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Tuesday, 5 June 2012

approach to Anemia

One of the very common things we see in daily patient encounter is anemia.

Anemia is not a disease but is often a manifestation of some other processes.
Once a deficiency of...
  • iron
  • Vitamin B12
  • folic acid
has been ruled out, the anemia may be secondary to another pathology, and causes such as...
  • infection
  • inflammation
  • neoplasia
  • drug
  • chemical exposure
  • autoimmune disorder
  • acute blood loss
must be considered. 
the approach to anemia should be holistic - in a way that encompasses the patient details of
  • ethnicity
  • diet history
  • drug history
must be obtained, and there is a paramount importance of physical examination and Investigations (which would fill the baulk of this post). 

we need to avoid a "shotgun" approach of anemia where you test for every single test available, the approach to anemia should be systematic.

Most anemia has a single cause, but secondary and symptomatic anemias may be multifactorial and do not fit in a specific category. it is useful to consider anemia in 3 groups;
  • microcytic hypochromic
    • suggests a disturbance in iron metabolism
      • iron deficiency
      • Anemia of chronic disease (impaired availability of iron)
      • thalassasemia syndromes (defective globin chain synthesis)
      • sideroblastic anemia (defective haem synthesis)
  • normocytic normochromic
  • macrocytic (MCV>100fl)
I have summarized the investigation into an algorithm as follows. (click to zoom)

at the end of the post will be a HTML format of this mindmap.

as highlighted in Red in the mindmap, there are several important investigations on anemia.

  • Blood film
    • may provide clues to the cause of anemia
      • macrocytosis with normal RDW - 
        • suggests alcohol-related anemia
        • a raised gamma-glutamyltransferase confirms alcohol effect
      • oval macrocytes signify a disorder of RBC production
      • Hypersegmented neutrophils 
        • B12 / Folate deficiency
  • Serum Iron Study
  • Serum Folate / B12 study
  • bone marrow examination
    • stain for Iron with Perl's stain - comfirms Iron Deficiency Anemia
  • reticulocyte count

    • used to help determine if the bone marrow is responding adequately to the body’s need for red blood cells (RBCs) and to help determine the cause of and classify different types of anemia
    • The number of reticulocytes must be compared to the number of RBCs to calculate a percentage of reticulocytes
    • basically, it is a good measure of how responsive the marrow is, towards lack of RBCs. if it is high, the marrow is actively responding to the lack of RBC, e.g. post bleeding.


Investigation into Anemia
  • Macrocytic
    • blood film
    • reticulocyte count
      • high
        • acute blood loss
        • hemolytic anemia
      • normal / low
        • bone marrow
          • non-megaloblastic
            • normoblastic
              • alcohol liver disease
              • hypothyroid
            • dyserythropoietic
              • myelodysplasia
          • megaloblastic
            • Folate and B12
              • folate low
                • folate deficiency
              • B12 low
                • B12 deficiency
  • Microcytic
    • serum iron
      • high
        • bone marrow origin
          • sideroblastic anemia
      • normal high
        • HbF / A2
          • thalassaemia, abnormal haemoglobin
      • low
        • ferritin
          • low
            • iron deficiency
          • normal / high
            • anemia of chronic disease
    • blood film
  • Normocytic
    • Blood film
    • Reticulocyte count
      • high
        • acute blood loss
        • hemolysis
      • low / normal
        • bone marrow morphology
          • normal
            • secondary anemia
          • abnormal
            • hypoplastic
              • aplastic anemia
              • RBC aplasia
            • Infiltration / fibrosis
              • Leukemia
              • Myelomatosis
              • metastases
              • Myelofibrosis
            • dyserythropoietic
              • myelodysplasia


  1. In this case, how can vitamin b12 aid in the recovering process of an anemic person. Any thoughts on this?

  2. Hello.

    Not All types of anemia needs Vitamin B12 supplements.

    Vitamin B12 is mainly used in the management of Megaloblastic Anemia - which is a type of anemia where the Red Blood Cells are not being manufactured properly in the body. the Reason why there is a malfunction of RBC in this type of anemia is because of lack of Vitamin B12 in the patient's body.

    the reason why patient is having a lack of B12 is varied - it could be simply a lack in intake of B12 in diet - where Supplements of B12 will reverse the condition. however, the patient needs to be investigated so that other conditions which cause this are ruled out - like a defect in the Gastrointestinal system (like Pernicious Anemia - lack of intrinsic factor by the stomach), Celiac Disease and Pancreatitis etc etc.

    other causes of anemia, for example Iron Deficiency anemia, or anemia of blood loss, you need not administer B12 supplements. you may have to give iron supplements, though.

    It is most effectively used in alcoholic patients who have been malnourished for an extended period of time.

    furthermore, Vitamin B12 supplements must be administered together with Folic Acid to be effective.

    in patients who vitamin B12 is not deficient, normal diet with Meat are sufficient.

    I hope that helped :)

  3. I fainted in the market. Somewhere between a nice big pile of red, juicy tomatoes and the most beautiful, robust carrots I’ve ever seen. My mom was there and almost fainted when she saw me faint, haha. Good thing the vendors picked me up, put me on a chair and massaged me to consciousness.

    This is what I get for:
    forgetting to take ferrous sulfate supplements for my anemia,
    getting little sleep, and
    doing TurboFire and Insanity at the same time.

    As for my food intake, I know it’s not a reason because I’m getting enough calories from clean, healthy eating. I just forgot that, having iron-deficiency anemia, I can’t pull off long bouts of intense exercise without supplements and enough sleep.

    My plan now is to increase my caloric intake to 1400 (from 1200), set a daily alarm to remind me to take my ferrous sulfate tablets, be sure to get at least 8 hours of sleep, and, albeit against my will, drop either TurboFire or Insanity. I’m not trying to lose weight as fast as I can—slowly but surely is key.

    So goodbye, Insanity. I hardly knew ye. :-( Maybe we’ll meet each other again when I’m done with TF. Just can’t handle both of you at the same time, you know?


hi. any kinds of comments are welcome! thank you...