severe anemia
Introduction
Introduction The term "anemia" refers to hemoglobin in a unit volume of circulating blood, and the red blood cell count or hematocrit (pressure) is lower than the lower limit of the normal value. This normal value may vary depending on gender, age, altitude of living area, and changes in physiological plasma volume. The severity of anemia can be divided into four levels depending on the amount of hemoglobin. Severe anemia is hemoglobin 60g / liter ~ 31g / liter, has been flustered at rest.
Cause
Cause
According to the cause of the disease, anemia can be divided into three categories: hematopoietic, hemorrhagic and hemolyzed.
First, poor hematopoietic anemia (red blood cell production)
(1) Hemoglobin synthesis disorder
1. Iron deficiency anemia: insufficient iron intake, relatively increased iron requirement (pregnancy, child growth and development) iron absorption disorder (chronic gastrointestinal disease, postoperative gastrectomy), chronic blood loss.
2. Iron granulocyte anemia.
3. Vitamin B6 reactive anemia.
4. Ferritin deficiency anemia.
(2) Nuclear maturity disorder
1. Pernicious anemia.
2. Other causes of folic acid and or vitamin B12. Lack of megaloblastic cell anemia caused by the use of disorders: malnutrition (lack of food, improper feeding of infants and young children, long-term alcohol abuse, intractable anorexia, increased demand (pregnancy, lactation, child growth, aphid, aphid infection, Hemolysis, infection, hyperthyroidism, etc., malabsorption (complete gastric or gastrectomy, chronic atrophic gastritis, gastric cancer, chronic liver disease, chronic enteritis, malabsorption syndrome, postoperative intestinal resection, intestinal bacterial infection) The effect of drugs on nucleic acid metabolism (such as antifolate, anticonvulsant, antituberculosis, oral contraceptive, neomycin, nitrite, etc.).
(3) Reduced bone marrow hematopoietic function
Stem cell defect
(1) Aplastic anemia.
(2) Congenital aplastic anemia.
(3) Pure red blood cell aplastic anemia.
(4) Myelodysplastic syndrome.
2. Bone marrow hematopoietic tissue is crowded by other cells
Leukemia, malignant lymphoma, multiple myeloma, bone marrow metastasis, myelofibrosis, systemic mastocytosis, marble bone disease, etc.
3. Red blood cell production regulatory factor deficiency
Renal anemia, endocrine glands (such as pituitary, thyroid) dysfunction, infectious anemia.
Second, blood loss anemia
(1) Acute blood loss anemia
Such as trauma caused by massive external bleeding or visceral rupture, ectopic pregnancy, gastrointestinal bleeding.
(2) Chronic blood loss anemia
Such as menorrhagia, hemorrhoids, hookworm disease, stomach cancer, peptic ulcer and so on.
Third, hemolytic anemia (red cell destruction
(1) Red blood cell intrinsic defects
Congenital hereditary
(1) erythrocyte membrane abnormalities: hereditary spherocytosis, hereditary ellipsoidosis, hereditary orthostatic syndrome.
(2) erythrocyte enzyme abnormality: deficiency of enzyme in sugar anaerobic glycolysis (such as pyruvate kinase deficiency) lack of enzyme in hexose phosphate bypass (~glucose dehydrogenase deficiency, often due to broad bean, primary ammonia Oxidative drugs such as quinine or infection induce hemolysis; hemolytic anemia caused by lack of other related ingredients).
(3) abnormal globin chain: abnormality of peptide chain amount (Q thalassemia, B thalassemia), abnormal structure of peptide chain (polymeric hemoglobin disease, unstable hemoglobinopathy).
2. Acquired paroxysmal nocturnal hemoglobinuria (PNH).
(two) red blood cell external factors
Immune
(1) Autoimmune: warm antibody type (acute idiopathic acquired hemolytic anemia, chronic idiopathic warm antibody immunological hemolytic anemia, symptomatic warm antibody immunological hemolytic anemia) cold antibody type (special Chronic cold agglutinin disease, paroxysmal cold hemoglobinuria, symptomatic cold agglutinin patients).
