 All right, so good morning everyone. So good day to each and every one of you who's watching this video right now. So for today, we will be continuing our discussion about anemia. So last time, we did a brief introduction about anemia already. We did talk about absolute anemia, relative anemia, and we did talk about and classify anemia based on its, based on inadequacy in hematopoiesis or inadequacy in production or impairment or inefficiency in the, or ineffective, ineffective or inefficient production or hematopoiesis. So for this morning, we will continue on with different types or different kinds of anemia. So for this morning, we will be talking about iron deficiency anemia. We will be talking about anemia due to chronic disease. We'll be talking about hemosiderosis, hemochromatosis, and also megaloblastic anemia. So let's get started. So first one is impaired or defective production of anemia. So when we say impaired or defective production of anemia, we're not talking about the number of RBCs being produced but the quality of the RBCs that are being produced. So the first one, okay, the first one is iron deficiency anemia. So iron deficiency anemia is actually the most common cause of anemia. So there can be a lot, there can be a lot of etiology unto why iron deficiency anemia is happening. First and foremost is inadequate intake of iron. So inadequate intake of iron. So you all know that around one to two milligrams per, one to two milligrams per day of iron is being excreted out of the body. So what, and if you're gonna think about that, that's very small amount naman din, niba. But when we say inadequate intake, meaning to say yung nawawala sa katawan mo is greater than your intake. Okay, so eventually that would cause deficiency and the iron reserves in the iron that is in your body. So secondly, increased need. So there is an increased need of iron when you are of course growing and developing. So that can also pose threat of iron deficiency anemia if the need for iron is not compensated. So the need for iron is increases but the intake or the reserve of iron is already been depleted and not replenished. Second third, okay. Third is impaired absorption. Impaired absorption heal malabsorption due to celiac disease, person's thin production of hepsidine and this increased stomach acidity or presence of antacids. So let me elaborate impaired absorption first. So you all know that the main source of iron in our body are of course the reserves. Okay, the ferritine that is stored in your bones and in your liver. But aside from that, the one to two milligrams per, the one to two milligrams of iron is actually being replenished because of your diet. So if you have impaired absorption due to malabsorption, due to celiac disease, then iron absorption will be impaired. Aside from that is persistent production of hepsidine. Sir, what is hepsidine all about ba? Please take it, take down note that hepsidine is actually a hormone that decreases the absorption of iron in your gut. So do remember, okay, do remember na kapag madaming hepsidine binablock niya ang absorption ng iron. So therefore no iron will be absorbed from your diet. Sir, what about decreased stomach acidity? And I will be correlating it to antacids already. Decrease stomach acidity, okay, decrease stomach acidity. So meaning to say nagiging alkalin, okay, nagiging alkalin na yung stomach. And for iron to be absorbed, okay, I want you to remember this. For iron to be absorbed, okay, for iron to be absorbed, it needs to have an acidic environment. Okay, it needs to have an acidic environment. The reason why impaired yung iron absorption during decreased stomach acidity, it's because it decreases the conversion of your dietary ferric iron to its absorbable ferrous iron. So kapag hindi acidic yung stomach, yung ferric iron mo, nagiging ferric iron lang and that is not the one being absorbed by your body. The one absorbed by your body is your ferrous iron. So for it to be converted to ferrous iron, it first needs to, it actually being aided by the acidity dun sa stomach mo, okay? So may purpose talaga kung bakit din acidic yung stomach natin and that is to convert the ferric iron into ferrous iron, ferrous iron which is absorbable inside your body. And meaning to say, kapag may antacids, ano bang job no antacid? Antacid is to what? Antacid is a medication for hyperacidity, okay, hyperacidity. At kapag nasobrahan ka naman ng antacid, okay, magiging alkalin din yung pH ng yung stomach. So therefore, babalik ulit ako dun, your ferric iron will not be converted to ferrous, ergo will not be absorbed by your body, okay? Next is your chronic blood loss. So chronic blood loss, chronic hemorrhage or hemolysis can also cause iron deficiency anemia, okay? It can also cause chronic, it can also cause iron deficiency anemia. So it can either be through repeated blood donations, chronic hemorrhage or even hemolysis na small amount lang but over time accumulated it