Step two: ask if underproduction of red cells, excessive destruction of red cells (hemolysis), or both, are occurring. The possibility of bleeding as the primary, or a contributing, cause should be a prominent suspicion in every anemia work-up. Bleeding is the most common cause of iron deficiency, but acute bleeding or brisk chronic bleeding can cause anemia before iron deficiency develops, especially if bone marrow compensation is compromised (e.g., renal failure). Menometrorrhagia, gastrointestinal (GI) bleeding, and blood losses incurred during pregnancy and delivery are the most common. There are four steps in an anemia work-up, and these are listed below: Step one: ask if the patient is losing blood.Īnemias due to acute or chronic blood loss are by far the most common, and commonly overlooked, forms of anemia.
The most practically useful among many possible diagnostic approaches is to consider first whether the anemia is due to blood loss, underproduction of red cells, or to excessive red cell destruction recognizing that in some cases more than one process can contribute. This invariably guides the proper choice of further tests that will narrow down the possible causes for anemia, and elucidates the appropriate approach to therapy. While there are many sophisticated tests that can be done to assist a work-up for anemia, most cases will be diagnosed on the basis of a thorough history (particularly for bleeding or systemic diseases, nutritional inadequacies, medications), physical examination, and simple laboratory evaluations that include a complete blood count with differential, a reticulocyte count, and an expert review of the peripheral blood smear. Bleeding frequently uncovers other subclinical abnormalities that predispose to anemia. A thorough bleeding evaluation should accompany every anemia work-up even if other factors contributing to or causing the anemia co-exist. However, in the majority of patients with anemia, the underlying cause will be systemic disease processes, toxic exposures, medications, infectious agents, or physical factors (e.g., heat, fresh water drowning) that adversely affect the erythron.īy far the most common cause of anemia is bleeding. Many forms of anemia are due to intrinsic defects in bone marrow function, or the structure or function of erythroid progenitors or erythrocytes.
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