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Pearl Dixon and her husband are new patients of the practice. They had shifted to Melbourne to live near their son and his family.  For a few months Pearl had been feeling weary and totally lacking in energy. She had put it down to the effort of moving house and just getting older. However, when she became short of breath while shopping she decided it was time for a check-up. 

There was no history of any illnesses in the past and no other symptoms to go on. There was nothing much to find when I examined her; she looked quite well for her age. I also tested her urine for sugar and it was clear.  With the history of shortness of breath I decided to send her for a chest X-ray, a cardiograph and a full blood examination. The X-ray and the cardiograph were normal but to my surprise she was quite anaemic. Her haemoglobin was 9.5 g/dl. 

I gave her a call and saw her the following day. She said that she had not been taking aspirin or any anti-inflammatory medications, and her periods had stopped nearly 10 years ago. She also had a very balanced diet and had not lost any weight. When I asked her further about her bowels she said that she had been a little looser for a few months and had put it down to the stress of shifting house. Again, I could find no abnormalities when I examined her, and a rectal examination was also normal.  

I explained to her that she was anaemic and that she might be losing some blood from her bowel or her stomach. Because of the change in her bowel pattern I referred her for a colonoscopy.  This revealed a small cancer in the left side of her large bowel. She was referred to a colorectal surgeon, and several days later the bowel cancer was removed. Pearl made a good recovery after the operation. 

However, the pathology test showed that the cancer was not an early one and further treatment will be required. 

When blood is pumped to the lungs, carbon dioxide is exchanged for oxygen; the carbon dioxide is exhaled and oxygenated blood is returned to the heart. The amount of oxygen carried depends on the amount of haemoglobin in the red blood cells. Anaemia occurs when the amount of red blood cells or the amount of haemoglobin is reduced. In practical terms, being anaemic is like a car running on standard instead of super.

Haemoglobin is a substance made of an iron-containing, red pigment called haem, bound to four protein chains called globulins. A healthy male adult should have a haemoglobin level between 13.0 and 18.0 g/dl ( grams per 100 mls ). Because of normal menstrual loss, most women have a slightly lower haemoglobin level, usually between 11.5 and 16.5 g/dl. There is a growing trend to express haemoglobin levels in the International Unit, grams/litre or g/l. In these units the normal ranges are 130 to 180 g/l for men and 115 to 165 g/l for women.

Anaemia is more common at certain times of life. Breast-fed infants are prone to anaemia just before they get started on a full diet; at this stage the baby's stores of iron from the mother have begun to run low and there may not be quite enough iron in the milk. Women tend to become anaemic during pregnancy and towards the menopause, as do some elderly people not having an adequate diet.

Anaemia may not always be obvious. How low the haemoglobin level can go before causing symptoms depends on the overall health of the patient. An older person with heart disease might show symptoms when the haemoglobin level is about 10 g/dl. Younger people who are otherwise well might have a level of 7 g/dl and no symptoms at all.

The symptoms of anaemia can be quite variable. The person may complain of fatigue, shortness of breath, dizziness or even palpitations. In turn, the anaemia might cause symptoms of angina or even heart failure, especially in older patients. It may be quite insidious and develop over a period of months or even years. There may also be symptoms of the actual cause of the anaemia, for instance dark black motions and abdominal pain in someone with a bleeding ulcer, or very heavy periods with clots if the cause is gynaecological.

The person with anaemia sometimes looks very pale, but this is not always the case. The pulse may be faster than normal and in older patients there may be signs of heart failure. There may also be signs of the underlying cause of the anaemia such as abdominal tenderness, or perhaps the presence of blood on an internal examination.

A range of fairly simple tests will usually allow the precise cause of anaemia to be promptly identified. Broadly speaking, there are three main categories of anaemia:-

  • Conditions where there is blood loss, like heavy menstrual periods or bleeding from a stomach ulcer.
  • Defective production of blood like nutritional or vitamin deficiencies, and any chronic illness where the bone marrow is not working properly.
  • Anaemia due to blood destruction. Sometimes the red blood cells are destroyed well before their usual lifespan. This might be due to various hereditary conditions where the blood cells are excessively fragile or as a side-effect of certain drugs.

The treatment of anaemia depends very much on the underlying cause. Unless the cause of the anaemia is treated the anaemia will persist. More importantly, there could be a delay in attending to some serious problem like a stomach ulcer or a bowel tumour that has caused the anaemia in the first place.

Some anaemias can be treated by simply correcting nutritional or vitamin deficiencies. In some cases the haemoglobin can be so low that a blood transfusion is required. This is more likely to be the case if continuing blood loss has been the cause of the anaemia.

Health Tips:
* If you are tired and lacking in energy you may be anaemic.

* It is always important to find the actual cause of the anaemia. Rather than just taking some iron tablets, see your doctor for a proper check-up. In all cases of anaemia, follow-up and review by the doctor is essential.

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: August 18, 2001