will actually be, it will actually cause increase hem iron loss in your body. So it's very important for you to remember that especially if the chronic hemorrhage is in the gastrointestinal tract because of ulcers, it can also have some tumors, ulcerative colitis, and even hemorrhoids, gastritis. So all those things can actually cause chronic hemorrhage or hemolysis. And as you can see, sinabi ko nga dito, chronic blood loss. So chronic when I say chronic, it's actually for a longer period of time. This is not an acute blood loss na short time, all of a sudden you lose this blood, no. Over time na uubos or nawawala yung dogo, okay? So iron deficiency anemia is actually prevalent, okay? It's prevalent among infants and children, again going back to the reason because they need more iron when they are growing. Second day pregnant women, of course pregnant women, dalawa na kasi yung sinusoplayan niya ng iron, one for the baby and also for the mothers need excessive menstrual flow. That's why it's very much common to women, okay? It's very much common to women dahil sa kanilang menstrual flow. Elderly and poor diet. So elderly has something to do with their absorption already, okay? So yung absorption na katawan nila. At the same time, elderly that doesn't consume enough iron in their diet. Malabsorption syndroms, so malabsorption syndroms is also one. Next is chronic blood loss. It can either be through gastrointestinal bleeding or hookworm infection. So what hookworm infections that may be, it's your nekator americanos okay, your nekator americano. So hookworm infection can actually cause iron deficiency anemia due to chronic blood loss. And also men can also have iron deficiency anemia and postmenoposal women are also prevalent to iron deficiency anemia. So in short, no one is actually safe. So let's just have a quick review of iron metabolism first. So what is the regulatory hormone for iron metabolism? The answer here is your hepsidine, okay? The answer here is your hepsidine, okay? Site of maximum absorption of your iron is in your gastrointestinal tract. It's your duodenum and your jejunum, okay? Duodenum and your jejunum. What about how many milligrams of iron is being absorbed by the body? So I hope you all know this. It is one to two milligrams of iron per day, okay? And also that is the very same amount of iron excreted by the body. So absorb and excreted is the same one to two milligrams of iron. So major transport protein of iron in the plasma. So what is the major iron, transport protein for iron in the plasma? We call it transferrin, okay? Napakadaling tandaan, it transfer, what does it transfer? Your ferrin, your iron, okay? Transferrin. So inside your body, there are two storage forms of iron that is your ferritin and your hemociderin, okay? Ferritin and your hemociderin. That's two. Ferritin and your hemociderin. And what is excretion or average daily loss? So I guess alam nyo na to, sinabi natin kanina, one to two milligrams of iron through your sweat, through your urine, or either through your feces. So all of those are due, all of them accumulated is one to two milligrams per deciliter, okay? So why do we talk, why are we talking about this? Okay, why are we talking about all these things? Because we're gonna talk about how can we diagnose iron deficiency anemia, okay? So, but before I continue, it's very important for us to remember why is it that transferrin levels are increased in iron deficiency anemia. So transferrin, to be exact, okay? Transferrin is actually your carrier protein for iron. Why is it that transferrin is increased during iron deficiency anemia? Sabihin na natin na, sabihin na natin na yung transferrin mo para yung jeep, okay? Para yung jeep na matagal, para yung jeep na nangangailangan pumarada, nangangailangan bumyahe, rather, nangangailangan bumyahe para makuhan niya yung boundary niya, yung kota niya. And take for example, there are only a few passengers and we will compare the passengers into your iron, okay? To your iron. So madaming sasakyan, madaming jeep na kailangan para makakumarich nila yung boundary nila, marich nila yung kota nila. But there are only a few, there are only a few iron. And that is also the same thing when it comes to iron deficiency anemia, okay? Yung katawan mo, okay? There is a need for more iron, okay? Para kailangan nila ng boundary, kaya madaming lalabas na jeep, madaming lalabas na transferrin. At dahil madaming lalabas na transferrin, your transferrin now will be increased in your body. So parang sadahan, da dami yung jeep na na sadahan. So that in that sense, okay? Transferrin levels, okay? Balik na ako kay transferrin. Transferrin levels tend to increase during iron deficiency anemia because this is your body's attempt, okay? This is your body's attempt to gather more iron, okay? To gather more iron and the body is now trying to capture as much iron as possible to compensate the need of your body. So naku-kuha tayo doon. That is the