貧血總論-課件

ANEMIA：GeneralAspects貧血總論河北醫(yī)科大學第二醫(yī)院HEBEIMedicalUniversitySecondHospitol血液科Hematologydepartment邢麗娜1貧血總論-內(nèi)容Contents貧血的定義Definition貧血的分類classification臨床表現(xiàn)Clinicalmanifestation診斷Diagnosis治療Treatment2貧血總論-簡介Introduction

貧血是一種臨床常見的癥狀，由獲得性或者先天性的原因造成的紅細胞或其前體細胞異常的疾病引起。還有可能是其他非造血系統(tǒng)疾病引起。

Anemiaisacommonlyencounteredclinicalsymptomthatiscausedbyanacquiredorhereditaryabnormalityofredbloodcells(RBC)oritsprecursors,ormaybeamanifestationofannonhematologicdisorder

3貧血總論-

貧血是指人體外周血紅細胞容量減少，即單位容積內(nèi)血紅蛋白（Hb）、紅細胞（RBC）和／或紅細胞比積（HCT)低于正常參考值下限而由此帶來的血液攜氧能力的下降。

AnemiaisdefinedasadecreaseinthecirculatingRBCorhemoglobin,haematocrit,andacorrespondingdecreaseintheoxygen-carryingcapacityoftheblood.定義Definition4貧血總論-正常值Normalvaluesofthehemogram:

RBC(×1012/L)Hb(g/L)Hct(L/L）成年男性(adultmen）

4.0～5.5120～1600.40~0.50成年女性(adultwomen)3.5～5.0110～1500.37~0.48新生兒(newborn)6.0～7.0170～200孕婦(pregnant)

＞1001972WHOcriteria

HCT:HaematocritHb:hemoglobin5貧血總論-定義DefinitionAdecreaseinanyofthesevalues(HCT,Hb,RBCcount)iscalledanemia.

(sealevel)TEST WOMENMENHCT(%)＜

37＜

42

Hb(g/L)＜

110＜

120RBCCount(1012/L) ＜

4.0＜

4.5

我國貧血診斷標準（海平面地區(qū)）成年男性：Hb<120g/L成年女性（非妊娠)：Hb<110g/L孕婦：Hb<100g/L6貧血總論-

影響因素Influentialfactor貧血標準的正常值受多種因素影響：Themeannormalvalue,lowlimitsofthenormalrangedependon:

年齡：Age—newborns,infants

性別:Gender—erythropoieticeffectsofandrogens

居住海拔高度:Altitudeofresidence—adultslivingathighaltitudes

血漿容量:Plasmaticvolumes—pregency↑，congestiveheartfailure↑，dehydration↓，acutehemorrhage

↓7貧血總論-8貧血總論-生理性貧血Physiologicanemia妊娠中、后期Pregnancymiddle-late

3個月后的嬰幼兒至15歲前的兒童Infantsandyoungchildren

from3mouthsto15yearsold老人Elderly9貧血總論-

貧血分類AnemiaClassification

一、貧血的嚴重程度分級AccordingtoseverityClassification二、按紅細胞形態(tài)分類

Accordingtocellmorphologicalclassification三、按骨髓增生程度分類

AccordingtoBonemarrowproliferativedegree四、根據(jù)病因和發(fā)病機理分類

Accordingtoetiology/pathogenesis10貧血總論-一、貧血的嚴重程度分級Classificationaccordingtoseverity

DegreeHb（g/L）Mildanemia90～120

Moderateanemia

60～90Severeanemia

＜60VerySevereanemia

＜30輕度120/110中度90重度60極重度3011貧血總論-二根據(jù)紅細胞形態(tài)學分類CellMorphologicalClassification

cellmorphologicaltypeMCV（fl）MCHC(%)大細胞性貧血Macrocyticanemia＞10032～35正常細胞性貧血Normocyticanemia80～10032～35小細胞低色素性貧血Microcytichypochromicanemia＜80＜32紅細胞平均體積MCV：meancorpuscularvolume；紅細胞平均血紅蛋白濃度MCHC：meancellhemoglobinconcentration12貧血總論-13貧血總論-大細胞性貧血Macrocyticanemia巨幼細胞貧血（葉酸和VB12缺乏）Megaloblasticanemias(folicacidandvitaminB12deficiency)

酒精中毒

Alcoholism

藥物

Drugs肝病

Liverdiseases

甲狀腺機能減退癥Hypothyroidism脾臟切除術(shù)后Splenectomy14貧血總論-

Macrocyticanemia

大細胞性貧血15貧血總論-正常細胞性貧血Normocyticanemia慢性病貧血（肝臟，腎臟，內(nèi)分泌疾?。〤hronicdiseaseanemia(hepatic,renalorendocrinedisorders)

