Medicine Marrow Pg 61-70 (Hematology)
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Questions and Answers

What is the hemoglobin level characteristic of anemia in an average 40-year-old healthy male?

  • Between 13 and 15 g/dL
  • Below 13 g/dL (correct)
  • Above 15 g/dL
  • Exactly 14 g/dL

    • A healthy male is defined as having a hemoglobin level above 15 g/dL according to the WHO definition.

    False

    What does the WHO use to define anemia in males?

    Hemoglobin levels

    Anemia is characterized by a reduction in _____ levels.

    <p>hemoglobin</p> Signup and view all the answers

    Match the term with its definition:

    <p>Anemia = A condition marked by low levels of hemoglobin Hemoglobin = The protein in red blood cells that carries oxygen WHO = World Health Organization Healthy Male = A male with normal hemoglobin levels above 13 g/dL</p> Signup and view all the answers

    Which staining method can be used to detect RNA in reticulocytes?

    <p>Brilliant cresyl blue</p> Signup and view all the answers

    The normal range for reticulocyte count (RC) is between 0.5% and 1.5%.

    <p>True</p> Signup and view all the answers

    What range of absolute reticulocyte count is considered normal?

    <p>25,000 - 75,000 cells/μL</p> Signup and view all the answers

    Which medication is used to reduce diarrhea in IBS D+ patients?

    <p>Loperamide</p> Signup and view all the answers

    If a male patient has a desired hemoglobin level of 15 g/dL and a reticulocyte count of 1%, the corrected reticulocyte count (CRC) can be calculated using the formula CRC = Reticulocyte count × Desired hemoglobin level in patient. Fill in the blank: CRC = __________________.

    <p>1% × 15g/dL</p> Signup and view all the answers

    Antidepressants are only prescribed for IBS C+ patients.

    <p>False</p> Signup and view all the answers

    Match the following reticulocyte conditions with their descriptions:

    <p>Reticulocytopenia = Decreased production of RBCs Reticulocytosis = Increased destruction of RBCs/blood loss Corrected reticulocyte count (CRC) = Adjustment based on hemoglobin level Reticulocyte Production Index (RPI) = Correction for life span of reticulocytes</p> Signup and view all the answers

    What is the main action of the medication Alosetron?

    <p>5-HT3 antagonist</p> Signup and view all the answers

    ______ is a stool bulking agent that helps add bulk to stool.

    <p>Psyllium husk</p> Signup and view all the answers

    Match the following IBS medications with their side effects:

    <p>Alosetron = Ischemic colitis Eluxadoline = Pancreatitis Tegaserod = Cardiac Toxicity Lubiprostone = Nausea</p> Signup and view all the answers

    What percentage of body iron is bound with hemoglobin?

    <p>67%</p> Signup and view all the answers

    Hemosiderin is more soluble than ferritin.

    <p>False</p> Signup and view all the answers

    What is the daily iron requirement for adult females?

    <p>2 mg</p> Signup and view all the answers

    The total absorption of iron from the diet is approximately _____ percent.

    <p>10</p> Signup and view all the answers

    Match the types of iron storage with their characteristics:

    <p>Hemosiderin = Less common, less available for storage Ferritin = More common, available for storage</p> Signup and view all the answers

    Which stage of erythropoiesis is characterized by the presence of nucleoli?

    <p>Pro-normoblast</p> Signup and view all the answers

    Reticulocytes have a nucleus.

    <p>False</p> Signup and view all the answers

    What is the appearance of the cytoplasm in the Late/Orthochromatic normoblast stage?

    <p>Reddish</p> Signup and view all the answers

    The _____ stage of erythropoiesis is when cell division ceases.

    <p>Intermediate/Polychromatic normoblast</p> Signup and view all the answers

    Match the following erythropoiesis stages with their characteristics:

    <p>Pro-normoblast = High N:C ratio, nucleoli present Early/Basophilic normoblast = High N:C ratio, nucleoli absent Reticulocyte = Bluish tinge due to RNA Mature RBCs = Normal appearance after staining process</p> Signup and view all the answers

    What is the most important symptom of gastrinoma?

    <p>Abdominal pain</p> Signup and view all the answers

    Diarrhea associated with gastrinoma is solely a secretory component.