reason why transferrin is increased during iron deficiency anemia. Nag-i-increase sila, pinoproduce sila ng katawan mo para madaming mag-collecta ng iron. Ang hindi alam, okay? Ang hindi na rirealize is that it is actually because there is already depleted iron inside our body, okay? So talking more about iron metabolism, okay? Let's talk about iron metabolism. So regarding the transportation of your iron. Plasma transferrin, okay? Transferrin that carry your protein for your iron. The level is usually expressed as iron binding capacity. So meaning to say, we don't measure transferrin directly, okay? We don't measure transferrin directly instead. We are measuring the total iron binding capacity, okay? Total iron binding capacity. So it is an indirect measure of your transferrin, okay? So, sir, bakit po ganon, okay? Bakit po T-I-B-C or total iron binding capacity yung minimesher natin? Parang ganito yan, okay? What we count is not the number of cars but the number of seats available. Nakukuhat na, can you get that analogy? Konwari, may isang jeep. Hindi natin binibilang kung ilang jeep yung nakalabas. Ang binibilang natin ay kung ilang upuan or ilang upuan yung available sa isang jeep. Konwari, shaman yan. Shaman by one side to other side. So 18 all in all, okay? 18 all in all. So that is how we actually measure the transferrin level. So those seats na sinasabi natin, those binding sites are actually the binding sites for your iron. So meaning to say yun yung capacity nung transferrin to absorb the iron, okay? So that is very important for you guys to remember, ha? That when it comes to transferrin, what we measure is actually your total iron binding capacity. Okay? Total iron binding capacity. So it's very important for us to remember that, okay? So by the way, before I move forward, okay? Ferritin on the other hand makikisulat po ako, okay? Mamaya kasi pag-uusapan natin. Yung ferritin and hemosiderin again are the storage form of your iron. So that is for the transportation. Let's go now to the utilization, okay? Saan siya ginagamit? So the mitochondrial iron is incorporated into your protoporferin to form your hems. Sounds familiar? Why mitochondrial? So your iron, first and foremost, bakit nga ba kasi importante ang iron sa katawan ng tao? And again, I will, dito na again papasok yung sinasabi ko how important it is for us to master the pathway that we did discuss before. So what about the utilization of iron, the utilization of iron? Please do remember everyone that your iron is a very important component for hemoproduction. Hemoproduction is very important on the other hand in the production of your hemoglobin. Hemoglobin is a very important component in the transport of oxygen and other gases inside your body. So going back now to utilization of iron. Your mitochondrial iron is being incorporated to your protoporferin-9 through the help of your ferroquelatase or your hemsintase. Remember, hemsintase. So this particular enzyme incorporates your iron to your protoporferin-9 ring for it to produce your hems. So bakit maytokondriyan? Remember sa maytokondriyan ng yayare, yung last stage ng hemoglobin production. So that is where your iron is being utilized. Let's go down. We did discuss about the transportation of iron, the utilization of iron. Now let's talk about the storage of iron. So again, sabi ko nga kanina there are two forms of iron storage inside your body. The first one is ferritin, which is the soluble form and the hemosidarin, which is the insoluble form. Later on, we will be talking about hemosidarin in hereditary hemosidarosis and hemochromatosis. And I think you've heard that already in your histopathology, the hemochromatosis. So in iron storage, we have two. The ferritin, one the ferritin, and the other one is your hemosidarin. Those are the two forms, both insoluble and the soluble form of iron storage inside our body. So moving forward, let's talk about now the iron metabolism with regards to its excretion. So the average daily loss of iron in the urine, in the fizzes and sweat collectively, and even through cell desquamation is actually 1 to 2 milligrams per deciliter. 1 to 2 milligrams per deciliter. Although normal dietary diet contains about 15 milligrams of iron, yung normal diet natin contains 15 milligrams of iron, only 1 to 2 milligrams of iron are actually absorbed by the body. And this is actually being closely monitored by your hepsidine. So again, kapag 1 to 2 milligrams of iron na yung naproduce, hepsidine will be produced, therefore stopping the absorption of your iron. Guys, I want you to remember hepsidine. Hepsidine is a hormone that blocks the absorption of your iron. So that is for iron metabolism. So a while back, we were talking about measures on how we can diagnose anemia. And one that we talked about is through the increased transferring, the increased level of T-IBC, increased amount of T-IBC. There's also another thing that I want you guys to remember, which is your