貧血總論-課件

ANEMIA：GeneralAspects貧血總論河北醫(yī)科大學(xué)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(lèi)classification臨床表現(xiàn)Clinicalmanifestation診斷Diagnosis治療Treatment2貧血總論-簡(jiǎn)介Introduction

貧血是一種臨床常見(jiàn)的癥狀，由獲得性或者先天性的原因造成的紅細(xì)胞或其前體細(xì)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(xì)胞容量減少，即單位容積內(nèi)血紅蛋白（Hb）、紅細(xì)胞（RBC）和／或紅細(xì)胞比積（HCT)低于正常參考值下限而由此帶來(lái)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(guó)貧血診斷標(biāo)準(zhǔn)（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(biāo)準(zhǔn)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(gè)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(lèi)AnemiaClassification

一、貧血的嚴(yán)重程度分級(jí)AccordingtoseverityClassification二、按紅細(xì)胞形態(tài)分類(lèi)

Accordingtocellmorphologicalclassification三、按骨髓增生程度分類(lèi)

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

Accordingtoetiology/pathogenesis10貧血總論-一、貧血的嚴(yán)重程度分級(jí)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(xì)胞形態(tài)學(xué)分類(lèi)CellMorphologicalClassification

cellmorphologicaltypeMCV（fl）MCHC(%)大細(xì)胞性貧血Macrocyticanemia＞10032～35正常細(xì)胞性貧血Normocyticanemia80～10032～35小細(xì)胞低色素性貧血Microcytichypochromicanemia＜80＜32紅細(xì)胞平均體積MCV：meancorpuscularvolume；紅細(xì)胞平均血紅蛋白濃度MCHC：meancellhemoglobinconcentration12貧血總論-13貧血總論-大細(xì)胞性貧血Macrocyticanemia巨幼細(xì)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(jī)能減退癥Hypothyroidism脾臟切除術(shù)后Splenectomy14貧血總論-

Macrocyticanemia

大細(xì)胞性貧血15貧血總論-正常細(xì)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(shí)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(xì)胞低色素性貧血Microcyticanemia缺鐵性貧血IronDeficiencyamemia鐵粒幼細(xì)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(xì)胞低色素性貧血18貧血總論-三、按骨髓增生程度分類(lèi)

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(xì)胞無(wú)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(jī)理分類(lèi)

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

Theclassificationaccordingtoetiology/pathogenesiscanrepresentthenatureofanemia1.紅細(xì)胞生成減少

DeficientRBCproduction2.紅細(xì)胞破壞增多

IncreasedRBCdestruction3.失血性貧血

RBCLossanemia21貧血總論-1.紅細(xì)胞生成減少性貧血

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

1.再生障礙性貧血（Aplasticanemia，AA）

2.純紅細(xì)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(xì)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(xì)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(dǎo)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(xì)胞功能亢進(jìn)導(dǎo)致貧血（lymphocytehyperfunction）

免疫相關(guān)性全血細(xì)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(jī)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(xì)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(xì)胞破壞增多---溶血性貧血

IncreasedRBCdestruction---hemolyticanemia1.紅細(xì)胞內(nèi)在缺陷（RBCinternaldefect）(1)紅細(xì)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(xì)胞外在缺陷（RBCexopathicdefect）

免疫性，化學(xué)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(dǎo)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(dǎo)致失血（例如子宮內(nèi)膜異位癥，肌瘤）Gynecologicaldisorders(e.g.endometriosis,fibroids)寄生蟲(chóng)Parasitism

鉤蟲(chóng)病Hookworms26貧血總論-

Relatedfactor;引起貧血的病因

causeofanemia貧血導(dǎo)致血液攜氧能力的下降程度

Degreeofdecreaseofoxygencarryingcapacity

3.貧血時(shí)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(mèng)、耳鳴、眼花、記憶力減退、注意力不集中，感覺(jué)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(dòng)過(guò)速Tachycardia血壓升高

Increasedarterybloodpressure心臟擴(kuò)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(xì)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(jiàn),男性性征減弱，女性月經(jīng)紊亂月經(jīng)失調(diào)如月經(jīng)過(guò)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(lèi)

Classificationofanemia

貧血的病因Causeofanemia

診斷

Diagnosis34貧血總論-

詢問(wèn)病史History(inquisition):現(xiàn)病史（癥狀和持續(xù)時(shí)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(xí)慣

Diethabit6.接觸的危險(xiǎn)因素（例如化學(xué)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(rùn)infiltration：lymphadenectasis，hepatosplenomegaly,bonetenderness

感染infection

營(yíng)養(yǎng)不良malnut