Blood Hematopoietic Disease:Anemia

• Insufficient oxygen to brain is accompanied by hypoglobulia or low hemoglobin (Hb).
• Inflammation may cause Anemia.
• Primary symptoms are dizziness, palpitation, or breath shortness.
• Endoscopic examination is performed for unexplained acute loss.
• Blood infusion should be minimum in consideration of the risk for iron overload disorder.

Insufficient oxygen to brain is accompanied by hypoglobulia or low hemoglobin (Hb).

Anemia is caused by the decrement of the number of red blood cell which is one of the element of blood flown in vessel, or low hemoglobin (Hb) contained in red blood cell. As Hb combined with oxygen is flown in entire body, in case when anemia is caused, oxygen becomes short in brain so that the symptoms like postural hypotension, dizziness, or lipothymia are appeared. Definition of Anemia is set as the stage where RBC or Hb becomes lower than normal age range value. And it is grouped by the size of RBC or Hb amount contained in blood to microcytic hypochromic anemia, normocytic normochromic anemia, and macrocytic normochromic anemia. The cause of them are in broader range.

Inflammation may cause Anemia

Influencing factors for the development of Anemia are nutrition (iron, vitamin B12, folic acid), kidney (it produces hormone named erythropoietin which enhances the production of red blood cell), spleen (it has a function of destroying red blood cell), and peripheral blood (flows in entire body with carrying red blood cell). In case when some problem occurs at any of the above, Anemia is developed. Furthermore, there are anemia caused by inflammation or acute blood loss, and especially for anemia, the involvement of digestive tube, i.e. gastrointestinal disease exist in many cases. (Chart 1) The cause for anemia is summarized as below.

• Decreased intake of nutrition (lack of iron, vitamin B12, lack of folic acid)
• Impaired utilization of nutrition (for example, in the impaired iron utilization there are hereditary iron bud anemia (XLSA) and iron deficiency globules anemia by the infection of helicobacter pylori in stomach, and in the impaired vitamin B12 utilization, there is macrocytic anemia which is caused after gastric resection or end of the ileum resection, or caused by the production of antibiotics against the stomach intrinsic factor.
• Shortage of erythropoietin (anemia by renal failure or kidney dialysis case)
• Bone-marrow suppression or shortage of red blood cell life cycle caused by inflammatory cytokine. (Inflammation involved anemia, like rheumatism, inflammatory bowel disorder (IBD))
• Hematopoietic disorder at bone-marrow. (by spleen disorder like aplastic anemia or MDS, or by bone marrow occupying lesions like leukemia or bone-marrow metastasis of solid cancer.)
• Spleen involved anemia (Life duration of Red blood cell is shortened so that it becomes easy to break down.) (There is immune type such as autoimmune hemolytic anemia or non-immune type such as Hb disorder (thalassemia) or erythrocyte membrane abnormalities (Hereditary globular red blood cell disease).
• Blood Loss (traumatic, alimentary canal bleeding)

Primary symptoms are dizziness, palpitation, or breath shortness.

Symptoms like bad complexion, sluggish feeling, having a palpitation, feeling dizzy, having shortness of breath. In hemolytic anemia, symptom like jaundice (bulbar conjunctiva turns yellow, skin also turns yellowish) may appear. It may also be complicated with gallstone or splenic tumor.

Endoscopic examination is performed for unexplained acute loss.

Anemia is classified into acute anemia (suddenly turns into anemia) and chronic anemia (turns into anemia chronically without even noticing). Examination for the diagnosis are as shown below.

General Examination / peripheral blood test

Differentiating between lung inflammation or lung infiltration by simple X-ray check, and searching existence or non-existence of infection focus, splenic tumor, or fibroid by CT Examination. In general blood drawing, RBC, Hb, Ht, MCV, WBC, blood platelet counts, or reticulated corpuscle are checked. Regarding to shortage of iron, serum iron, binding ability (TIBC, UIBC), serum ferritin, helicobacter pylori infection is checked. For macrocytic anemia, vitamin B12 and folic acid are checked. Kidney function is also checked whether or not renal failure is involved. In case hemolytic anemia is suspicious, coombs test or cold agglutinin value are checked. Test for spherocytosis is also tested. Furthermore, when symptom of spherocytosis shows acute anemia, test for parvovirus infection (parvo IgM antibody) is necessary.

Endoscopic Examination

To find gastric ulcer or duodenal ulcer at earlier stage, endoscopic examination is conducted. Especially when unexplained acute blood lost, esophagogastroduodenoscopy is inevitable. Also, in case when infiltrative shadow is seen at iron deficient anemia, it may be an idiopathic pulmonary Hemosiderosis so that pick gastric fluid, then check the existence or non-existence of macrophage which phagocytize hemosiderin.

Bone-marrow Test

When hematopoietic failure is suspicious, bone-marrow test (bone-marrow puncture or bone-marrow biopsy) is inebitable.

Other than the above, in matured female’s iron deficient anemia, there are many cases of the fibroid of uterus involvement, so that it may be requested to perform gynecological treatment.

Blood infusion should be minimum in consideration of the risk for iron overload disorder.

Identifying the causative disease of anemia first and being concentrated for the treatment is the priority issue. During the recovery period of anemia with the primary disease treatment, there is a case where QOL needs to be improved by tentative blood infusion.

For the moment, Hb>8.0g/dL level condition has to be accomplished. But even though at whatever caused anemia, blood infusion should be set at inevitably minimum in consideration of the risk of iron overload disorder (hemochromatosis) after the treatment. Especially for hypoferric anemia with which helicobacter pylori infection involved, pylorus eradication becomes necessary. For the anamnestic case of gastric resection or ileocecal bowel resection, or for the case of autoimmune disease with positive antibody to intrinsic factor, parenteral dosing of vitamin B12 becomes necessary. Erythropoietin is administrated for renal failure condition. In hemolytic anemia, there is a case where administration of immunosuppressants or removal of the spleen is effective. For macrocytic anemia, since it may appear as the bone-marrow toxicity by alcohol, improvement of life-style habit is necessary. Take care of the meals not being shortage of the nutrition inevitable for blood forming. Since the elderly person often becomes shortage of folic acid, compliment of folic acid is necessary, and also folic acid is complimented for expectant mother.

Esophageal varices	blood loss anemia
Gastric ulcer, duodenal ulcer, stomach cancer, colon cancer	Blood loss anemia
Gastric Pylori infection	Idiopathic thrombocytopenia purpura
	Iron deficiency anemia
	Gastric MAL lymphoma
	Atrophic gastritis (cause for anemia)
Atrophic gastritis	Anemia macrocytic due to B12 deficiency(anemia pernicious)
After the total gastrectomy	Anemia macrocytic due to B12 is unable to combine with intrinsic factor, (anemia pernicious)
After the resection of the end of the ileum	Anemia macrocytic due to B12 intrinsic factor is not absorbed into the body. (anemia pernicious)
Inflammatory bowel disease (IBD)	Inflammatory anemia

Chart 1: Relation between gastric disease and blood disease