gastrointestinal bleeding

COMMON ANAEMIAS:

The vast majority of anaemias are due to three primary causes.

(a)             Iron Deficiency

(b)            Folate Deficiency

(c)             Thalassaemia

Iron deficiency anaemia being the most prevalent needs a little more elaboration.

IRON DEFICIENCY ANAEMIA: 

The daily requirement of iron

Male ' 1mg / day

Female - 2mg / day

              - 3mg / day (during pregnancy and lactation)

Iron deciency anaemia can occur under the following four conditions:

A.      Less Intake of Fe, Vitamins and Protein:

          Iron rich foods are 

                   Mutton especially liver

                   Chicken

                   Fish (Tuna fish and sardine are very rich in iron)

                   Egg

                   Spinach

                   Plantain (unripe banana)

                   Lentils

                   Rajma

                   Soya bean

                   Wheat Bran

                   Brown Bread

                   Green pea

                   Almond

                   Dates

                   Molasses

          Milk is a highly nutritious food containing protein, fat, carbohydrate, Vitamin A & D, Calcium, but it is poor in iron content.

          As a result the pure vegetarians often suffer from Fe def anaemia. Fortification of wheat with iron may be taken up as a national policy to reduce the prevalence of anaemia in general population.

B.      Diminished Absorption:

          Only a small portion of dietary iron is absorbed. The following factors favour absorbtion:

          Acidity of gastric juice

          Vit C

          Haem bound iron (animal protein)

          Alcohol consumption

          Low serum iron level

          Ferrous iron better than Ferric form

Diseases like Chron Disease and Malabsorbtion Syndrome hamper iron absorbtion.

C.      Increased Loss:

          The commonest cause is chronic blood loss from any source:

Monthly Menstrual Loss:      It is one the commonest cause of anaemia in female of child bearing age.

Hook Worm Infestation:       Common among villagers who move about barefoot and defaecate in the open field. The hook worm larva enters their body through their feet.

Bleeding Peptic Ulcer

Bleeding Piles

Repeated Haematuria (blood in urine)

Repeated Blood Donation

Bleeding from colon Cancer

Repeated Epistaxis (nose bleeding)

D.      EXCESSIVE DEMAND:

Pregnancy:           The mother has to cater for her requirement as well as of the foetus. It is mandatory that all pregnant women must take iron and folic acid supplement during the 2^nd and 3^rd trimester of pregnancy and continue during lactation.

Growth during puberty

DIAGNOSIS:

The diagnosis in most cases is rather easy and straight forward. Hamogram and peripheral smear examination alone is sufficient to arrive at a reasonably accurate diagnosis. The only differential diagnosis is Thalassaemia minor, which may give a blood picture of microcytic hypochromic anaemia. Any anaemic individual who fails to respond to iron trerapy within three weeks should be investigated for haemoglobinopathies. Serum iron level and Hb electrophoresis will settle the issue once for all.

TREATMENT:

In almost all cases treatment ix simple supplementation with an iron preparation. The response is dramatic. On the average Hb rises by 1g / dl / 7 to 10 days. The real intolerance to oral iron is very very remote. Minor GI problems like gastritis or constipation may occur in a few cases. The problem can be minimized by reducing the dosage of iron and taking the drug after a heavy meal. Diets rich in protein and intake of folate and Vit C improves anaemia at a faster rate. The treatment should be continued for six weeks more after the Hb reaches 14g/dl for buiding up body iron reserve.

MY PERSONAL OPINION:

My advice to all friends especially young ladies to get your Hb tested today. In case it is less than 13g/dl, please visit your personal phycsician and srart some iron tonic. I bet ypur Hb is bound to increase by at least 1g/dl within 15 days.

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