Anemia

Blood is actually a liquid made up of several different cell types. One of the most important and most numerous cell types is the red blood cell. The purpose of the red blood cell is to deliver oxygen to the body. Anemia describes the condition in which the number of red blood cells in your blood is low. For this reason, doctors sometimes describe someone with anemia as having a low blood count. A person who has anemia is called anemic.

• Preventing anemia and having the correct number of red blood cells requires cooperation among the kidneys, the bone marrow, and nutrients within the body. If your kidneys or bones are not working, or your body is poorly nourished, then you might not be able to maintain a normal red blood cell count.



• Anemia is actually a sign of a disease process rather than a disease itself. It is usually classified as either chronic or acute. Chronic anemia happens over a long period of time. Acute anemia happens quickly. Determining whether anemia has been going on a long time or whether it is something new helps doctors to find its cause. This also helps predict how severe the symptoms may be.



• Red blood cells live about 100 days, so the body is constantly trying to replace them. In adults, red blood cell production occurs in the bone marrow. Doctors try to determine if a low red blood cell count is caused by increased blood loss or from decreased production in the bone marrow. Knowing whether the number of white blood cells has changed also helps determine the cause.



• In the United States, 2-10% of people have anemia. Other countries have even higher rates of anemia. Women are twice as likely to have anemia than men. Anemia happens in both young people and in old people, but older people are more likely to have other medical problems associated with anemia.

• Many medical conditions cause anemia. Common causes of anemia include the following:
  
  
  • External bleeding: Loss of blood through heavy menstrual bleeding, wounds, as well as stomach ulcers can cause anemia.
    
    
  • Iron deficiency: The bone marrow needs iron to make red blood cells.
    
    
  • Anemia of chronic disease: Any long-term medical condition can lead to anemia.
    
    
  • Kidney disease: The kidneys help the bone marrow to make red blood cells.
    
    
  • Pregnancy: Water weight gain during pregnancy dilutes the red blood cells.
    
    
  • Poor nutrition: Vitamins and minerals are required to make red blood cells.
    
    
  • Alcoholism: Poor nutrition and lack of vitamins and minerals are associated with alcoholism.
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• Uncommon causes of anemia include bleeding disorders, liver disease, thalassemia, infection, cancer, arthritis, enzyme deficiency, sickle cell disease, hypothyroidism, toxins, or hereditary conditions.

Because a low red blood cell count decreases oxygen delivery to every tissue in the body, anemia causes many signs and symptoms. It makes almost any other underlying medical condition worse. For example, if you have an underlying heart problem and become anemic, you are more likely to have problems associated with your heart disease than you would have if you were not anemic.

How severe the anemia is will determine how severe the signs and symptoms will be.

• Signs of anemia may include the following:
  
  
  • Black and tarry stools (sticky and foul smelling)
    
    
  • Maroon, or visibly bloody stools
    
    
  • Rapid heart rate
    
    
  • Rapid breathing
    
    
  • Pale or cold skin
    
    
  • Yellow skin called jaundice
    
    
  • Low blood pressure
    
    
  • Heart murmur
    
    
  • Enlargement of the spleen
  
  
• Symptoms of anemia may include the following:
  
  
  • Fatigue
    
    
  • Trouble breathing
    
    
  • Chest pain
    
    
  • Abdominal pain
    
    
  • Weight loss
    
    
  • Weakness
    
    
  • Dizziness and passing out, especially upon standing

The diagnosis of anemia at home is difficult unless bleeding is obvious. How rapidly anemia occurs determines how severe the symptoms will be. If significant bleeding is obvious, go to a hospital's emergency department. If you experience any of the signs and symptoms of anemia, call your doctor for an appointment.

Anemia can be life threatening. If you have any of the signs or symptoms and cannot contact your doctor, or if you are having severe symptoms, you should go to a hospital's emergency department for help. A large amount of blood loss, even without signs and symptoms of anemia, should cause you to go to the emergency department.

If possible, have a friend or a neighbor take you to the hospital if you suspect you have anemia. It is dangerous for a severely anemic person to drive because you could pass out while driving and cause an accident.

• Doctors can easily determine if you are anemic by drawing blood for a complete blood count. This routine blood test often shows that you should have more tests, so it is one of the first tests done in the evaluation of anemia.
  
  
• Because anemia is only a symptom of a disease, doctors will want to determine what is causing your anemia. Many tests exist to help find the cause of anemia, and most of these are blood tests. Doctors choose these tests based on each person. Some people may need many tests, and some people may need very few. For example, an anemic person with known stomach ulcers may not need multiple blood tests but may need to have his or her stomach looked at and to have the ulcers treated. On the other hand, a person with a family history of anemia and without an obvious source of blood loss may need multiple laboratory tests and other testing.
  
