CAUSES MALNUTRITION: - Starvation, poverty, vegetarianism, tea-toast diet - Inc req adolescent, childhood, preg BLOOD LOSS - Menstruation,

, trauma, freq blood donation, haemodialysis, surgery - Peptic ulcer, hookworm, haemorrhoids, carcinomas, NSAIDS MALABSORPTION: -crohns dis, celiac dis, partial & total gastrectomy, gut resection or bypass, antacids, antisecretory agents

S&S Appearance : tired, listless, lifeless Skin: pale, inelastic, often dry skin Hair : often sparse Mouth: erythema of the tongue, angular cheilosis, glossitis Eyes: pallor of conjunctiva sclera Nails: flattened, longitudinally rigid, concave nails Cardiovascular: tachy, slight cardiomegaly Difficulty concentrating Severe IDA: Bilateral angular cheilosis, pale coloured lips, smooth bald inflamed tongue (glossitis), pica, craving for ice

PREVENTION -identification of persons at risk Pregnancy : 60-120mg elemental iron daily orally -dietary modification - haem iron : lean red meat, fish, chicken, organ meats, seafood - non haem : lentils, beans, peas, tofu, eggs, iron fortified cereals, spinach,apricots, peaches, potato Citrus fruits, broccoli, capsicum (vit c) enhance absorption

Iron deficiency anemia Chronic anemia characterised by small, pale RBCs and iron depletion TREATMENT Look for the cause of deficiency DIET THERAPY : once deficiency estab, diet therapy is not sufficient but recommended ORAL IRON REPLACEMENT (1st 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 weeks - Reticulocyte count starts to rise 2-3days after tx - Once level is normal, tx for further 3-6mths to replenish iron stores - Monitor Hb during tx, if no response in a month, consider non compliance, non absorption, cont source of iron loss PARENTERAL IRON Iron polymaltose - IM or IV - IM pain n skin discoloration Iron sucrose - IV or slow inj - Pts undergoing chronic haemodialysis with hypersensitivity to iron poly Indicated for: - Severe iron malabsorption - Non compliance, severe intolerance with oral iron tx/ inadequate to meet demand (surgery) - Excessive iron loss eg renal dialysis patients INCREASE: Inorganic ion : ionic form, particularly ferrous state Ascorbic acid: assists conv ferric to ferrous Gastric acid: promotes release & conv of dietary iron to ferrous state Clinical state: iron def, pregnancy, inc erythropoesis, anoxia DECREASE: Drugs: antacids, H2 blockers, ppi, tetracylines Diet: phytates and phosphates in cereals, wholegrain bread. Tannins in coffee, tea Clinical state: adeq iron stores, dec eryhtropoeisis, acute or chronic inflammation, chronic diarrhea

FACTORS INC/DEC IRON ABS

CAUSES Inadequate diet - Alcoholics, elderly, vegans Inadequate GI absorption - Inadequate release of B12 from food : achlorhydia, partial gastrectomy - Drug induced malasorption: H2RA, PPI, metformin - Lack of intrinsic factor or parietal cells (pernicious anemia) : antibodies against IF and parietal cells, total gastrectomy, chronic gastritis Intestinal causes - Small bowel disease : ileum resection or bypass, blind loops syndrome with abnormal gut flora - Malabsortion : tropical sprue, crohns disease, celiac disease, pancreatic insufficiency Biologic competition for abs - Fish tapeworm - Bacterial overgrowth Defective transport - Transcobalamin 2 deficiency

S&S General - Pallor, slight jaundice, anorexia, mild weight loss, diarrhoea, dyspnea, palpitations, weakness, vertigo, tinnitus, atrophic glossitis, sore tongue Neurologic - Paresthesia, diff walking, loss of vibratory sense, incoordination of movements, sense of touch impaired, peripheral neuropathy Psychiatry - Irritability, personality change, depression, mild memory impairment, dementia, psychosis

DIAGNOSIS Early diagnosis important- long term neurologic effects become irreversible Haematologic : - Macrocytic MCV > 100fl - Anisocytosis and poikilocytosis Biochemical: - Low serum B12 - Serum methylmalonic acid - Antibodies to intrinsic factor - Transcobalamin B12 content

Macrocytic anemia : vit b12 anemia : rbcs are large, immature, malformed and fragile

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

S&S Very similar to B12 def except for neurological lesions Lab results : Low serum folate, low red cell folate, normal methylmalonic acid and high homocysteine level

CAUSES Absolute inadequate intake - Alcoholism and nutritional def Relatively inadequate intake from increased requirement - Pregnancy, severe haemolysis, dialysis Inadequate absorption - 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 MANAGEMENT Exclude B12 def - High dose folic acid can alleviate anemia of B12 def but does not prevent the associated neurological damage Tx of folate def - Orally 5mg once daily for at least 4 months - IM/IV/SC 1-5mg once daily Management of underlying disorder PREGNANCY High risk women - Diabetes - Previous preg with neural tube defect - Close family hx of neural tube defect - On epileptic meds - 5mg orally daily before conception and for first 12 weeks of preg Low risk women - 500 mcg orally daily before conception and for first 12 weeks of preg Patients taking methotrexate - 1-5 mg orally once daily