    <p>False</p> Signup and view all the answers

    What is an indicator of gastrinoma in peptic ulcer disease (PUD)?

    <p>Unusual location in the duodenal region and refractory to medical therapy</p> Signup and view all the answers

    The fasting gastrin levels are considered diagnostic if they exceed ______ pg/mL.

    <p>1000</p> Signup and view all the answers

    Match the symptom with its description in gastrinoma:

    <p>Abdominal pain = Most important symptom Peptic ulcer = Most common manifestation Diarrhea = Both secretory and osmotic components Fasting Gastrin levels = Indicator of gastrinoma diagnosis</p> Signup and view all the answers

    What is the preferred investigation for small tumors in MEN-1?

    <p>Endoscopic USG</p> Signup and view all the answers

    Gastrectomy is required in the treatment of MEN-1.

    <p>False</p> Signup and view all the answers

    What is the maximal acid output formula used for diagnosing gastrinoma?

    <p>70 - 6</p> Signup and view all the answers

    The most common site of metastasis in gastric tumors is the ______.

    <p>Liver</p> Signup and view all the answers

    Match the surgical approach with its location:

    <p>Enucleation = Pancreatic head Distal pancreatectomy = Pancreatic body/tail Full thickness excision = Duodenum No surgery required = Gastrectomy</p> Signup and view all the answers

    Which of the following symptoms is most consistent with irritable bowel syndrome (IBS)?

    <p>Altered bowel habits</p> Signup and view all the answers

    Irritable bowel syndrome predominantly affects males over females.

    <p>False</p> Signup and view all the answers

    What is the minimum frequency of abdominal pain episodes required for a diagnosis of irritable bowel syndrome according to the Rome IV criteria?

    <p>1 episode/week for at least 3 months</p> Signup and view all the answers

    The __________ factor that often aggravates symptoms of irritable bowel syndrome is stress.

    <p>aggravating</p> Signup and view all the answers

    Match the type of bowel habit with its description:

    <p>D+ = Diarrhea predominant (Small volume, associated with mucus) C+ = Constipation predominant m+(m/c) = Mixed (Prolonged constipation interrupted by episodic diarrhea)</p> Signup and view all the answers

    What is the primary reason for visceral hypersensitivity in patients with IBS?

    <p>Minimal rectal distension</p> Signup and view all the answers

    Dietary reduction of FODMAPs has shown improvement in 70% of cases of visceral hypersensitivity.

    <p>True</p> Signup and view all the answers

    Name one key symptom associated with visceral hypersensitivity.

    <p>Abdominal pain</p> Signup and view all the answers

    The graph displays rectal hypersensitivity in IBS patients, indicating pain reported at lower distending volumes compared to ______ controls.

    <p>healthy</p> Signup and view all the answers

    Match each management strategy for visceral hypersensitivity with its description:

    <p>Walking = Improves symptoms by a specific range of steps Reduce FODMAPs = Eliminates specific fermentable sugars from the diet Medical management = Used when dietary changes show no improvement Dietary modifications = Involves changing food habits to alleviate symptoms</p> Signup and view all the answers

    What characterizes hypoproliferative anemia?

    <p>RPI &lt; 2.5</p> Signup and view all the answers

    Megaloblastic anemia can result from vitamin B12 deficiency.

    <p>True</p> Signup and view all the answers

    What is the normal myeloid to erythroid ratio in bone marrow?

    <p>3:1</p> Signup and view all the answers

    The average volume of red blood cells, indicated by MCV, is _____ fL.

    <p>80-100</p> Signup and view all the answers

    Match the following types of anemia with their characteristics:

    <p>Hypoproliferative anemia = RPI &lt; 2.5 Hyperproliferative anemia = RPI &gt; 2.5 Megaloblastic anemia = Due to Vitamin B12 deficiency Aplastic anemia = Marrow failure with fat replacement</p> Signup and view all the answers

    Study Notes

    WHO Definition of Anemia

    • Hemoglobin levels are measured to diagnose anemia.
    • A normal hemoglobin level for a 40-year-old healthy male is not specified in the provided text.

