营养性贫血巡诊—培训课件.pptVIP

巨幼细胞性贫血 叶酸：四氢叶酸；水溶性B族；蔬菜、水果、蘑菇、动物肝肾；空肠吸收；储存够4月；血透可出 VitB12：R蛋白、内因子（壁细胞）、回肠吸收；肝肾肉蛋乳；储存数年；乙酰辅酶A→神经系统 摄入不足：过度烹饪、酒精 吸收不良：内因子、短肠综合征等 需求增加：妊娠、幼儿、血透 药物影响：对氨水杨酸钠、新霉素、秋水仙碱、二甲双胍 胃泌素瘤、慢性炎症 巨幼细胞性贫血 临床：贫血、原位溶血、舌炎、牛肉舌、萎缩性胃炎、神经系统（亚急性脊髓联合变性、周围神经病变） 血象：RBC、WBC 骨髓象：巨幼变、Howell-Jolly小体、Cabot环；发育异常、病态造血 特殊检查：血清VitB12、Schilling试验 内因子抗体！慢性萎缩性胃炎！全胃切除！回肠末段切除！ Schilling试验 空服口服57钴标记的维生素B12 0.5μg，2hrs后肌注未标记的维生素B12 1mg，收集24h尿测定排出的放射性。正常人应超过7%，低于7%表示维生素吸收不良，恶性贫血常在4%以下。如吸收不良，间隔5天重复上述试验，同时口服60mg内因子。 实用内科学 恶性贫血 胃壁细胞自身免疫性破坏（毒性T淋巴细胞）破坏，胃黏膜萎缩导致内因子缺乏，使维生素B12吸收障碍。 好发于北欧斯堪的纳维亚人 治疗 叶酸：5-10mg tid VitB12：100μg Qd im→2W→Qw 全胃切除、恶性贫血：终生 Ret4-6-10 血象：1-2月 不单用叶酸！ 参考文献 BMJ-Best Practice数据库 实用内科学 导致全血细胞减少的药物？ SLE全血细胞减少的机制：WBC、溶贫、ITP * * 容易骨转移的肿瘤：前列腺癌 * 插图蘑菇云 * IBMFS, inherited bone marrow failure syndromes * fatigue, shortness of breath, dependent oedema, chest pain in patients with ischaemic disease * Musculoskeletal examination Short stature (Fanconis anaemia, other congenital syndromes) Swelling/synovitis (SLE) Abnormal thumbs (e.g., Fanconis anaemia) Signs associated with HIV disease Morbilliform rash early Kaposis sarcoma, ulcerating nodules later * An FBC and examination of peripheral blood film by a haematologist are essential. A standard battery of evaluative tests may include: Serum reticulocyte count Serum LFTs and hepatic serology Serum coagulation profile, bleeding time, fibrinogen, and D-dimer Serum direct antiglobulin test Serum B12 and folate Serum HIV and nucleic acid testing. * Fanconis anaemia: diepoxybutane (DEB) test for chromosomal breakage in peripheral blood lymphocytes Lymphoproliferative disorders: immunophenotyping, cytogenetics, lymph node biopsy Multiple myeloma: immunoelectrophoresis PNH: peripheral blood immunophenotyping for deficiency of phosphatidylinositol-glycan-linked molecules on peripheral blood cells (e.g., CD16, CD55, CD59) CMV infection: serum IgM and IgG Epstein-Barr: serum monospot, viral capsid antigen (VCA), and Epstein-Barr nuclear antibody (EBNA) Leishmaniasis