free erythrocyte protoporphyrin, or your FEP, free erythrocyte protoporphyrin. So remember that protoporphyrin is the last stage in the heme synthesis or the heme synthesis whereby the protoporphyrin 9 will be combined with your ferrous iron to produce your heme. So sir, anong mangyayare kapag walang iron? What will happen kapag may deficiency sa iron brought about and causing iron deficiency? Anemia, na iisip nyo ba kung anong pwede ng mangyare? Na iisip nyo ba na kapano kapag walang ano? Pano kapag walang iron? Sabi na natin, pano pag walang lalaki? Pano pag walang lalaki? Puro girls. Mayipon yung mga girls na single. Mayipon yung mga girls na single kasi wala ng enough na male or lalaki for them to be wedded with. Parang ganun din pagdating sa protoporphyrin. Let's assume that your erythrocyte protoporphyrin are the bride, pero wala ng groom, wala ng iron as the groom. So because of that, the free erythrocyte protoporphyrin will increase during iron deficiency anemia. Why is it? So protoporphyrin without iron is not incorporated to hemoglobin. So what will happen therefore is erythrocytes normally produce a slight excess of protoporphyrin over what is needed for hemsynthesis. But when iron is deficient, protoporphyrin increases. So dahil nga wala po tayong enough na iron may iiwan, must stock dun sa stage na yun lahat ng protoporphyrin na pinuproduce ng katawan mo. Sir, bakit po ba siya nagpuproduce? Of course, this is the normal cycle of your body, the normal cycle of your RBC and your mitochondria within your RBC which is to produce protoporphyrin for hemsynthesis and eventually incorporation to become hemoglobin. So anong nangyari, okay? So anong nangyari sa protoporphyrin na stock sila, dumami sila dahil nga wala ng iron for them to be combined with. And did you know that the free erythrocyte protoporphyrin or FEP is actually a measurement of FEP provides a very sensitive it provides a sensitive and early indicator of iron deficiency. It provides an early indicator for that is for iron deficiency. So your free erythrocyte protoporphyrin can also be increased in conditions such as iron deficiency anemia chronic disease states and lead poisoning. For the lead poisoning I will elaborate the correlation of lead poisoning and free erythrocyte protoporphyrin when we discuss your porphyria and I want you to be excited to that, okay? So that will be soon. So aside from that aside from the IBC aside from free erythrocyte protoporphyrin what other laboratories for iron can we use we can make use of serum ferritin. So again what is ferritin? This is the soluble storage of iron. So iron storage status so it is measured using radioimmunoase so as you can see the reserve or the serum ferritin is higher in men compared to women again one factor to consider here is the monthly menstruation of your female. In addition to that we also have here your total iron binding capacity so again it is an indirect measurement of your transferin so okay it is the indirect it is the indirect measure of your transferin so this is the ability of your transferin to bind with your iron okay? Next is your serum iron your serum iron is the measure of the amount of iron bound to transferin okay? So you are now measuring the not the storage but actually the iron being carried by your transferin so when doing serum iron measurement it is very important to have a 12 hour fasting okay a 12 hour fasting and also the urinal variation should be remembered should be remembered ergo your sample should be collected or obtained in the morning and in addition to that laboratory test for iron deficiency anemia can also be free eritricide protoporphyrin increase FEP and increase free eritricide protoporphyrin signifies that there is a decrease or deficient amount of iron inside your body so when we are talking about iron deficiency anemia there are different stages in the development of iron deficiency anemia so as you can see here we have the normal iron status the stage 1, stage 2 and stage 3 so as you can see during the normal iron normal iron status all parameters that such as hemoglobin, your serum your tibc and your ferritin are all normal these are all normal and as you can see in stage 1 the iron storage compartment starts to be depleted but ato yung gusto ko makita ninyo but during the stage 1 it would actually appear normal so it's already being depleted but the tibc, the serum iron and even hemoglobin is still normal this is why iron deficiency anemia is actually a chronic disease hindi mo minsan na mamalayan na meron ka ng anemia probably at this very moment while we are talking some of you could actually be potentially having your iron deficiency anemia and this is due to the very slow development of iron deficiency anemia not until in stage 2 that this time transport iron depletion already so meaning to say serum iron decreases already the serum iron meaning to say the iron being carried by your transferin already decreases same thing