    Reticulocytes

    • Reticulocytes are immature red blood cells (RBCs) that still contain some RNA.
    • Supravital stains are used to detect RNA in reticulocytes.
    • Examples of supravital stains are Brilliant cresyl blue and New methylene blue.
    • Romanowsky stain is not used to detect RNA in reticulocytes.
    • A normal reticulocyte count (RC) is 0.5 - 1.5%.
    • A low RC indicates hypoproliferative anemia, meaning there’s a decreased production of RBCs.
    • A high RC indicates hyperproliferative anemia, meaning there’s increased destruction of RBCs or blood loss.
    • The absolute reticulocyte count is 25,000 - 75,000 cells/μL.
    • The corrected reticulocyte count (CRC) adjusts the RC for the degree of anemia.
    • The CRC is calculated by multiplying the RC with the desired hemoglobin level.
    • The desired hemoglobin level for males is 15g/dL, and for females is 13g/dL.
    • The reticulocyte production index (RPI) corrects for the longer life of prematurely released reticulocytes.
    • The RPI is calculated by dividing the CRC by a factor (a) to account for the longer lifespan of prematurely released reticulocytes.

    Erythropoiesis Stages

    • Erythropoiesis is the process of red blood cell (RBC) production.
    • The stages of erythropoiesis are:
      • Pro-normoblast (Pro-erythroblast):
        • Largest cell in the series.
        • Cytoplasm is basophilic (blue-staining).
        • Nucleoli are present (due to fine chromatin).
        • Nucleus to cytoplasm ratio (N:C) is high.
      • Early/Basophilic normoblast:
        • Cytoplasm is basophilic.
        • Nucleoli are absent (as chromatin condensation begins).
        • N:C ratio is high
      • Intermediate/Polychromatic normoblast:
        • Cytoplasm is grayish (due to hemoglobin synthesis initiation).
        • Nucleus is rounded.
        • Chromatin shows condensation (clumping)
        • Cell division ceases at this stage.
      • Late/Orthochromatic normoblast:
        • Cytoplasm is reddish due to well-hemoglobinized cytoplasm.
        • Nucleus is dense and pyknotic (small and condensed).
      • Reticulocyte:
        • Nucleus is absent.
        • Cytoplasm has a bluish tinge due to RNA.
      • Mature RBCs:
        • Nucleus is absent.
        • Cytoplasm appears normal after staining.
    • Giant Pro-erythroblasts are seen in pure red cell aplasia.

    Iron Metabolism

    • Total body iron:

      • Males: 50 mg/kg
      • Females: 40 mg/kg

    • Iron is distributed:

      • 67% bound to hemoglobin
      • 27% stored as ferritin and hemosiderin
      • 0.08% transported by transferrin
      • 3.5% in myoglobin
      • 2.2% in the labile pool

    • Hemosiderin vs Ferritin:

      • Hemosiderin is less common and less available for storage. Ferritin is more common and readily available for storage.
      • Hemosiderin is water-insoluble, while ferritin is water-soluble.
      • Hemosiderin is found in macrophages and bone marrow iron stores. Ferritin is found in various tissues.
      • Hemosiderin is detected by Prussian blue stain, which turns hemosiderin blue-black.

    • Daily requirements:

      • Adult male: 1 mg
      • Adult female: 2 mg
      • Pregnancy: 3 mg
      • Children: 0.5 mg
      • Infants: 1 mg.

    • Normal diet contains ~10mg of iron with a 10% absorption rate.

    Irritable Bowel Syndrome (IBS)

    • IBS is a functional bowel disorder characterized by a reaction of the gastrointestinal (GI) system to stress.
    • Associations include lactose intolerance, celiac disease, fibromyalgia, chronic fatigue syndrome, and generalized anxiety disorder.
    • Clinical presentations:
      • More common in females than males.
      • Most common in individuals under 45
      • Abdominal Pain:
        • Most important symptom.
        • Rome IV criteria: Recurrent abdominal pain, at least 1 episode per week for ≥3 months, associated with two of the following:
          • Change in stool frequency.
          • Change in stool form (appearance).
          • Pain related to defecation.
        • Typically crampy lower abdominal pain occurring episodically (once a week).
        • Often aggravated by stress and eating, and relieved by defecation.
      • Altered bowel habits:
        • The most consistent symptom.
        • Types:
          • D+: Diarrhea predominant (small volume with mucus).
          • C+: Constipation predominant.
          • M+ (most common): Mixed (prolonged constipation interrupted by episodic diarrhea).
    • Features that argue against a diagnosis of IBS include:
      • Nocturnal diarrhea
      • Steatorrhea
      • Blood in the stool
    • Other symptoms:
      • Fever
      • Weight loss, anemia, or malabsorption
      • Increased Erythrocyte Sedimentation Rate (ESR).

