1、第一页，共39页。教学课件贫血教学课件贫血教学课件贫血D e f i n i t i o n A Definition A reduction below normal in the concentration of hemoglobin,the mass of red blood cells and/or the hematocrit in the blood.In men Hb 120g/L RBC 4.51012/L HCT 0.42 In women Hb 110g/L RBC4.0 1012/L HCT0.37 2021/1/122第二页，共39页。D e f i n i t i o
2、 n A r e d u c t i o n b e l o w n oFactors influencing Hb concentrationSexAgeAltitudeAlterations in plasma volume2021/1/123第三页，共39页。F a c t o r s i n f l u e n c i n g H b c o n c e n tClassification Morphologic classificationTypeMCV(um)MCH(PG)MCHC(%)DiagnosisMacrocytic1003232-35Megaloblastic anemi
3、aNormocytic80-10026-3232-35AA,HA,Acute posthemorragic anemiaMicrocytic802632IDA,Sideroblastic anemiaThalassemias2021/1/124第四页，共39页。C l a s s i f i c a t i o n Mo r p h o l o g i c Kinetic classification(Classified according to etiology and pathogenesis)一、一、Decreased erythropoiesisDecreased erythropo
4、iesis 1Proliferation and differentiation 2 abnormalities of SCHSC:AA,Fanconis anemia,MDSErythrocytic progenitors:Pure red cell aplasia,Anemias caused by kidney failure and endocrine disorders2021/1/125第五页，共39页。K i n e t i c c l a s s i f i c a t i o n(C l a s s i2Marrow infiltration leukemiascarcino
5、mamultiple myeloma myelofibrosisMalignant histocytosis2021/1/126第六页，共39页。Ma r r o w i n f i l t r a t i o n l e u k e mi3Production and maturation blockages of differentiating cells DNA synthesis blockage:Vit B12,falic acid difficiencies,嘌呤和嘧啶嘌呤和嘧啶 metabolic defectsMegaloblastic anemiaHb synthesis b
6、lockage:Heme production defect:IDA Heptoglobin production defect:Thalassemias2021/1/127第七页，共39页。P r o d u c t i o n a n d ma t u r a t i o n b l o c4 Unknown reason or several mechanismsSideroblastic anemiaChronic disease anemias(chronic inflummation,infections,尿毒症尿毒症,Hepatic disorders,neoplasm,conn
7、ective tissue disease,endocrine disorders)2021/1/128第八页，共39页。4 U n k n o w n r e a s o n o r s e v e r a l m二、二、Accelerated destruction of red cells 1Endogenous(intra-erythrocyte defects)1.Membrane defects of erythrocytes:Hereditary:Hereditary spherocytosis(HS)Hereditasy elliplocytosis(HE)Acquired:P
8、NH2.Enzyme defects Glucose-6-Phosphate Dehydrogenase (G6PD)deficiency Pyruvate kinase deficiency 3.Abnormal haptogllbin synthesis:Sickle cell anemia,Hemoglobinopathies Thalassemias2021/1/129第九页，共39页。二、A c c e l e r a t e d d e s t r u c t i o n o f r2)Extragenous1.Immune HA:AIHA,neonatal HA,mismatch
9、ed transfusion,drug-induced HA2.2.Mechanical:march hemoglobinuria,cardiac valves prostheses,microangiopathic hemolytic disorders.3.3.Due to chemical,physical or microrganisms:Chemical toxin-and drug-induced hemolysis,large scale burned patient(severe burned patient)Infection-induced,benzene,radiatio
10、n4.microrganisms:Malaria,virus,etc.5.4.Increased damage of monocyte-macrocyte system:Hypersplenism2021/1/1210第十页，共39页。2)E x t r a g e n o u s I mmu n e H A :A I H A,三三.Blood lossAcute posthemorrage anemiaChronic bleeding IDA2021/1/1211第十一页，共39页。三.B l o o d l o s s A c u t e p o sClassified accordind
11、 to the proliferative situations of BMHyperplastic anemias(增生性贫血增生性贫血):Hemolytic anemiaAnemia caused by blood lossMegaloblastic anemia,IDA Hypoplastic anemias(增生减低性贫血增生减低性贫血):AA2021/1/1212第十二页，共39页。C l a s s i f i e d a c c o r d i n d t o t h e p rClinical manifestationsFactors influencing symptoms
12、:Severity of anemia Hb8090g/LsymptomsRapidity of anemia Abrupt loss of 20%of the circulating blood volume marked pallor,postural hypotension and tachycardia(心动过速心动过速)The loss of 50%severe shock even dealth.2021/1/1213第十三页，共39页。C l i n i c a l ma n i f e s t a t i o n s F a c t o rIn contrast,the gra