with your storage and now your tibc starts to increase again bakit maging increase tibc dahil nag increase si transferin again go back to that part of the video why transferin is increased during iron deficiency anemia so in this case kung makikitanin nyo I want you guys to take a look at hemoglobin most of the time most of you knew that for us to be able to diagnose anemia or for us to have a screening for anemia you would go for hemoglobin but that is not true because your hemoglobin can appear normal your hemoglobin can appear normal until the stage 2 of iron deficiency anemia so in this case normal pa din yung hemoglobin mo pero meron ka na pa lang iron deficiency anemia not until you reach the stage 3 where the functional iron depletion this is now the last stage of iron deficiency anemia where all even the functional iron compartment are already depleted as you can see your serum iron and your ferritin starts to decrease your tibc is now increased now you can say kapag napansin mababa na yung iron it's already kind of an advance or a progress form of iron deficiency anemia already kasi sobrang bumabana yung hemoglobin sa katawan so as you can see the first laboratory test to decrease in iron deficiency anemia is what your ferritin and I want you to take note of this the first laboratory test the first laboratory test the first laboratory test to decrease in iron deficiency anemia is your serum ferritin serum ferritin serum ferritin okay other laboratory diagnosis so we can have your screening cbc although sabi kung anap until stage 3 it will not be reflecting on your on your cbc in your hemoglobin hematocrit diagnostic when we say diagnostic we can actually perform serum ferritin your tibc your serum iron and percent saturation for your transferin and in addition to that we can also do specialized testing or diagnostic test bone marrow assessment specifically iron stain to check if there are enough storage of iron in the body enough iron in the body so again specimen for iron study should be fasting and with diurnal variation hence to be collected in the morning so what is now the laboratory finding so now that we knew the test we knew the manifestation or the signs and symptoms for iron the manifestation of anemia when it comes to laboratory test what is now most prominent laboratory finding firstly we have the microcytic hypochromic anemia iron deficiency anemia IDA is actually a form of microcytic hypochromic anemia so low serum iron ferritin hemoglobin hematocrit low RBC indices and low reticulocyte count low reticulocyte count are all associated with iron deficiency anemia but there is one thing that's high and that is your TIBC and dag dag na natin dito sa tabay your TIBC enhance your transferin because your TIBC is directly proportional to your is directly proportional to your transferin directly proportional to your transferin in addition to that when you are looking at the smear your smear may show ovalo sites or pencil forms of your red blood cells what are the clinical symptoms on the other hand satsa clinical symptoms on the other hand well you all know that one of the most common one of the most common na manifestation of anemia is actually fatigue fatigue and dizziness so fatigue and dizziness is one is the two first in the list we also have pika what is pika? pika is pag-crave ng isang tao sa non-edible ng mga bagay ang mga ang mga weird na cravings like you crave for you crave for eyes alam yung mga minamon pero hindi naman siya edible so that's a sign you also have stomatitis the corners of the mouth we also have stomatitis we also have glossitis glossitis is the sore mouth so later on i'll be showing a picture and we also have your coelonicia we also have your coelonicia your coelonicia is the spooning of your nails kung kiting naman yung nails mo ngayon para yung may anasya kung baga hindi siya flat pero anong mangayari this is how it looks like kung makikita ninyo yung nails para siyang flat spoon shaped na yung kanyang nails yung coelonicia again spoon shaped na spoon shaped na po yung ating mga nails this is glossitis kung makikita mo this is atrophic so inflammation of your tongue and at the same time we can also have your stomatitis whereby the both ends are also affected are also affected so these are the usual physical examination findings with patients with iron deficiency anemia so moving forward now so that is for your iron deficiency anemia hopefully you understood what iron deficiency anemia is all about your anemia of chronic disease anemia of chronic disease is because of the inability to use available iron for hemoglobin production so yung katawan mo what's unable now your body now is unable to what your body is unable to utilize the iron in your body for hemoglobin production your third release of iron storage iron is associated with increased hepsidine levels increased hepsidine levels an dito na naman po si hepsidine ano bang ginagawa ni hepsidine ano bang ginagawa ni