Thanks Kaleb for presenting an excellent case! This was a case of a patient with decompensated cirrhosis from alcohol use disorder presenting with refractory anemia thought secondary to spur cell anemia of end stage liver disease.
(Img: ASH image bank #00002637)
1) When admitting a patient with end stage liver disease, it helps to have a systematic approach or checklist to make sure you have at least thought about all the complications of this multisystemic condition [eg neuro (encephalopathy), GI (transplant status, ascites, SBP, HCC), heme (coagulopathy, PVT, variceal status), pulm (portopulmonary HTN, hepatopulmonary syndrome), cardiac (cardiomyopathy)]
2) We discussed several ways to approach anemia including thinking about it as a production, destruction or loss. Another approach is microcytic, normocytic (which could be multifactorial from microcytic + macrocytic) and macrocytic.
3) Spur cell anemia of end stage liver disease has a poor prognosis and treatment is transplant. Spur cell anemia is reported mostly in case reports and most commonly affects young patients with alcohol use disorder but also can be caused by other etiologies of liver failure as well.
Want to learn more?
Differential diagnosis of anemia
Here is an example of the production/ destruction/ loss approach to anemia:
- Production – deficiency of building block (iron, B12, folate, copper), AoCI (dx of exclusion), primary marrow failure (eg MDS, red cell aplasia)
- Destruction – autoimmune, drugs, MAHA, congenital (hereditary spherocytosis, G6PD, sickle cell disease)
- Loss – splenic sequestration, bleeding
Check out these fantastic handouts on anemia and other common benign hematologic conditions by our expert Tom DeLoughery.
Also if you ever want nice high-res pictures of smears (eg for ACP), check out ASH image bank which is a free online resource with a fantastic collection.
Alcohol consumption and cirrhosis
Per 2010 guidelines in the green journal/ Hepatology, there isn’t a clear linear relationship between cirrhosis and amount of alcohol ingested however >80g per day (about 1.5 bottles of wine/ 6x 12 oz beers/ 5 shots distilled spirits) leads to cirrhosis in 5-10 years for 10-40%. A “fifth” (1/5 of a gallon) is approximately 750mL or 24 oz.