ANEMIA WITH QUESTIONS AND ANSWERS

1. WHAT IS ANEMIA

Since anemia is both a disease and a symptom, it should always be discussed in detail and its cause must be revealed.

A decrease in hemoglobin concentration below normal is called ANEMIA. Hematocrit value is not a parameter that can be directly evaluated to evaluate anemia.

WHO (World Health Organization) has determined the lower limit of hemoglobin in the definition of anemia as 13gr/dl for adult men and 12gr/dl for women. It has been accepted that these values ​​may differ between races, and it has been stated that this difference may be around 1-2gr/dl.

2. WHAT ARE THE SYMPTOMS OF ANEMIA

Patients with anemia usually consult a doctor with symptoms such as decreased exercise capacity or easy fatigue, palpitations, and shortness of breath. Pallor of the skin and mucous membranes is observed in patients with anemia.

Information about the cardiovascular system: palpitations and exertional dyspnea. Severe and long-lasting anemia is one of the causes of "Hyperdynamic heart failure".

Patients with anemia may experience symptoms such as headache, tinnitus, dizziness, feeling of faintness, decreased ability to concentrate, decreased muscle strength, and feeling cold.

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Gastrointestinal diseases cause anemia for different reasons, especially iron deficiency. Additionally, anemia itself can lead to some gastrointestinal symptoms. These may include changes such as loss of appetite, nausea, constipation or diarrhea.

Men with anemia may experience a loss of libido. Amenorrhea or menorrhagia may occur in women. It should not be forgotten that menorrhagia or metrorrhagia may be the cause of anemia.

3. MORPHOLOGICAL CLASSIFICATION OF ANEMIA

In this classification, which is made especially based on the mean erythrocyte volume (MCV), anemias are divided into 3 groups as NORMOCYTIC (MCV: 80-100FL), MICROCYTIC (MCV below 80/FL) and MACROCYTIC (MCV above 100FL). examined in the group.

MICROCYTIC ANEMIA:

• Iron deficiency anemia

• Thalassemias, hemoglobin E, hemoglobin C disease

• Sideroblastic anemia

• Lead poisoning

• Anemia of chronic disease (some cases)

NORMOCYTIC ANEMIA:

• Bone bone Diseases that infiltrate the spindle (metastasis of solid tumors, leukemia, lymphoma, multiple myeloma)

• Anemia of chronic disease (most cases)

• Kidney failure

• Acute bleeding

• Hemolytic anemias

• Liver disease

• Hypothyroidism and scurvy (vitamin C deficiency)

MACROCYTIC ANEMIA

• Vitamin B12 deficiency

• Folic acid deficiency

4.ETIOPATHOGENETIC ANEMIA CLASSIFICATION

I. DECREASE IN ERYTHROCYTE PRODUCTION

A)Decrease in hemoglobin synthesis

• Iron deficiency anemia

• Thalassemias

• Sideroblastic anemia

• Lead poisoning

B) Disorder in DNA synthesis

• Vitamin B12 deficiency

• Folic acid deficiency

C) Hematopoietic root cell differentiation disorder

• Leukemia or MDS

• Aplastic anemia

II. BLOOD LOSS: ANEMIA DUE TO ACUTE BLEEDING

III. INCREASE IN ERYTHROCYTE DESTRUCTION: Anemias under this heading are hemolytic anemias. Shortening of erythrocyte life span is at the forefront.

5. FACTORS CAUSING IRON DEFICIENCY

The most common cause of anemia in our country and the world is iron deficiency. Approximately 30% of the world's population is anemic, and at least half of them, that is, 500 million people, have iron deficiency anemia.

Iron deficiency is a process in which iron loss and/or need exceeds the absorbed amount (negative iron balance). It occurs as iron deficiency, first due to depletion of iron stores (latent period) and subsequent inability to synthesize sufficient hemoglobin.

FACTORS CAUSING IRON DEFICIENCY

Increased requirement: pregnancy, lactation, developmental ages

Increased iron loss: hypermenorrhea, menometrorrhagia, intrauterine contraceptive devices, esophagitis, hiatal hernia, peptic ulcer, gastritis, aspirin use, inflammatory bowel diseases, hemorrhoids, ulcerative colitis, parasitic diseases

Inadequate iron intake

• Nutritional deficiency: vegetarians, elderly

• Absorption disorders: achlorhydria, stomach-small intestine resection

6. CLINICAL FINDINGS IN IRON DEFICIENCY

Findings specific to iron deficiency anemia; It is found in skin, nails and mucous membranes. Hair loss, hair matting, breakage, nail breakage, thinning and collapse of the nail bed, spoon nails (koilonychia), pain in the tongue, loss of filliform papillae, angular stomatitis, and ozena in the nose are the main epithelial changes. In addition, "Web", which is usually seen in young female patients and causes narrowing at the upper end of the esophagus, and usually disappears with treatment, are also typical features of IDA.

7. FINDINGS IN IRON DEFICIENCY

The most typical laboratory finding of IDA is HYPOCHROME MICROCYTERY ANEMIA, that is, MCV average erythrocyte volume is below 80fl and MCHC is lower than 27 picograms. The distribution of erythrocyte sizes –RDW has increased. HYPOCHROMIA, ANISOCYTOSIS AND POIKYLOCYTOSIS are evident in peripheral smear preparations. Serum iron and transferring saturation and serum ferritin levels decreased. Total iron binding capacity-TDBK increased.