(2) Alloimmunity: neonatal hemolytic disease, ABO blood group incompatible hemolytic transfusion reaction, Rh blood group incompatibility hemolytic transfusion reaction.
(3) drug-induced hemolytic anemia: can be found in ammonia salicylic acid, isoniazid, rifampicin, quinidine, phenacetin, aminopyrine, sulfonamides, chlorpromazine, chlorsulfuron , insulin, penicillin, cephalosporin and the like.
2. Non-immune
(1) Mechanical factors (red blood cell debris syndrome): hemolytic anemia after microangiopathic hemolytic anemia and artificial heart valve replacement.
(2) Infectious hemolytic anemia: malaria, sepsis, and the like.
(3) hemolytic anemia caused by biological factors; snake venom, poisonous phlegm and so on.
(4) Hemolytic anemia caused by drugs and chemicals.
(5) hypersplenism.
(6) Disseminated intravascular coagulation (DIC)
(7) Ionizing radiation.
Examine
an examination
Related inspection
Hemoglobin reticulocyte erythropoiesis index reticular red blood cell count bone marrow cell line morphology erythropoietin
Physical examination
(1) General conditions
The patient's development, nutrition, expression, blood pressure and body temperature can provide clues for the diagnosis of anemia. Such as childhood developmental delay is common in hereditary hemolytic anemia. Patients with malignant tumors are generally in poor condition and often present with cachexia. Dampness and edema in the sagging area suggest malnutrition anemia. Increased blood pressure with facial or peripheral edema is seen in kidney disease. Apathy, unresponsiveness, and facial edema suggest hypothyroidism. People with severe anemia may have low fever. High fever is often caused by primary disease or concurrent infection, and acute hemolysis can also be seen with high fever.
(2) Special signs
Can provide an important basis for the definition of anemia.
1. skin, sclera jaundice
Skin and sclera jaundice is one of the important signs of hemolytic anemia. It is usually light lemon color. Acute hemolysis can be deep, hemolytic anemia of newborns is severe, and there are nervous system symptoms of nuclear jaundice. Skin stasis and plaque suggestive of leukemia, aplastic anemia or bleeding with thrombocytopenic purpura. Chronic hemolytic anemia such as hereditary spherocytosis, sickle cell anemia, etc. should be considered in the chronic or medial side of the lower extremity. Spider Confucianism and liver palm suggest liver disease. Flat or depressed nails are common in iron deficiency anemia. Tongue nipple atrophy, pale and smooth tongue is seen in nutritional anemia and megaloblastic anemia, iron deficiency anemia. The megaloblastic anemia may have a reddish tongue and is often accompanied by pain.
2. Face, bones
The severe thalassemia is caused by bone marrow spasm, thickening of the skull, forehead bulging, collapse of the bridge of the nose, and special face of the eyelid edema. Chest tenderness suggests leukemia or hemolytic anemia. Multiple bone myeloma, bone metastases, and leukemia should be considered in many parts of the ribs, spine, frontal bone and other bone pain and tenderness.
3. Lymph nodes, splenomegaly
Anemia with obvious local or systemic lymphadenopathy often suggests malignant lymphoma, acute or chronic lymphocytic leukemia, malignant histiocytosis, and the like. With mild to moderate splenomegaly, hemolytic anemia, malignant lymphoma, cirrhosis, and parasitic infection should be considered. If the spleen is obviously swollen, it is often chronic myeloid leukemia and myelofibrosis. Chronic lymphocytic leukemia is often less common than chronic myeloid leukemia. There is no splenomegaly in the early stage, but there are also a few cases with significant splenomegaly as a unique manifestation. For some diseases, negative signs are also diagnostic. For example, an anemia patient has a complete blood cell reduction. If lymph nodes and splenomegaly are found, primary aplastic anemia is no longer considered.
(three) nervous system performance
The megaloblastic anemia caused by vitamin B12 deficiency may have peripheral neuritis and combined degeneration of the posterior and lateral cords of the spinal cord, and the sense of touch, position and tremor may be reduced or disappeared, and the movement is inconvenient.