13、dual loss(even Hb 3040g/L)of the circulating red cell mass in a patient with pernicious anemia may occur without any symptoms at all.2021/1/1214第十四页，共39页。I n c o n t r a s t,t h e g r a d u a l l o s s Why?Red cell 2,3 DPG(RBC内内2,3-二磷酸甘油酸二磷酸甘油酸In anemia the oxyhemoglobin dissociation curve usually s
14、hifts(右右移移)in a manner to increase the quantity of oxygen released in tissues without oppeciably altering the quantity of osygen bound in the lungs.Red cell 2,3 diphophoglycerate(2,3 DPG)regularly increases in anemic patients to mediate this effect.Maximum elevation of RBC 2,3 DPG increases oxygen d
15、elivery only about 30 per cent,but this is a highly efficient form of compensation requiring no significant expenditure of energy.2021/1/1215第十五页，共39页。Wh y?R e d c e l l 2,3 D P G 2 0 2 1/1/The aged patients or patients with vascular or cardiac diseases may not stand to milder anemia.2021/1/1216第十六页
16、，共39页。T h e a g e d p a t i e n t s o rThe level of anemia at which symptoms occur is highly variable among individuals as would be expected from the widely differing degrees of physical activity,physical conditioning,circulatory adequacy,and sensitivity or stoicism of the population.2021/1/1217第十七页
17、，共39页。T h e l e v e l o f a n e mi a a t w h i c h sGeneral manifestations:(Nonspecific and reflect tissue hypoxia)Tiredness,fatigue the most common,the earliest symptom Pallor of skin and mucosashared chracteristicCardiovascular systems:Palpitations and dyspnea on exertion,breathlessnesscommon symp
18、tomsValvulae murmurs Hb 3mAnemic cardic disease2021/1/1218第十八页，共39页。G e n e r a l ma n i f e s t a t i o n s:(N o n 3 Neurologic system:Headache,Dizziness,Confusion,decreased mental acuity(记忆力衰退记忆力衰退),晕厥，注意力不集晕厥，注意力不集中，失眠，耳鸣中，失眠，耳鸣 severe anemiaComa 4 Digestive system:Anorexia(食欲不振食欲不振)，厌食，厌食early m
19、egaloblastic anemia Nausea(恶心恶心)，flatulence(胀气胀气)，diarrhoea(腹泻腹泻)or constipation(便秘便秘)lingual abnormalities(舌的改变舌的改变)：common2021/1/1219第十九页，共39页。3 N e u r o l o g i c s y s t e m:H e a d a5Genitourinary system:severe anemiapolyurea(多尿多尿),hypobaric urine(尿比重低尿比重低),proteinuria(蛋白尿蛋白尿):肾小球滤过功能和小管分泌及回收功
20、能肾小球滤过功能和小管分泌及回收功能障碍障碍female:disturbed menstruation(月经紊乱月经紊乱),性功能减退多见性功能减退多见6Other:7.Manifestations of underlying disease:2021/1/1220第二十页，共39页。5 G e n i t o u r i n a r y s y s t e m:s e v e r eThe process of correct diagnosis is the one of differential diagnosis.Steps:1.To Establish the type of ane
21、mia 2.To find out the cause or underlying diseases of anemiaDiagnosis2021/1/1221第二十一页，共39页。T h e p r o c e s s o f c o r r e c t d i a g n o s1.1.Cause or inducer of anemia:Cause or inducer of anemia:Nutrition,special habits for food change in stool habits:stool Guaiacs in all professioninfluation o
22、f surrounding environment chronic diseases menstruation,marriage一一History 2021/1/1222第二十二页，共39页。C a u s e o r i n d u c e r o f a n e mi a:N2.Developing processes,severity 2.Developing processes,severity&complications of anemias&complications of anemias Duration and onset of symptoms 3.Important lab
23、oratory results,3.Important laboratory results,diagnosis,treatments and their diagnosis,treatments and their effects.effects.2021/1/1223第二十三页，共39页。2.D e v e l o p i n g p r o c e s s e s,s eskin and mucosa:pallor,jaundice,petechiaehair and nails adenopathy(淋巴结肿大淋巴结肿大)hepatomegaly-splenomegalyneurolo
24、gic abnormalities 肛门及妇科盆腔检查肛门及妇科盆腔检查二二Physical examination2021/1/1224第二十四页，共39页。s k i n a n d mu c o s a:p a l l o r,j a u n d、The hemogram The hemogram 血像血像Routine blood exam(Hb,RBC)Routine blood exam(Hb,RBC)The reticulocyte count(RC)The reticulocyte count(RC)RC:hyperplasticRC:hyperplasticRC:hypopl
