History and Examination

History:

• Weight loss
• Bone pain
• Night sweats

Examination:

• Jaundice
• Lymphadenopathy
• Hepatosplenomegaly

Determine the most likely cause by arranging or assessing all of the following:

• Full Blood Count (FBC) (indicates severity and whether other cell lines are involved)
• Blood film (gives blood cell morphology which helps indicate the likely cause). This needs to be specifically requested on the laboratory form
• Reticulocyte count (indicates whether bone marrow is active). This needs to be specifically requested on the laboratory form. If reticulocyte count is:
  • low i.e. decreased production - indicates nutritional anaemias, anaemia of chronic inflammation, renal failure, or bone marrow failure or infiltration
  • normal, assess in relation to the mean cell volume (MCV)
  • high i.e. increased destruction - indicates haemolysis or acute blood loss

• MCV identifies whether macrocytic (MCV more than 98), normocytic (MCV 82 to 98), or microcytic (less than 82)

Further investigations will depend on these results:

• Increased reticulocytes
  • Look for haemolysis or acute blood loss
  • Haemolysis:
    • Determine whether it is congenital or acquired:
    • Ask about family history e.g. hereditary spherocytosis, thalassaemias, sickle cell anaemia
    • Ask about medications
    • May be auto-immune

• Macrocytic anaemia
  • Consider alcohol excess, B12 deficiency or folate deficiency, hypothyroidism, primary bone marrow failure or bone marrow malignancy including multiple myeloma and secondary cancers
• Microytic anaemia
  • Consider iron deficiency or anaemia of chronic inflammation. If neither of these, consider haemoglobinopathy such as thalassemia, and request haemoglobinopathy screen
  • Anaemia of chronic inflammation
    • Previously known as anaemia of chronic disease
    • Can be caused by any systemic inflammatory condition e.g. malignancy, infection, autoimmune conditions
    • May have normal or elevated ferritin and reduced serum iron
    • May have an elevated C-reactive protein (CRP) and other inflammatory markers
    • Can present as either microcytic or normocytic anaemia
• Normocytic anaemia
  • Consider recent haemorrhage, renal failure, thyroid or other endocrine abnormality, anaemia of chronic inflammation or bone marrow malignancy including multiple myeloma and secondary cancers
• Cause is not obvious
  • Measure:
    • Ferritin, B12, folate
    • Urea and electrolytes (U&Es) and liver function tests (LFTs)
    • Thyroid-stimulating hormone (TSH)
    • Serum protein electrophoresis plus urine Bence-Jones protein

Note: When iron deficiency coexists with inflammatory disease, ferritin may be spuriously normal - it is an acute phase protein. Requesting additional iron studies may assist in these situations.

Most anaemia is managed in general practice.

• Identify the cause and treat the underlying problem e.g. blood loss, chronic inflammation, folate, or B12 deficiency.
• If no identifiable cause, it may be appropriate to monitor until symptomatic or until a treatable cause is found. In the elderly, about one third of anaemias are unexplained.
• If severe symptomatic anaemia, consider whether the patient may benefit from red cell transfusion.

Referral Criteria

Most anaemia is managed in general practice, request haematology assessment if anaemia is associated with:

• Blood film or other findings which are indicative of haematological disease, such as leukaemia, myelodysplasia, myeloma
• Abnormalities of other blood cell lines, such as thrombocytopenia, neutropenia
• Investigations suggest haemolysis, such as reticulocytosis, hyperbilirubinaemia, elevated Lactate dehydrogenase (LDH), positive direct antiglobulin test
• Include FBC, blood film, reticulocytes result, and any other relevant tests, in your referral
• Urgent or written advice is available

Referral Instructions

e-Referral Service Selection

• Specialty: Haematology
• Clinic Type: Not otherwise specified
• Service: DRSS-Northern-Haematology- Devon ICB- 15N

Referral Form

DRSS Referral Form

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: July 2016