Hematologic Problems

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Causes of Anemia

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Decreased RBC Production- deficient nutrient, iron, cobalami, folic acid, decreased erythropoietin, decreased iron availability.

Blood loss- chronic hemorrhage (bleeding duodenal ulcer, colorectal cancer, liver disease), acute trauma, ruptured aortic aneurysm, GI bleeding

Increased RBC destruction- hemolysis (sickle cell disease, medication like methyldopa, incompatible blood, trauma like cardiopulmonary bypass.

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Integumentary Manifestations of Anemia

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pallor due to reduced blood flow, jaundice due to increased destruction of RBC increasing bilirubin, and pruritus due to increased serum and skin bile salt concentration.

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Eyes and mouth manifestations of Anemia

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Icteric conjunctiva and sclera, retinal hemorrhage, blurred vision

Glossitis, smooth tongue

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Cardiovascular manifestations of Anemia

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Palpitations, "bounding pulse", tachycardia, increased pulse pressure, systolic murmurs, intermittent claudication, angina, heart failure, myocardial infarction.

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Pulmonary CM of Anemia

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dyspnea, tachypnea, orthopnea

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Neurologic and musculoskeletal CM of Anemia

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Headache, vertigo, irritability, depression, impaired thought process, bone pain, sensitivity to cold, weight loss, lethargy

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GI CM of Anemia

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Anorexia, hepatomegaly, splenomegaly, difficulty swallowing, sore mouth

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Iron deficiency anemia

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Cause: result from inadequate dietary intake, malabsorption, blood loss, or hemolysis.

CM: Pallor, glossitis, cheilitis, headache, parasthesia, burning tongue

Diagnostics: Decreased Hgb/Hct, MCV, iron, ferritin, bilirubin. Increased TIBC

Drug therapy: enteric-coated is best for better abosrption and lower GI tract, should be taken an hour before meal for a better acidic environment, or can be take with orange juice or vitamin C. GI side effects can be heartburn, constipation, diarrhea. Use a Z track injection site.

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Thalassemia

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An autosomal recessive genetic basis. Group of diseases involving inadequate production of normal hemoglobin causing decreased RBC production. Caused due to an absent or reduced globulin protein. a-globin chains are absent or reduced in a-thalassemia, and b-globin chains are absent or reduced in b-thalassemia.

CM: palor, jaundice, splenomegaly due to continuous trying to remove the damaged RBC, hepatomegaly and cardiomyopathy due to iron deposition, continuous erythropoiesis due to chronic bone marrrow hyperplasia and expansion of marrow space.

Collaborative care: managed with blood transfusion or drug therapy to reduce iron overload (deferasirox, deferiprone, deferoxamine)

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Megaloblastic anemias

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Cause: by impaired DNA synthesis, and characterized by presence of large RBCs (macrocytic- refered to as megaloblasts), can be due to vitamin B12-coblalamin deficiency or folic acid deficiency, supression of DNA synthesis by drugs, inborn errors of cobalamin, and folid acid metabolism, and erythroleukemia.

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Cobalamin (vitamin B12 deficiency)- Pernicious Anemia

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Cause: pernicious anemia is caused by an absence of Intrinsic factors which are needed for cobalamin (b12) absorption. The secretion of IF can be disrupted by gastric mucous atrophy or autoimmune destruction of parietal cells. there is also a decrease in HCl in the stomach. patients with small bowel resection ,crohns disease, ileitis, celiac disease, diverticuli of small intestine or chrnoic atrophic gastritis, chronic alcoholism, long term usrs of h2 histamine receptor blockers and proton pump inhibitors and strict vegetarians can also have b12 deficiency.

CM: sore,red,beefy, and shiny tongue, anoreixa, N/V, abdominal pain, weakness, paresthesia of feet and hand, ataxia, muscle weakness, and impaired thought process ranging from confusion to dementia.

Treatment: parenteral vitamin B12, or intranasal cyanocabalamin.

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Folic Acid deficiency

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deficiency of folic acid required for DNA synthesis leading to RBC formation and maturation. GI disturbances include dyspepsia and smooth, beefy red tongue. Serum folate level is low and serum cobalamin level is normal. It is treated by replacement therapy.

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Anemia of Chronic Disease/ Anemia of inflammation

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caused by chronic inflammation, autoimmune disease, and infectious disorders like HIV, HF and malignant diseases. RBC are usually normocytic normochromic, and hypoproliferative. Findings of elevated serum ferritin and increased iron stores distinguish it from iron-deficiency anemia.

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Aplastic Anemia

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Cause: peripheral blood pancytopenia (decrease of all blood cell types- RBC's, WBC's and platelets) and hypocellular bone marrow. Can be congenital or acquired. General manifestations like fatigue, dyspnea, low neutropenia may be seen .

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Hemolytic Anemia

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caused by destruction or hemolysis of RBCs at a rate that exceeds production. Intrinsic hemolytic are caused by defects in RBC's themselves. More common are acquired hemolytic anemia which are caused by damage in the external factors and not the RBCs itself.

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Sickle Cell Disease

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