Anaemia

Question 1

What are 5 causes of normocytic anaemia?

Answer 1

1. Anaemia of chronic disease
2. Chronic kidney disease
3. Aplastic anaemia
4. Haemolytic anaemia
5. Acute blood loss

Question 2

What are 5 causes of microcytic anaemia?

Answer 2

1. Iron-deficiency anaemia
2. Thalassaemia
3. Congenital sideroblastic anaemia
4. Anaemia of chronic disease (more commonly normocytic, normochromic)
5. Lead poisoning

Question 3

What should you be worried about if you see normoal haemoglobin level with microcytosis?

Answer 3

if not at risk of thalassaemia, should raise possibility of polycythaemia rubra vera

Question 4

What should you investigate for in new onset microcytic anaemia in elderly patients?

Answer 4

urgently investigate to exclude underlying malignancy

Question 5

What are 2 groups that macrocytic anaemia can be grouped into?

Answer 5

megaloblastic bone marrow, and normoblastic bone marrow

Question 6

What are 2 megaloblastic causes of macrocytic anaemia?

Answer 6

1. Vitamin B12 deficiency
2. Folate deficiency

Question 7

What are 7 normoblastic causes of macrocytic anaemia?

Answer 7

1. Alcohol
2. Liver disease
3. Hypothyroidism
4. Pregnancy
5. Reticulocytosis
6. Myelodysplasia
7. Drugs: cytotoxics

Question 8

What is the most common cause of anaemia worldwide?

Answer 8

iron deficiency anaemia

Question 9

How does iron deficiency cause anaemia?

Answer 9

iron is needed to make haemoglobin in red blood cells, therefore a deficiency of iron leads to a reduction in red blood cells/ hb i.e. anaemia

Question 10

What are the 4 main causes of iron deficiency anaemia?

Answer 10

1. Excessive blood loss
2. Inadequate dietary intake
3. Poor intestinal absorption
4. Increased iron requirements

Question 11

Which age group has the highest prevalence of iron deficiency anaemia?

Answer 11

preschool age children

Question 12

What is the commonest cause of excessive blood loss leading to IDA in women?

Answer 12

blood loss due to menorrhagia

Question 13

What is the commonest cause of excessive blood loss leading to IDA in men and post-menopausal women?

Answer 13

gastrointestinal bleeding - always suspect colon cancer

Question 14

What are 2 sources of iron in the diet?

Answer 14

1. meat
2. dark green leafy vegetables

Question 15

What are 2 states of increased iron requirements which can lead to IDA?

Answer 15

1. Children - during periods of rapid growth
2. Pregnancy

Question 16

What are 2 reasons why IDA is common in pregnancy?

Answer 16

1. Increased demand as baby will receive iron supply from mother
2. Increase in plasma volume causes dilution

Question 17

What are 9 features of IDA?

Answer 17

1. Fatigue
2. Shortness of breath on exertion
3. Palpitations
4. Pallor
5. Nail changes: koilonychia
6. Hair loss
7. Atrophic glossitis
8. Post-cricoid webs (see picture)
9. Angular stomatitis

Question 18

What are 6 investigations in suspected iron deficiency anaemia?

Answer 18

1. Taking history - diet, medication, menstrual, weight loss, bowel habit
2. FBC
3. Serum ferritin
4. Total iron-binding capacity (TIBC)/ transferrin
5. Blood film
6. Endoscopy to rule out malignancy in males and post-menopausal females

Question 19

What are 5 things to ask about in the history if anaemia is suspected?

Answer 19

1. Changes in diet
2. Medication history
3. Menstrual history
4. Weight loss
5. Change in bowel habit

Question 20

What will FBC show in IDA?

Answer 20

hypochromic microcytic anaemia

Question 21

What is serum ferritin likely to show in IDA?

Answer 21

likely to be low as serum ferritin correlates with iron stores;

however, important to recognise that ferritin can be raised during states of inflammation so if raised doesn’t rule it out i.e. in co-existent inflammatory disease

Question 22

What is the total iron binding capacity likely to show in IDA?

