CAUSES
S&S
PREVENTION
MALNUTRITION:
Appearance : tired, listless, lifeless
-identification of persons at risk
-
Starvation, poverty,
Skin:: pale, inelastic, often dry skin Skin
vegetarianism, tea-toast diet
Hair : often sparse
iron daily orally
Inc req – adolescent,
Mouth: erythema of the tongue,
-dietary modification
childhood, preg
angular cheilosis, glossitis
BLOOD LOSS -
-
Eyes: pallor of conjunctiva sclera
Pregnancy : 60-120mg elemental
- haem iron : lean red meat, fish, chicken, organ meats, seafood
Menstruation, trauma, freq
Nails:: flattened, longitudinally rigid, Nails
- non haem : lentils, beans, peas,
blood donation,
concave nails
tofu, eggs, iron fortified cereals,
haemodialysis, surgery
Cardiovascular:: tachy, slight Cardiovascular
spinach,apricots, peaches, potato
Peptic ulcer, hookworm,
cardiomegaly
Citrus fruits, broccoli, capsicum (vit
haemorrhoids, carcinomas,
Difficulty concentrating
c) – enhance absorption
NSAIDS MALABSORPTION:
Severe IDA:
-crohns dis, celiac dis, partial & total
Bilateral angular cheilosis, pale
gastrectomy, gut resection or bypass,
coloured lips, smooth bald inflamed
antacids, antisecretory agents
tongue (glossitis), pica, craving for ice
Iron deficiency anemia Chronic anemia characterised by small, pale RBCs and iron depletion TREATMENT
FACTORS INC/DEC IRON ABS
Look for the cause of deficiency
DIET THERAPY : once deficiency estab, diet therapy is not sufficient but recommended
ORAL IRON REPLACEMENT (1
st
choice) -
Ferrous salt
-
Adult : 100-200mg daily
-
Non coated for better abs
-
SR- less GI eff but low bioavailability
Expect Hb to rise 20g/l over 3-4
PARENTERAL IRON INCREASE: Iron polymaltose -
IM or IV
particularly ferrous state
-
IM pain n skin discoloration
Ascorbic acid: assists conv ferric
Iron sucrose
-
IV or slow inj
Gastric acid: promotes release &
-
Pts undergoing chronic
conv of dietary iron to ferrous
haemodialysis with
state
hypersensitivity to iron poly
Clinical state: iron def, pregnancy,
Indicated for:
inc erythropoesis, anoxia
-
Severe iron malabsorption
-
Non compliance, severe
DECREASE:
intolerance with oral iron Reticulocyte count starts to
Drugs: antacids, H2 blockers, ppi,
tx/ inadequate to meet
rise 2-3days after tx
tetracylines
demand (surgery)
Diet: phytates and phosphates in
Excessive iron loss eg renal
cereals, wholegrain bread.
dialysis patients
Tannins in coffee, tea
Once level is normal, tx for further 3-6mths to replenish iron stores
-
to ferrous
-
weeks -
Inorganic ion : ionic form,
Monitor Hb during tx, if no response in a month, consider non compliance, non absorption, cont source of iron loss
-
Clinical state: adeq iron stores,
dec eryhtropoeisis, acute or chronic inflammation, chronic diarrhea
S&S
CAUSES Inadequate diet -
Alcoholics, elderly, vegans
General -
Pallor, slight jaundice, anorexia, mild weight loss, diarrhoea,
Inadequate GI absorption -
dyspnea, palpitations,
Inadequate release of B12
weakness, vertigo, tinnitus,
from food : achlorhydia, partial gastrectomy -
Drug induced malasorption: H2RA, PPI, metformin
-
atrophic glossitis, sore tongue Neurologic -
Paresthesia, diff walking, loss of vibratory sense, incoordination
Lack of intrinsic factor or
of movements, sense of touch
parietal cells (pernicious
impaired, peripheral
anemia) : antibodies against IF and parietal cells, total gastrectomy, chronic gastritis
neuropathy -
Irritability, personality change,
Small bowel disease : ileum
neurologic effects become Haematologic :
depression, mild memory
-
Macrocytic MCV > 100fl
impairment, dementia,
-
Anisocytosis and poikilocytosis
psychosis
resection or bypass, blind
-
Early diagnosis important- long term irreversible
Psychiatry
Intestinal causes -
DIAGNOSIS
Biochemical:
loops syndrome with
-
Low serum B12
abnormal gut flora
-
Serum methylmalonic acid
-
Antibodies to intrinsic factor
-
Transcobalamin – B12
Malabsortion : tropical sprue, crohns disease, celiac
Macrocytic anemia : vit b12 anemia :
disease, pancreatic
rbcs are large, immature, malformed
insufficiency
and fragile
content
Biologic competition for abs -
Fish tapeworm
-
Bacterial overgrowth
Defective transport -
Transcobalamin 2 deficiency MANAGEMENT
Hydroxo and cyanocobalamin
Parenteral replacement (im) if antibodies to IF and abs problem
Initial tx: IM 1000mcg on alternate days for 1 -2 weeks or until improvement
Pernicious anemia : lifelong tx, B12 injection 1000 mcg IM every 3 months
Prevention and maintenance : -
Hydroxocobalamin IM 1000mcg every 2-3 mth
-
Cyanocobalamin IM 1000mcg once a month
Oral replacement for prevention of B12 def due to inadequate dietary intake -
Oral cyanocobalamin 100mcg bd
Monitor for hypokalemia at start of VIT B12 therapy
CAUSES S&S
Absolute inadequate intake
Very similar to B12 def except for
-
Alcoholism and nutritional def
neurological lesions
Relatively inadequate intake from increased
Lab results :
requirement
Low serum folate, low red cell folate, normal methylmalonic acid
-
Pregnancy, severe haemolysis, dialysis
Inadequate absorption
and high homocysteine level
-
Tropical sprue, crohns disease, intestinal resections or diversions, diabetic enteropathy, lymphoma of small bowel
Drugs Methotrexate, trimethoprim, sulphasalazine, phenytoin, oral conraceptives
Folate deficiency anemia
FOLATE SUPP PREGNANCY MANAGEMENT Exclude B12 def -
High risk women -
Diabetes
High dose folic acid can alleviate
-
Previous preg with neural tube defect
anemia of B12 def but does not
-
Close family hx of neural tube defect
prevent the associated
-
On epileptic meds
neurological damage
-
5mg orally daily before conception
Tx of folate def -
Orally 5mg once daily for at least 4 months
-
and for first 12 weeks of preg Low risk women -
IM/IV/SC 1-5mg once daily
500 mcg orally daily before conception and for first 12 weeks of
Management of underlying disorder
preg Patients taking methotrexate -
1-5 mg orally once daily