骨髓病性貧血（再障，MDS,骨髓纖維化）Primarybonemarrowdisorders(aplasia,myelodisplasia,myelofibrose血液系統(tǒng)腫瘤和實體瘤，HIV感染，肉芽腫性疾病hematologicandsolidtumors,HIVinfection,granulomas溶血性貧血Hemolyticanemia失血性貧血Bloodlossanemia16貧血總論-小細胞低色素性貧血Microcyticanemia缺鐵性貧血IronDeficiencyamemia鐵粒幼細胞性貧血sideroblasticanemia珠蛋白生成障礙性貧血

Thalassemia慢性病貧血

CDA17貧血總論-

Microcytichypochromicanemia小細胞低色素性貧血18貧血總論-三、按骨髓增生程度分類

AccordingtoBonemarrowproliferativedegree

骨髓Bonemarrow貧血anemia增生性貧血HyperplasiaIDA,hemolyticanemia,bloodlossanemia增生不良性貧血HypoplasiaAA,PRCA成熟障礙性（紅細胞無效生成）DysmaturityMyelodysplasticsyndrome(MDS)(ineffectiveerythropoiesis)Megaloblasticanemias19貧血總論-HypoplasiaHyperplasia20貧血總論-四、根據(jù)病因和發(fā)病機理分類

Classificationaccordingtoetiology/pathogenesis根據(jù)病因和發(fā)病機制的分類更能反映貧血的病理本質(zhì)

Theclassificationaccordingtoetiology/pathogenesiscanrepresentthenatureofanemia1.紅細胞生成減少

DeficientRBCproduction2.紅細胞破壞增多

IncreasedRBCdestruction3.失血性貧血

RBCLossanemia21貧血總論-1.紅細胞生成減少性貧血

DeficientRBCProduction（1）骨髓干祖細胞異常BMstemcellsabnormality

1.再生障礙性貧血（Aplasticanemia，AA）

2.純紅細胞再生障礙性貧血（Pureredcellanemia，PRCA）

3.骨髓增生異常綜合癥（Myelodysplasticsyndrome，MDS）

4.先天性紅細胞生成異常性貧血（Congentialdyserythropoieticanemia，CDA）

5.造血系統(tǒng)腫瘤HemotologictumoregAL,NHL,MM22貧血總論-1.紅細胞生成減少性貧血

DeficientRBCProduction（2）造血調(diào)節(jié)異常所致貧血

Hematopoiesismodulationabnormality

1.骨髓基質(zhì)受損導致貧血（Marrowstromaldamage）骨髓纖維化

(Myelofibrosis,MF)

骨髓壞死（Bonemarrownecrosis）

骨髓硬化癥（Myelosclerosis）

骨髓轉(zhuǎn)移癌（Metastasistobonemarrow）

骨髓炎（

Infectiousornon-infectiousosteomyelitis）2.淋巴細胞功能亢進導致貧血（lymphocytehyperfunction）

免疫相關(guān)性全血細胞減少（Immunorelatedpancytopenia，IRP）

3.造血調(diào)控因子水平異常(lackoferythropoietinproduction)

腎功能不全，垂體或甲狀腺機能低下，肝病等慢性病貧血（ACD)

Renaldisease,Hypopituitarism,Hypothyroidism,LivediseaseAnemiaofchronicdisease（ACD)

23貧血總論-1.紅細胞生成減少性貧血

DeficientRBCProduction（3）造血原料不足或利用障礙

DeficiencyofessentialsubstancesorUltilizationobstacle1.缺鐵性貧血Irondeficiencyanemia2.葉酸或維生素B12缺乏或利用障礙

Folicacidand/orVitB12deficiency

Perniciousanemia24貧血總論-2.紅細胞破壞增多---溶血性貧血

IncreasedRBCdestruction---hemolyticanemia1.紅細胞內(nèi)在缺陷（RBCinternaldefect）(1)紅細胞膜缺陷（RBCmembranedefect）

獲得性acquired:PNH

先天性hereditary:hereditaryspherocytosis(2)酶缺陷enzymedeficiency：G6PDdeficiency

(3)血紅蛋白異常Hbabnormality：hemoglobinopathy(4)卟啉代謝異常porphyrinmetabolism：porphyrinopathy2.紅細胞外在缺陷（RBCexopathicdefect）

免疫性，化學性，生理性，物理性因素

immunologic,chemical,biological,orphysicalfactors25貧血總論-3.失血性貧血

RBCLossanemia

Hemorrhage

急性失血Acutebloodloss慢性失血Chronicbloodloss

創(chuàng)傷失血Duetotrauma組織損失導致的失血，例如腫瘤，潰瘍病，結(jié)核病，應(yīng)激性腸?。ò冃越Y(jié)腸炎和克隆氏病Duetodisorders:ncer,ulcers,tuberculosis,andirritablebowelsyndrome(includingulcerativecolitisandCrohn’sdisease)月經(jīng)出血Menstrualflow婦產(chǎn)科疾病導致失血（例如子宮內(nèi)膜異位癥，肌瘤）Gynecologicaldisorders(e.g.endometriosis,fibroids)寄生蟲Parasitism