  
• Doctors also take into consideration the severity of the anemia when deciding which tests to order. When a person has severe anemia, the cause must be determined rapidly so that it can be treated.
  
  
• Lab tests for anemia may include the following:
  
  
  • Complete blood count - Determines the severity of the anemia and is almost always the first test ordered
    
    
  • Stool guaiac - Tests for blood in stool
    
    
  • Peripheral blood smear - Looks at the red blood cells under a microscope
    
    
  • Iron level - Low iron is one of the most common causes of anemia
    
    
  • Transferrin level - Looks at a protein that carries iron around the body
    
    
  • Ferritin - Looks at the total iron available in the body
    
    
  • Folate - A vitamin needed to produce red blood cells, which is low in people with poor eating habits
    
    
  • Vitamin B12 - A vitamin needed to produce red blood cells, low in people with poor eating habits
    
    
  • Bilirubin - Useful to determine if the red blood cells are being destroyed within the body
    
    
  • Lead level - Lead toxicity used to be one of the more common causes of anemia
    
    
  • Hemoglobin electrophoresis - Sometimes used when a person has a family history of anemia
    
    
  • Reticulocyte count - A measure of new red blood cells produced by the bone marrow
    
    
  • Liver function tests - Uncommon tests to determine how the liver is working
    
    
  • Bone marrow biopsy - One of the last tests done; looks at production of red blood cells

|Self-Care at Home|

Very little can be done at home to treat anemia. In general, if you have anemia, you should continue to take your medications for chronic medical problems. Because dehydration accompanies anemia, you will want to make sure you are drinking plenty of fluids.

Because anemia itself is not a disease but a sign of some other process, the best way to minimize the symptoms of anemia at home is to control other medical problems.

• For example, if you have had a heart attack, you should be sure to take your heart medications because anemia can make the heart problem worse.
  
  
• If you have stomach ulcers, you will want to avoid alcoholic beverages, aspirin, and medications such as ibuprofen (Advil), which can make ulcers worse and lead to bleeding.

|Medical Treatment|

• Because dehydration accompanies anemia, you may be given fluids through an IV in your vein to maintain blood pressure in severe cases.
  
  
• Treatment of anemia involves treating its cause, but severe anemia is life threatening and can be treated in the hospital with a transfusion of red blood cells.
  
  
  • Doctors try to avoid giving red blood cell transfusions unless it is absolutely necessary.
    
    
  • Rarely, transfusing red blood cells can transmit diseases such as hepatitis B or C, which cause liver damage, and HIV, which causes AIDS.
    
    
  • With current blood testing, however, the risk of getting hepatitis or HIV from a blood transfusion is very low.
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• Depending on severity and cause, other therapies that treat anemia itself include the following:
  
  
  • Oxygen - To ensure that each red blood cell can deliver the maximum oxygen to body tissues
    
    
  • Fluids - To help to elevate blood pressure when blood loss causes blood pressure to drop
    
    
  • Vasopressors - Medications to elevate the blood pressure when fluids aren’t enough
    
    
  • Fresh frozen plasma (FFP) - A normal part of blood, which replaces the lost plasma
    
    
  • Platelets - Replaces missing platelets when bleeding is severe

|Medications|

Medications and treatments that correct the common underlying causes of anemia include the following:

• Iron - Taken during pregnancy and when iron levels are low
  
  
• Vitamin supplements - To replace folate and vitamin B12 in people with poor eating habits
  
  
• Erythropoietin (Procrit) - To increase red blood cell production in people with kidney problems
  
  
• Antibiotics - To treat infections that can cause anemia

|Surgery|

Hysterectomy helps women who are anemic from having heavy or long periods.

|Follow-up|

Follow-up care for anemia will depend on its type. Most will require repeat blood counts. Also, repeat visits to the doctor’s office are likely in order to determine your response to treatment.

|Prevention|

Some common forms of anemia are most easily prevented by eating a healthy diet and by limiting alcohol use. All types of anemia are best avoided by seeing a doctor regularly and when problems arise

|Outlook|

How well someone with anemia will recover depends on the cause of the anemia and how severe it is. For example, if a stomach ulcer is causing anemia and it can be cured, then the anemia can be cured. If anemia is caused by kidney failure, however, then it most likely will require long-term treatment.

In general, young people recover from anemia more quickly than older people do. Younger people also tolerate anemia better than elderly people because elderly people tend to have more chronic medical problems. Anemia makes almost any medical problem worse.

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Author: Patrick Yorba, MD, Staff Physician, Department of Emergency Medicine, University of Virginia Health Sciences Center.

Coauthor(s): J Stephen Huff, MD, Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health System; Mark A Mullins, MD, Staff Physician, Department of Emergency Medicine, UMASS Memorial Medical Center.

Editors: Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Anthony Anker, MD, FAAEM, Attending Physician, Emergency Department, Mary Washington Hospital, Fredericksburg, VA.