Laboratory inspection
Laboratory tests are an important way to determine the presence and extent of anemia and to clarify the nature and cause of anemia.
(1) General hematology examination
Blood routine
According to traditional requirements, its contents include red blood cell count, hemoglobin content, white blood cell count and its classification. The results not only determine the presence or absence of anemia but also the degree of anemia, and can also estimate the morphological type of anemia. Positive cell positive anemia, the ratio of the red blood cell count per microliter per million to the hemoglobin amount per liter is 33-34:1. If this ratio is significantly reduced or increased, it suggests macrocytic or small cell hypochromic anemia, respectively.
2. Platelet count
It can be combined with blood routine to provide an important basis for the diagnosis of anemia.
3. Determination of red blood cell index
The mean volume of red blood cells (MCVL red blood cell mean hemoglobin (MCH) and red blood cell mean hemoglobin concentration (MCHCX can be used for morphological classification of anemia, helps to infer the cause of anemia).
4. Reticulocyte count
It can reflect the activity level of erythroid hematopoiesis and has certain reference value for judging the nature of anemia. Its normal range is 0.005-0.15 (0.5%-1.5%); for patients with severe anemia, it is more meaningful to observe the absolute value. Its normal range (24~84) X10 (2.4-8.4 million/k). Significantly increased in hemolytic anemia (after acute hemolysis) acute hemorrhagic anemia, megaloblastic anemia, folic acid and or vitamin B; After treatment, iron deficiency anemia after iron treatment; mild increase in chronic hemolytic anemia remission, bone marrow fibrosis, splenectomy. Decrease in counts and even lack of bone marrow hematopoietic failure, such as aplastic anemia, pure red aplastic anemia, acute hematopoietic stagnation, and bone marrow anemia. Before iron deficiency anemia and megaloblastic anemia treatment, secondary anemia and a part of chronic aplastic anemia, reticulocyte count can be normal.
5. Blood smear observation of red blood cell morphology
This test has been inclusive in traditional blood routines, that is, while counting white blood cells, attention should be paid to understanding red blood cell morphology. Nowadays, when the white blood cell count is normal in some medical units, the smear is no longer listed as a routine examination, as is the case with a fully automated blood cell analyzer. Therefore, the blood smear examination is highlighted here as an independent project. The morphology of red blood cells, including their size, shape, color change and its inclusions, have their corresponding clinical significance (Table 8-l-3).
6. Automatic analysis of blood cells
At present, most automatic blood cell analyzers are developed according to the Coulter principle, the electric resistance method. The cell count is performed according to the number of pulses formed by the suspended particles in the cell suspension, and the volume is reflected by the different amplitudes of the pulses. Perform white blood cell classification. A pulsed input channel analyzer formed by blood cells can also give a histogram (cell volume distribution curve) for reference in clinical diagnosis. The clinical significance of the red blood cell, platelet and white blood cell counts, blood index and other parameters in the test report is the same as that of the traditional test method. It should be noted that the classification and counting of white blood cells are treated by special dilutions (destroying red blood cells and destroying part of the cell membrane of leukocytes, causing cytoplasmic outflow) according to the size of various types of white blood cells rather than the characteristics of cell morphology. The reported parameters LY (lymphocytes XMO (monocytes) and GR (granulocytes) and other reported values, only reflect the situation when the white blood cell classification is normal.
7. Bone marrow examination
The bone marrow examination is to understand that the anemia is less than 15%. Iron binding is significantly increased, often in the birth mechanism, revealing the cause of anemia is essential. Check for 64.4umoi/L (360ug/dl) or more. Iron use disorders attention to the proliferation of bone marrow hematopoietic tissue, the serum of each line is higher than serum iron and iron saturation (the normal range of the two ranges, the cell morphology is abnormal, the content of dyeable iron and iron particles are 20.6umol / L + 9.0u, ol / L soil 0.35 0.15) and the number of young cells and the distribution of iron particles, whether the parasitic iron binding capacity is normal or reduced (normal value 15 ~ 200ug / L soil insects, etc.. bone marrow puncture Many times I was not satisfied with the specimen and the 5.4 human serum ferritin was measured. When the rabbit method was used to reduce the "dry pumping", the suspected bone marrow fibrosis and other conditions should be made of bone marrow at 12ndL (normal male 15-200 ML, female biopsy) 12-150ug/L prompts the storage of iron in the body to support the diagnosis of iron deficiency anemia.
