Teaching Rounds Day 4
Anemia - Part 2
Slow loss
&
The Bone Marrow Factory
Check out part 1 here -bit.ly/2PJRo18
Join us #medtwitter & #medstudenttwitter
Anemia - Part 2
Slow loss
&
The Bone Marrow Factory
Check out part 1 here -bit.ly/2PJRo18
Join us #medtwitter & #medstudenttwitter
Ok, let's get out bearings..
1. Is there an approach to anemia?
I don't think so - we need a time course.
2. If you don't have a prior HgB, use the clues below to tease out between acute and chronic anemia.
3. Acute anemia =
Bleeding
Hemolysis or
Acute marrow disease
1. Is there an approach to anemia?
I don't think so - we need a time course.
2. If you don't have a prior HgB, use the clues below to tease out between acute and chronic anemia.
3. Acute anemia =
Bleeding
Hemolysis or
Acute marrow disease
With me?
Cool - 👊
Let's take on chronic anemia and bring this schema to life.
Ready??
Let's go!
Cool - 👊
Let's take on chronic anemia and bring this schema to life.
Ready??
Let's go!
Slow Loss...
HgB loss from bleeding or hemolysis usually results in an acute anemia.
Usually...but not always.
The loss can be slow enough to fundamentally change the tempo of presentation.
HgB loss from bleeding or hemolysis usually results in an acute anemia.
Usually...but not always.
The loss can be slow enough to fundamentally change the tempo of presentation.
Chronic blood loss = Iron deficiency anemia
If the bleeding is slow enough, the iron that is lost controls the presentation, NOT the actual HgB lost in the bleeding.
Caveat - not all iron deficiency is from blood loss.
Here is the @CPSolvers schema
bit.ly/38nXURR
If the bleeding is slow enough, the iron that is lost controls the presentation, NOT the actual HgB lost in the bleeding.
Caveat - not all iron deficiency is from blood loss.
Here is the @CPSolvers schema
bit.ly/38nXURR
Two outstanding resources about iron deficiency
1. @HannahRAbrams's terrific video - bit.ly/2Ijpsgt
2. @sargsyanz incredible breakdown of iron studies - bit.ly/3crWPvn
1. @HannahRAbrams's terrific video - bit.ly/2Ijpsgt
2. @sargsyanz incredible breakdown of iron studies - bit.ly/3crWPvn
Chronic hemolysis...
A tricky concept to absorb; we are so used to hemolysis being aggressive and acute.
The rate of RBC destruction can be slow enough to mold the presentation into an indolent one!
Hereditary Spherocytosis is one example..
Can you think of others?
A tricky concept to absorb; we are so used to hemolysis being aggressive and acute.
The rate of RBC destruction can be slow enough to mold the presentation into an indolent one!
Hereditary Spherocytosis is one example..
Can you think of others?
Alright, time to look back on the progress we've made.
The world of chronic anemia begins by borrowing from our acute anemia schema and dialing down the tempo
1. CHRONIC blood loss = Iron deficiency
2. CHRONIC hemolysis
Time to explore the world of RBC production..
The world of chronic anemia begins by borrowing from our acute anemia schema and dialing down the tempo
1. CHRONIC blood loss = Iron deficiency
2. CHRONIC hemolysis
Time to explore the world of RBC production..
The Bone Marrow Factory...
Such a magical place.
Seriously.
🤓🤓🤓
It's where the same cell, a stem cell, is miraculously transformed into a myriad different ones that serves all sorts of functions.
Blows my mind everytime!
Such a magical place.
Seriously.
🤓🤓🤓
It's where the same cell, a stem cell, is miraculously transformed into a myriad different ones that serves all sorts of functions.
Blows my mind everytime!
This factory has two fundamental components...
1. The Environment The Cells
&
2. The Cells
1. The Environment The Cells
&
2. The Cells
The Environment...
Even the healthiest of cells can't thrive in a suboptimal environment.
What could go wrong with the environment?
1. Raw Materials
2. Hormones
3. Toxins
4. Meds
Even the healthiest of cells can't thrive in a suboptimal environment.
