Differential Diagnosis of Macrocytic Anemia - Flowchart

Differential Diagnosis of Macrocytic Anemia - Flowchart

Differential Diagnosis of Macrocytic Anemia - Flowchart Anemia, Macrocytic Anemia, Macrocytic

«Flowchart»

Macrocytic anemia

Macrocytic anemia

Macrocytic anemia

Diagnosis: spurious elevation of MCV

Diagnosis: spurious elevation of MCV

Diagnosis: spurious elevation of MCV

Megaloblastic changes on peripheral blood smear (hypersegmented neutrophils)

Megaloblastic changes on peripheral blood smear (hypersegmented neutrophils)

Megaloblastic changes

No megaloblastic changes on peripheral blood smear

No megaloblastic changes on peripheral blood smear

No megaloblastic changes

Diagnosis: folic acid deficiency

Diagnosis: folic acid deficiency

Diagnosis: folic acid deficiency

Diagnosis: B₁₂ deficiency

Diagnosis: B₁₂ deficiency

Diagnosis: B₁₂ deficiency

₁₂

Serum B₁₂decreased

Serum B₁₂decreased

₁₂ Serum B(12) decreased

Serum B₁₂ normal, folate decreased^*

Serum B₁₂ normal, folate decreased^*

₁₂ ^* ^* Serum B(12) normal

Serum B₁₂ normal or increased, folate normal^*

Serum B₁₂ normal or increased, folate normal^*

₁₂ ^* ^* Serum B(12) normal or increased

Evaluate for etiology (see Section I, "Anemia, Pernicious")

Evaluate for etiology (see Section I, "Anemia, Pernicious")

Evaluate for etiology (see Section I, "Anemia, Pernicious")

InitiateB₁₂ replacement

InitiateB₁₂ replacement

InitiateB₁₂ replacement

₁₂

End

End

End

Evaluate for dietary causes

Evaluate for dietary causes

Evaluate for dietary causes

Possible medication effect

Possible medication effect

Possible

No possible offending medication

No possible offending medication

No possible

Change medication

Change medication

Change medication

Bone marrow aspiration and biopsy to evaluate for myelodysplasia

Bone marrow aspiration and biopsy to evaluate for myelodysplasia

Bone marrow aspiration and biopsy to evaluate for myelodysplasia

Improvement with discontinuing medication

Improvement with discontinuing medication

Improvement

No improvement with discontinuing medication

No improvement with discontinuing medication

No improvement

B₁₂ deficiency

B₁₂ deficiency

B₁₂ deficiency

₁₂

Initiate replacement

Initiate replacement

Initiate replacement

Examine peripheral smear for indices of nonreticulocyte red cells

Examine peripheral smear for indices of nonreticulocyte red cells

Examine peripheral smear for indices of nonreticulocyte red cells

R/O acute blood loss

R/O acute blood loss

R/O acute blood loss

Reticulocyte count, serum B₁₂ level, RBC folate, TSH, ALT, AST

Reticulocyte count, serum B₁₂ level, RBC folate, TSH, ALT, AST

Reticulocyte count, serum B₁₂ level, RBC folate, TSH, ALT, AST

₁₂

Reticulocyte count not elevated

Reticulocyte count not elevated

Reticulocyte count not elevated

Reticulocyte count elevated

Reticulocyte count elevated

Reticulocyte count elevated

^* Measure both serum and RBC folate levels.

^* Measure both serum and RBC folate levels.

^* Measure both serum and RBC folate levels.

^*

No treatment needed

No treatment needed

No treatment needed

Correct hypothyroidism

Correct hypothyroidism

Correct hypothyroidism

Evaluate for causes of liver disease

Evaluate for causes of liver disease

Evaluate for causes of liver disease

Abnormal liver function tests

Abnormal liver function tests

Abnormal liver

Abnormal thyroid function tests

Abnormal thyroid function tests

Abnormal thyroid

Down syndrome

Down syndrome

Down syndrome

Consider serum methylmalonic acid if cobalamin deficiency is suspected and B₁₂ level is normal

Consider serum methylmalonic acid if cobalamin deficiency is suspected and B₁₂ level is normal

Consider serum methylmalonic acid if cobalamin deficiency is suspected and B₁₂ level is normal

₁₂

Normal

Normal

Normal

Elevated

Elevated

Elevated