HOW I DO – Anemia – 19

HOW I DO – Anemia – PART – 19

(All the articles published in past are available at www.shyamhemoncclinic.com/blog/)

Question: In last part, we covered additional important points related to DVT 1. Portal vein thrombosis. How to approach if Acute, Chronic, Associated with HCC. For those not associated with HCC, work up for hypercoagulable state especially MPN, PNH is advisable. 2. DVT during pregnancy. LMWH preferred in first trimester. 2^nd, 3^rd trimester either continue same or warfarin.  If cost is an issue, UFH instead of LMWH. No role for DOAC during pregnancy or breastfeeding. Avoid epidural anesthesia while on anticoagulation – serious risk of spinal hematoma. Role of warfarin for some patients during first trimester as well, and its risks benefits for mother vs fetus. Role of DVT prophylaxis for some high risk patients.

We have covered DVT/PE in an extensive manner. Can we discuss ANEMIA? Most common issue faced by family doctors physicians gynecologists pediatricians.

Answer: Sure. This seems like a very simple topic, and yet it is a very wide and complex topic. Fortunately, majority cases are simple, but one has to be aware not to miss serious cases.

Que: So true. Most cases are nutritional but how can our readers differentiate which patients need more work up or referral to a specialist? Also, even with simple nutritional anemias, results are highly variable with iron or vitamin supplements, and very high rates of relapse. How to improve results in this category?

Ans:. Both are very important questions. Let us start with first question. More urgent one. At what level anemia is critical, or for which type of anemia further evaluation is urgent.

1. You all see patients with Hb of 4 or 6 doing well, while some are very tired at 8 g. what this means is that there is no one number to call it critical. In general, lower the number, more the urgency. Since at very low Hb, further small drop can also lead to a life threatening event.
2. More important, however is the history and vital signs. Means if someone is very tired, or has significant shortness of breath on minimal exertion, this patient is urgent. Regardless of Hb level mild low or too low. What this means is that patient’s body is reaching tolerance limit. This could be due to a rapid fall in Hb or low cardiac or pulmonary reserve. For example, if Hb drops from 12 to 8 in a matter of few days or weeks, patient will be very symptomatic. Such as in bleeding or hemolysis.

But if Hb drops from 12 to 6 over several months, patient may have minimal symptoms. What we typically see in nutritional iron def anemia, where ladies come with Hb of 4 and still working! Same as history, if heart rate is high, over 100, it is more urgent, suggesting heart is already working too hard to achieve tissue oxygenation! And any further burden, it can crash.

On the same line, if patient has chest pain or signs of angina, it is urgent. Heart has already reached the limit! For a patient with underlying coronary artery disease, this can happen with even a Hb of 10. For example, if someone’s baseline Hb is 14, and drops to 10 in a matter of days due to GI bleeding or hemolytic anemia, they can develop ischemia quickly. So, don’t just look at numbers, look at patient and talk to patient too!!

3. Additional symptoms. Other than just tiredness, if patient has either weight loss, fever, easy bruising, bleeding, pain in chest or abdomen, urinary symptoms etc, more evaluation is definitely required.
4. Signs. On examination, if you find jaundice, lymph node enlargement, spleen or liver enlarged, edema, ecchymoses or petechiae, abdominal distension, tremors etc, more evaluation is definitely required.
5. Lab – additional signs on cbc. If platelet or white cells are also abnormal – either high or low – definitely more evaluation is required, regardless of Hb level. Or if peripheral smear mentions atypical cells, rouleaux formation, left shift. Or differential count is abnormal. Other lab abnormalities – globulin is higher than albumin, higher creatinine or liver function, proteinuria, high ESR etc These are abnormalities found in most basic tests. But we need to pay attention to them carefully. REMEMBER however that even in many serious underlying disorders, apart from Hb, everything else may still be normal. Hence history and examination are very very important. For example, a colon cancer may present with anemia. Even in significantly high stage, all other tests may be normal.

Mild high creatinine may point to multiple myeloma. Mild low platelet may be seen in many conditions, including liver disease. In a compensated cirrhosis, all liver function tests may be normal. Only clue may be mild anemia and mild low platelets. And abdominal sonography will clinch the diagnosis. Many solid tumors like lung cancer, kidney cancer also may present with only anemia. Apart from basic cbc, liver function profile, creatinine, getting a chest xray and usg abdomen can pick up many disorders.

6. Failure of nutritional supplements or diet – if patient has been trying hard with good diet, or oral iron/b complex, and there is no improvement in one month approximately or if there is a drop in Hb, more evaluation is definitely required. Don’t just change the supplements or increase dose.
7. Few of the scenarios highlighted above suggest possible diagnosis of blood cancer, solid tumors, infections, autoimmune diseases, hemolytic anemias, hemoglobinopathies etc.

January 10^th 2026 Dr Chirag A. Shah; M.D. Oncology/Hematology (USA), 9998084001. Diplomate American Board of Oncology and Hematology. Ahmedabad. drchiragashah@gmail.com   www.shyamhemoncclinic.com