What could go wrong with the environment?
1. Raw Materials
2. Hormones
3. Toxins
4. Meds
Why think of about low production this way - Environment and Cells?
My take:
If the issue is with the environment, there is nothing wrong with the marrow.
My take:
If the issue is with the environment, there is nothing wrong with the marrow.
Practically speaking:
Explore the environment - blood tests/med rec/etc - well before you study the cells themselves.
Well before you get a bone marrow biopsy...
Here's a great case that illustrates that point.
bit.ly/32Q8WhF
Explore the environment - blood tests/med rec/etc - well before you study the cells themselves.
Well before you get a bone marrow biopsy...
Here's a great case that illustrates that point.
bit.ly/32Q8WhF
The Cells...
An inherent problem with the cells resulting in JUST anemia limits the DDx.
Prioritize
1. Multiple Myeloma
2. Myelodysplasia
3. Pure red cell aplasia - super RARE
An inherent problem with the cells resulting in JUST anemia limits the DDx.
Prioritize
1. Multiple Myeloma
2. Myelodysplasia
3. Pure red cell aplasia - super RARE
If we've got multiple cell lines down, we've just entered a new diagnostic sphere - pancytopenia.
We'll stay focused on the anemia and skip this for now.
I'll leave with one approach for you to keep on file, but we won't study it today.
We'll stay focused on the anemia and skip this for now.
I'll leave with one approach for you to keep on file, but we won't study it today.
Time to catch our breath, team.
We've covered a lot of ground.
Chronic anemia:
1. Slow Loss
Chronic bleeding
Chronic hemolysis
2. Dysfunctional Bone Marrow Factory
Environment
Cells
Study the environment well before you zero in on the cells.
We've covered a lot of ground.
Chronic anemia:
1. Slow Loss
Chronic bleeding
Chronic hemolysis
2. Dysfunctional Bone Marrow Factory
Environment
Cells
Study the environment well before you zero in on the cells.
Wait, wait, wait...
Have we really made it ALL this way in a talk about anemia without mentioning the Mean Corpuscular Volume - the MCV.
Whoops. My bad.
There's a reason. I promise.
Have we really made it ALL this way in a talk about anemia without mentioning the Mean Corpuscular Volume - the MCV.
Whoops. My bad.
There's a reason. I promise.
The MCV can be a terrific clue to the underlying cause.
It's a just a clue, though, not something to ANCHOR your schema on.
Patients with microcytosis are not immune to multiple myeloma. I've seen it.
Patients with combined B12 and iron deficiency can have a normal MCV.
It's a just a clue, though, not something to ANCHOR your schema on.
Patients with microcytosis are not immune to multiple myeloma. I've seen it.
Patients with combined B12 and iron deficiency can have a normal MCV.
Let the MCV grab your attention, not completely take over it.
And if the MCV is low, prioritize these causes..
@RahulBanerjeeMD reminded us that studying the MCV over time can be really helpful!
And if the MCV is low, prioritize these causes..
@RahulBanerjeeMD reminded us that studying the MCV over time can be really helpful!
And if the MCV is high, focus in on...
Folks..
Anemia is TOUGH.
It's incredible how something so common can so tough to have a systematic approach.
Some t
(1) Start with a time course -
acute & chronic anemia are very different
(2) Acute anemia =
hemorrhage > hemolysis > acute marrow disease
(3)Chronic anemia..
Anemia is TOUGH.
It's incredible how something so common can so tough to have a systematic approach.
Some t
(1) Start with a time course -
acute & chronic anemia are very different
(2) Acute anemia =
hemorrhage > hemolysis > acute marrow disease
(3)Chronic anemia..
Chronic anemia =
1. Slow Loss
-Chronic bleeding
-Chronic hemolysis
2. Dysfunctional Bone Marrow Factory
-Environment
-Cells
Rock on, team!
👊
1. Slow Loss
-Chronic bleeding
-Chronic hemolysis
2. Dysfunctional Bone Marrow Factory
-Environment
-Cells
Rock on, team!
👊