hepsidine so please remember that hepsidine is actually a liver hormone and it is increased during and it is a positive acute phase reactant sir pa ke-explain ano po bang ibig sabihin that acute phase reactant acute phase reactants are proteins proteins that are affected during inflammation so there are proteins that may increase and decrease because of inflammation pag sinabi natin positive acute phase reactants these are hormones or these are proteins that increases during inflammation that is for a positive acute phase reactant what about okay what about on the other hand your negative acute phase reactant obviously, kapag negative acute phase reactant they decreases during inflammation again, they decreases during they decreases during inflammation so what is the function of your hepsidine all along so the function of your hepsidine is for iron regulation how does it regulate your iron it influences intestinal absorption intestinal absorption and it also influence the release of storage iron from macrophages so what do you mean by macrophages macrophages are na dudoon ang ating mga sa macrophages and hepatocytes natin ang ating iron ang ating iron what happens during inflammation ito ang kwento sabi sa aming barangay kiting aside what happens during inflammation and why does chronic disease and inflammation can cause anemia ito ang kwento during inflammation during inflammation there will be acute phase reactants that will increase and decrease one of those positive acute phase reactants that is increased in the body is your hepsidine is your hepsidine in inflammation sa katawan tatas ang acute phase reactants and one of those are your hepsidine and because there is increased hepsidine inside your body increase din yung mga inhibition na nangyayare because of hepsidine and what are those inhibition the intestinal absorption of iron meaning to say because there is inflammation there is increased hepsidine there is low iron absorption but more so is that because there is inflammation hepsidine is increased therefore the release of iron storage from macrophages will also be inhibited again will also be inhibited so hepsidine production by hepa hepsidine production hepsidine increases enterocyte export less iron of less iron into the blood and macrophages and hepatocytes therefore retain the iron so hindi yung hepsidine it blocks the transport of iron out from the hepatocytes and the macrophages nandun lang sila so para itong IATF ayaw pa labasin yung mga tao dahil may pandemic so parang ganun din yung ginagawa nang hepsidine sa ating katawan sa ating katawan second D let's move forward in addition to that what are the laboratory what are the laboratory diagnosis for anemia of chronic disease so laboratory manifestation this are normalcytic normalcytic anemia kung mapapansin ninyo normalcytic sya normalcytic anemia although there can also be a slight microcytic hypochromic anemia especially if the iron is already really been the iron transport has been inhibited so in addition to that you can also see increase ESR or increase eritrocyte sedimentation rate sir bakit po increase dahil increase the ESR during inflammation during acute chronic anemia of chronic disease normal to elevated ferritin levels meaning normal or elevated kasi hindi na you use up ating iron reserves and here low serum iron and tibc again in acute and rather in anemia of chronic disease serum iron and tibc are both decrease parayas na mababa parayas na mababa so they are associated also with persistent infections dahil paulit-ulit yung infection mo paulit-ulit natatat at si hepsidin mo paulit-ulit niya i-inhibit yung transport ng iron mo chronic inflammatory disorder such as systemic lupus eritematosus and your humatorid arthritis and also your cancer and that is all about your acute and that is all about your anemia of chronic inflammation or chronic disease so i can say it through chronic disease or chronic inflammation okay chronic inflammation so in addition to that siguro i just want to add up na lang then during inflammation eritropoiesis can also be diminished eritropoiesis can also be diminished because during inflammation there are some cytokines that will be produced due to immune response and those cytokines will inhibit eritropoiesis those those what do you call this cytokines inhibit inhibit eritropoiesis or RBC production and last but definitely not the least at the same time those cytokines those cytokines can also shorten your RBC lifespan anemia of chronic inflammation has a shortened RBC lifespan further exaggerating or aggravating the anemia in your patient aggravating your anemia in your patient so again those things are found on chapter 17 of your product so to finish up to finish up this time to finish up this time i'll be ending this part one of our our discussion please do take a quick quick break before you proceed to the next video that i will be uploading so thank you so much and i'll see you guys in a short while