25、asticRC:hypoplastic三、三、Laboratory findings2021/1/1225第二十五页，共39页。、T h e h e mo g r a m 血像R o u t i n e bReticulocyte Count Is required in the evaluation of all patients with anemia as it is a simple measure of production Young RBC that still contains a small amount of RNA Normally take 1 day for reti
26、culocyte to mature.Under influence of epo takes 2-3 days 1/120th of RBC normally2021/1/1226第二十六页，共39页。R e t i c u l o c y t e C o u n t 2 0 2 1/1/1 2 2 6 第Absolute Retic count Retic counts are reported as a percentage:RBC count x Retic%=Absoulte retic count normal:(77+23)x 109/L Absolute Retic count
27、s need to be corrected for early release(If polychromasia is present)Absolute retic/2(for hct in mid 20s)Absolute retic/3(hct 20)2021/1/1227第二十七页，共39页。A b s o l u t e R e t i c c o u n t R e t i c c o u nMCV(the mean corpuscular volume):the most useful of the RBC indices.MCH,MCHC:are rarely as helpf
28、ul as the MCVThe leukocyte and platelet count:Anemia with a diminished leukocyteand platelet count-pancytopenia-suggests either primary marrow disease,megaloblastic anemia,or hypersplenism.Examination of the peripheral blood smear:2021/1/1228第二十八页，共39页。MC V(t h e me a n c o r p u s c u l a r v o l u
29、 m2.Examination of bone marrow2.Examination of bone marrow 骨髓涂片检查：主要观察骨髓涂片检查：主要观察BM增生程度，各系统细胞分类计数，增生程度，各系统细胞分类计数，异常细胞，正常异常细胞，正常BM组织有核细胞与脂肪组织各占组织有核细胞与脂肪组织各占1/2，前者增，前者增多尤其是红系见于增生性贫血，后者增多代表多尤其是红系见于增生性贫血，后者增多代表BM增生低增生低下，见于下，见于AA，骨髓小粒是血液稀释与否的一个重要标志。，骨髓小粒是血液稀释与否的一个重要标志。Examination of aspirated smears in g
30、eneral gives superior cytologic information while the core biopsy provides crucial information concerning the overall cellularity,as well as the presence of fibrosis,tumor,or granulomas.Both procedures are complemantary and are best performed together when the diagnosis is in doubt.Bone marrow iron
31、staining2021/1/1229第二十九页，共39页。2.E x a mi n a t i o n o f b o n e ma r r o w 3.Some useful ancillary tests3.Some useful ancillary tests1)Stools for occult blood 2)Tests for hemolytic anemia such as Coombstest3)Tests for nutritional anemia such as serum folic acid,serum Vitamin B12,SI,SF,etc.4)Liver a
32、nd kidney function tests5)Immunologic tests6)影像学检查：钡餐透视，钡灌肠影像学检查：钡餐透视，钡灌肠2021/1/1230第三十页，共39页。3.S o me u s e f u l a n c i l l a r y t e s t sTreatment一、一、Treatment of the causesThe purpose is the treatment of the underlying disease.Gastric cancerPernicious anemia恶性贫血恶性贫血 megaloblastic anemia2021/1/
33、1231第三十一页，共39页。T r e a t me n t 一、T r e a t me n t o f t h e c二、二、Drugs明确病因之前且忌乱投药明确病因之前且忌乱投药Iron agents;calculation of dosefalic acid,Vit B12Vit B6Corticosteroids:AIHA，AA,PNHAndrogens:may promate reythropoiesis:1.)刺激刺激EPO分泌。分泌。2增强增强BM对对EPO的的效应。效应。EPO:Anemia caused by kidney diseasesImmunosuppressio
34、n agentsALG(antilymphocyte globulinCsA:Acute and severe AA 2021/1/1232第三十二页，共39页。二、D r u g s明确病因之前且忌乱投药2 0 2 1/1/1 2 3 2三、三、Transfusions Avoid of complications as hepatitis and AIDSWhole bloodFrozed red cellsWashed red cellsLeukocyte poor packed cells 浓缩浓缩RBC Chronic anemia:Hb300)lowAnemia of Chroni
35、c DxlowlowNormal to highAplastic anemia HighExtremely highNormal to high2021/1/1236第三十六页，共39页。L a b E v a l u a t i o n o f H y p o p r o l i f e rLaboratory findings in anaemiaDrs Shepherd,Dexter,and Rapson Spring 20012021/1/1237第三十七页，共39页。L a b o r a t o r y f i n d i n g s i n a n a e mi aScanning Electron microscopy:normal red cell2021/1/1238第三十八页，共39页。S c a n n i n g E l e c t r o n mi c r o s c o p y:2 结结 语语第三十九页，共39页。谢谢大家！结 语第三十九页，共3 9 页。