    Gastrinoma

    • Most important symptom: Abdominal pain
    • Most common manifestation: Peptic ulcer disease (PUD)
    • Indicators of Gastrinoma in PUD:
      • Unusual location: Duodenal region and beyond
      • Refractory to medical therapy:
        • Upper GI > 12 weeks
        • Duodenum > 8 weeks
      • Recurrence
      • Abdominal pain
      • Diarrhea
    • Diarrhea in gastrinoma:
      • Both osmotic and secretory components
      • Secretory: Gastrin acts on enterocytes to absorb water into the lumen.
      • Osmotic: Increased acid inactivity of pancreatic enzymes, which reduces lipolysis, leading to steatorrhea.

    Management of Gastrinoma

    • Investigation
      • Fasting Gastrin levels (screening):

        • 1000 pg/mL: Carcinoma

        • 200-1000 pg/mL: Confirmatory test needed.
    • Treatment
      • MEN-1 associated
        • High-dose PPI (60-80mg): usually enough
        • If size ≥ 7.5 cm: Surgery
      • Sporadic
        • High-dose PPI + octreotide, followed by surgery
    • Surgery based on location
      • Pancreatic head: Enucleation
      • Pancreatic body/tail: Distal pancreatectomy
      • Duodenum: Full-thickness excision
      • Gastrectomy is not required.
      • Liver is the most common site of metastasis.

    Summary: Clinical Approach Anemia

    • Anemia can affect a single lineage or multiple lineages.
    • A reticulocyte production index (RPI) less than 2.5 suggests hypoproliferative anemia, while an RPI greater than 2.5 suggests hyperproliferative anemia.
    • Normocytic and microcytic anemias can be caused by Vitamin B12 deficiency, the most common type of Megaloblastic anemia.
    • The mean corpuscular volume (MCV) is the average volume of red blood cells (RBCs), with normal values ranging from 80-100 fL.
    • Megaloblasts are RBCs that are lagging in nuclear maturation but have normal cytoplasmic maturation.
    • Bone marrow cellularity normally ranges from 100% to the person's age, for example, in a 50-year-old individual, 50% is cellular and 50% is fat.
    • In marrow failure, all cells are replaced by fat, as seen in aplastic anemia.
    • The normal myeloid to erythroid (m:E) ratio is 3:1.

    Pathophysiology of Visceral Hypersensitivity

    • A theory of visceral hypersensitivity: minimal rectal distension stimulates pain receptors, leading to enhanced sensitivity.
    • Increased colonic motor potentials may contribute to hypersensitivity.
    • Central activation of the cingulate cortex.
    • Increased serotonin levels in enterochromaffin cells.
    • Vanilloid channels (TRP-VI).

    Management of IBS

    • Diet and lifestyle modifications:
      • 70% of cases show improvement with diet and lifestyle modifications.
      • Walking: 6000-8000 steps daily
      • Diet: Reduce FODMAPs (Fermentable oligo, di, monosaccharides, and polyols)
        • Sources: Apple, mango, wheat, honey, legumes, cauliflower, etc.
      • 30% of cases require medical management.

    Visceral Hypersensitivity - Diagram

    • The small intestine absorbs water into the bowel.
    • The large intestine experiences bacterial fermentation leading to gas production.
    • Symptoms, such as bloating, distension, flatulence, abdominal pain, and constipation, can occur.

    Visceral Hypersensitivity - Graph

    • Rectal hypersensitivity in IBS patients is visually represented.
    • The horizontal axis shows distending volume (mL).
    • The vertical axis indicates the number of subjects reporting pain.
    • Separate lines for healthy controls and IBS subjects show that IBS patients report pain at lower distending volumes compared to healthy controls.

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    Description

    This quiz covers the definitions and assessments related to anemia, focusing on hemoglobin levels and reticulocyte counts. It explains the significance of reticulocytes, their detection using supravital stains, and the implications of different reticulocyte counts for anemia diagnosis.

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