Answer 22

will be high - high TIBC reflects low iron stores

Question 23

What will transferrin saturation be in IDA?

Answer 23

low

Question 24

What are 3 things that will be seen on a blood film in IDA?

Answer 24

1. Anisopoikilocytosis (red blood cells of different sizes and shapes)
2. Target cells
3. ‘Pencil’ poikilocytes

Question 25

When is it important to perform endoscopy in iron deficiency anaemia?

Answer 25

males and post-menopausal females who present with unexplained iron-deficiency anaemia

Question 26

When should iron deficiency anaemia trigger a 2 week wait referral to gastroenterology?

Answer 26

* Post-menopausal women: Hb \<100 * Post-menopausal men: Hb \<110

Question 27

What are 3 aspects of the management of iron-deficiency anaemia?

Answer 27

1. Underlying cause identified and managed (exclude malignancy) 2. Oral ferrous sulfate 3. Iron-rich diet: dark green leafy vegetables, meat, iron-fortified bread

Question 28

For how long should oral ferrous sulfate be continued to manage IDA?

Answer 28

continue to take for 3 months after the IDA has been corrected in order to replenish iron stores

Question 29

What are 4 common side effects of oral ferrous sulfate?

Answer 29

1. nausea 2. abdominal pain 3. constipation 4. diarrhoea

Question 30

How do the blood test results compare for IDA vs anaemia of chronic disease? 4 points

Answer 30

1. Serum iron: IDA \<8, AOCD \<15 2. TIBC: IDA high, **AOCD low** 3. Transferrin saturation: low for both 4. Ferritin: low for IDA, **high for AOCD**

Question 31

What are 4 situations when NICE suggests you UST refer urgently (within 2 weeks) to colorectal services for investigation?

Answer 31

1. patients ≥40 years with unexplained weight loss AND abdominal pain 2. patients ≥50 years with unexplained rectal bleeding 3. patients ≥60 years with iron deficiency anaemia OR change in bowel habit 4. tests show occult blood in their faeces (see below)

Question 32

What are 7 situations when a 2 week wait referral to colorectal services for investigation should be **considered** according to NICE?

Answer 32

1. there is a rectal or abdominal mass 2. there is an unexplained anal mass or anal ulceration 3. patients \< 50 years with rectal bleeding AND any of the following unexplained symptoms/findings: * → abdominal pain * → change in bowel habit * → weight loss * → iron deficiency anaemia

Question 33

In addition to screening, when else is faecal occult blood testing (now faecal immunochemical test screening) offered?

Answer 33

1. patients 50years or older with unexplaiend abdominal pain or weight loss 2. patients \<60 years with changes in their bowel habit or iron deficiency anaemia 3. patients 60years or older who have anaemia even in the absence of iron deficiency

Question 34

If oral iron supplements do not resolve the situation what is the next line treatment?

Answer 34

IV iron e.g. Ferrinject

Question 35

What are 5 reasons why a patient may fail to respond to oral iron?

Answer 35

1. Malabsorption 2. Poor compliance 3. Ongoing iron loss 4. Concomitant anaemia of chronic disease 5. Erroneous diagnosis

Question 36

What are 5 things which can guide the decision to resort to blood transfusion for anaemia?

Answer 36

1. Anaemic heart failure 2. Hb \<5g/dL with symptoms 3. Hb \<4g/dL in any situation 4. Acute blood loss - shock or signs of heart failure despite IV fluids 5. Need for emergency major surgery with pre-operative Hb\<7g/dL

Question 37

What are 3 ypes of transfusion reactions?

Answer 37

1. Severe transfusion reaction: ABO incompatibility or bacterial contamination of the unit 2. Simple febrile and allergic reactions: temp rise by 1 degree, rash/itching 3. Delayed transfusion reaction: 5-10 days later, sensitisation to RBCs following previous transfusions/pregnancy