鉤蟲病Hookworms26貧血總論-

Relatedfactor;引起貧血的病因

causeofanemia貧血導致血液攜氧能力的下降程度

Degreeofdecreaseofoxygencarryingcapacity

3.貧血時血容量下降的程度

Degreeofdecreaseofbloodvolume4.發(fā)生貧血的速度Speedofanemiagenesis5.系統(tǒng)的代償和耐受能力

Compensationandtoleranceofanemia臨床表現(xiàn)

Clinicalmanifestation27貧血總論-1、神經(jīng)系統(tǒng)Nervoussystem：頭痛、眩暈、萎靡、昏厥、失眠、多夢、耳鳴、眼花、記憶力減退、注意力不集中，感覺麻木，智力發(fā)育異常。headache、dizzy、dispirited、faint、insomnia、dreamfulsleep，

earnoises、dimeyesight、memoryimpairment、impairedconcentration；acroanesthesia,intelligencedevelopmentabnormality2、皮膚粘膜：蒼白，粗糙，潰瘍，黃染，反甲skinandmucosa：pallor；rough；ulcer,stainedyellow,Koilonychia

臨床表現(xiàn)Clinicalmanifestation28貧血總論-29貧血總論-5.呼吸和循環(huán)系統(tǒng)

Respiratory&cardiovascularsystem心悸

Palpitation呼吸困難

Dyspnea呼吸急促

Tachypnea心動過速Tachycardia血壓升高

Increasedarterybloodpressure心臟擴大

Enlargementofheart心力衰竭

Evenheartfailure30貧血總論-4、消化系統(tǒng)：腹部飽脹，食欲減退，厭食，惡心,大便規(guī)律紊亂，便秘,吞咽異物感，鏡面舌Digestivesystem：abdominaldistention、Decreasedfoodappetite,anorexia,nausea,boweldisturbance,constipation,swallowforeignbodysensation；31貧血總論-6、泌尿系統(tǒng)：膽紅素尿，血紅蛋白尿，含鐵血黃素尿，急性腎功能衰竭Urinarysystem：bilirubinuria、hemoglobinuria、urinarysiderosis；ARF(acuterenalfailure)7、內(nèi)分泌系統(tǒng)：內(nèi)分泌功能異常Endocrinesystem：endocrinefunctionalabnormality8、免疫系統(tǒng)：免疫功能低下，容易感染immunesystem：immunodeficiency，vulnerabletoinfections

Clinicalmanifestation32貧血總論-

9、血液系統(tǒng)Hematologicalsystem：外周血：血細胞數(shù)量，形態(tài)和生化成分異常?？梢院喜⒀獫{或血清成分的異常。造血組織可以合并肝臟，脾臟，淋巴結(jié)腫大。

peripheralblood:bloodcellcount,

appearance

andbiochemicalcomponent；plasma,serumcomponentsabnormalhematopoieticorgan:liver,spleen,lymphnode,

Hepatosplenomegaly

10、生殖系統(tǒng)：在男女兩性中性欲減退均多見,男性性征減弱，女性月經(jīng)紊亂月經(jīng)失調(diào)如月經(jīng)過多或閉經(jīng)

Genitalsystem：hyposexuality,weakenmalesexualcharacteristics

，paramenia,mensesdisturbance，menorrhagia,menoschesis臨床表現(xiàn)Clinicalmanifestation33貧血總論-

完整的診斷Completediagnosis是否有貧血

Anemia貧血的程度Degreeofanemia

貧血的分類

Classificationofanemia

貧血的病因Causeofanemia

診斷

Diagnosis34貧血總論-

詢問病史History(inquisition):現(xiàn)病史（癥狀和持續(xù)時間）Presenthistory(symptomsandtheirduration)既往史（是否有胃切除，痔瘡，胃潰瘍病史）

Pasthistory(Gastrectomy,haemorrhoids,pepticulcer)3.家族史（遺傳背景）Familyhistory(hereditarybackground)4.月經(jīng)和生育史Mensesandchildbearinghistory5.飲食習慣

Diethabit6.接觸的危險因素（例如化學藥物和毒物）Exposuretoriskfactors(suchaschemicalsortoxins)診斷：病史Diagnosis:history35貧血總論-診斷：物理檢查

Diagnosis:Physicalexamination

蒼白（觀察嘴唇，眼瞼，結(jié)膜，甲床，舌乳頭萎縮）

Pale(lip,palpebral,conjunctiva,fingernail，atrophyoftonguepapillae)2.伴隨體征

accompanyingsymtoms

溶血hemolytic：jaundice

hepatosplenomegaly

出血bleeding：bleedingpoint，purpura，ecchymosis

浸潤infiltration：lymphadenectasis，hepatosplenomegaly,bonetenderness

感染infection

營養(yǎng)不良malnut