8. IRON DEFICIENCY ANEMIA TREATMENT

The treatment of IDA can be summarized as maintaining the total iron amount by replacing the missing iron orally or parenterally, and on the other hand, determining the etiological factor and providing the necessary treatment.

Unless there is a contraindication, oral administration of divalent iron drugs constitutes standard treatment. The earliest sign of response to oral iron treatment is the increase in the number of young erythrocytes, which we call reticulocytes, that occurs between the 5th and 10th days of treatment. However, replenishing iron stores requires 3-4 months of treatment.

Oral iron treatment is a cheap, easy but long treatment. In some patients, side effects such as bloating, gas, stomach pain, and staining of defecation black may occur due to oral treatment. In such situations, parenteral iron therapy is used when blood loss is very frequent and a rapid response is needed. Parenteral treatment is administered intravenously or intramuscularly. Parenteral iron therapy has serious risks, in particular First of all, intravenous iron therapy should not be administered outside the hospital. It may cause serious conditions such as hypotension, headache, urticaria, nausea, myalgia, fever and systemic anaphylaxis.

9. HOW IS BETA THALASSEMIA DIFFERENT FROM IRON DEFICIENCY AND DOES IT REQUIRE TREATMENT?

Although beta thalassemia has similar laboratories to IDA, a good doctor should distinguish these two conditions with a simple hemogram. Namely, while MCV is low in both cases, this value is extremely low in thalassemia. (MCV around 60). In such cases, iron, iron binding and ferritin are checked. While ferritin is low in IDA, it is normal in thalassemia. In such cases, hemoglobin electrophoresis is checked for a definitive diagnosis, and if HBA2 and HBF are found to be high, a definitive diagnosis of thalassemia is made. Thalassemia carrier is a genetic diagnosis and in such cases, other members of the family should also be screened. It does not cause any significant symptoms other than weakness and fatigue. As for treatment, it absolutely does not require treatment. Giving iron here causes more harm to the patient than benefit. However, there are some exceptional cases; In some cases, thalassemia and IDA may occur together; in such cases, the missing iron may need to be replaced first.

10. WHAT ARE THE CAUSES OF MACROCYTIC ANEMIA AND WHICH MACROCYTIC ANEMIA ARE MOST COMMON

Megaloblastic anemias are among the macrocytic anemias. Macrocytic anemias are divided into two groups: megaloblastic anemias, which are characterized by a defect in DNA synthesis, and non-megaloblastic macrocytic anemias, which do not cause a defect in DNA synthesis. Nonmegaloblastic macrocytic anemias may accompany liver failure, alcoholism, hypothyroidism, myelodysplasia and COPD.

The most common macrocytic anemias we see are vitamin B12 deficiency and folic acid deficiency anemia, which are megaloblastic anemias.

11. REASONS FOR VITAMIN B12 DEFICIENCY

• Malabsorption

• Pernicious anemia

• Gastrectomy

• Inflammatory bowel diseases

• Terminal ileum resection

• Pancreatic insufficiency

• Congenital deficiency of intrinsic factor

• Intestinal parasites (diphyllobothrium latum)

Nutrition disorder u: STRICT VEGETARIANS

12. REASONS FOR FOLIC ACID DEFICIENCY

• Inadequate diet

• Alcoholism

• Fresh fruit and deficiency in vegetable intake

• Malabsorption

• Gluten enteropathy (Celiac disease)

• Inflammatory bowel diseases

• Extensive small bowel resection

Rare causes: Hemodialysis, chronic hemolytic anemia, antiepileptic, antifolate drugs

13. SYMPTOMS SEEN IN VITAMIN B12 AND FOLIC ACID DEFICIENCY

They present with symptoms related to anemia. While there is no neurological defect in folic acid deficiency, there may be a neurological defect in vitamin B12 deficiency. Burning in the tongue, taste disturbance, loss of appetite and disgust, and weight loss may occur. In vitamin B12 deficiency, the posterior cord is affected and causes position sense impairment. It can cause all kinds of neurological defects such as numbness in the hands and feet, loss of motor power, urinary incontinence, and forgetfulness.

Vitamin B 12 deficiency can be seen at any age, but it occurs more frequently in the 60-year-old group. Its association with other autoimmune diseases is common. Such as Graves' disease, Hashimoto's thyroiditis, Addison's disease, hypoparathyroidism and vitiligo.

14. LABORATORY IN MEGALOBLASTIC ANEMIA

Macrocytic anemia (especially MCV 120fl>), accompanying mild leukopenia and thrombocytopenia, elevated LDH due to ineffective erythropoiesis, hypersegmentation in peripheral smear (1 neutrophil having more than 5 segments), tear-shaped or fragmented erythrocytes can be seen. The bone marrow is hypercellular and the red series is active. Folic acid and vitamin B12 levels are important in diagnosis. The presence of antibodies against parietal cells can be demonstrated in 90% of patients with pernicious anemia.

15. MEGALOBLASTIC ANEMIA TREATMENT

Treatment in folic acid deficiency; It can be achieved by eliminating the problem causing the deficiency and folic acid replacement. A daily dose of 400-500 micrograms is sufficient. (There are 5 mg tablets).

In mild vitamin B12 deficiency, it is possible to treat it with oral vitamin B12 preparations. In severe deficiencies and in the treatment of pernicious anemia, following the application of 1000mcg ampoules for 5 consecutive days, continue with 4-5 weeks of treatment.

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