(2) Special hematology examination
Iron metabolism test
Serum iron, iron binding force and hematopoietic condition of certain anemia of iron saturation, if necessary, the degree of determination can be used to identify iron deficiency anemia and iron utilization disorder examination for reference in clinical diagnosis. Anemia. Serum iron and iron saturation in iron deficiency anemia
2. Determination of serum folic acid and vitamin B concentration
Serum was reduced, serum iron was lower, and iron folate concentration was <3 dL, indicating folate deficiency. The determination of folic acid content in erythrocytes is not affected by folic acid intake, and the results are more reliable (normal reference value 150~500ug/L). If <100pg/L, it indicates folate deficiency. Serum vitamin B1. The concentration <90 is ug/L, which means vitamins. lack of.
3. In vitro culture of erythroid progenitor cells
In patients with low erythroid hematopoietic function, such as aplastic anemia and pure red aplastic anemia, the BFU-E yield of the late erythroid progenitor cells in the early erythroid progenitor stem cell colony (BFU-E) was significantly reduced. BFU work is more obvious.
4. Etiology of hemolytic anemia
The etiology of hemolytic anemia is complicated, and there are many test items. The necessary examination items should be selected step by step according to the clinical situation to clarify the cause of hemolysis.
5. Red blood cell life measurement
Red blood cell life is usually determined using ''Cr-labeled red blood cells. In the bed, ''Crgl cells T/ 22 d are generally used as the lower limit of normal. The half-life of red blood cells in hemolytic anemia is significantly shortened.
Device inspection
Bone marrow Y imaging
Reflects the distribution of hematopoiesis and hematopoietic function. If the radioactive substance intake in the normal hematopoietic site is low or absent, it means that the hematopoietic function is reduced, and it is found in aplastic anemia and myelofibrosis. Such as Ding imaging shows peripheral bone marrow expansion, under normal circumstances, the location of the distribution of radioactive substances is also developed, indicating that the bone marrow hematopoietic function is strong, often hemolytic anemia. Myeloproliferative diseases, etc.
2. Other equipment inspection
It is mainly used to seek the cause of anemia or the primary disease of secondary symptomatic anemia. Such as endoscopy and gastrointestinal angiography to diagnose the cause of digestive tract tumors or other gastrointestinal bleeding. Bone X-ray film assists in the diagnosis of multiple myeloma and bone metastases. CT, ultrasound, etc., examination of multiple organs, multiple sites of lymph node lesions.
Diagnosis
Differential diagnosis
When the skin is severely anemia, the skin tends to be waxy yellow. The longer course of the disease is often fatigued, dry hair, low nutrition, and sluggish growth. Physical examination revealed increased heart rate, increased pulse, increased arterial pressure, and sometimes capillary pulsation.
Mild anemia and severe anemia need to be diagnosed by routine blood tests. Hemoglobin below the following values is anemia: 6 months to 6 years old l10 grams / liter, 6 to 14 years old 120 grams / liter, adult male 130 grams / liter, adult female 120 grams / liter, pregnant women 110 grams / liter. The standard of anemia is (g/L): adult male <125, adult female <110, pregnant woman <100. According to the hemoglobin content, the severity of anemia can be divided into the following four levels:
1 Mild: Hemoglobin low limit ~ 91 g / liter, mild symptoms.
2 Moderate: Hemoglobin 90g / liter ~ 61g / liter, flustered and short after physical labor.
3 Severe: Hemoglobin 60g / liter ~ 31g / liter, has been flustered and short when resting.
4 extreme: hemoglobin <30 g / liter, often associated with anemia.
