Anemia: sintomi e diagnosi
Definizione di anemia
Per anemia si intende unariduzione della quantità totale di emoglobinacircolante nel sangue periferico e all’interno degli eritrociti. La quantità totale di emoglobina si misura conoscendo la sua concentrazione nel sangue periferico e il volume totale ematico. La determinazione di quest’ultimo parametro richiederebbe l’impiego di una metodica lunga e complessa, per cui non è possibile utilizzare routinariamente la conoscenza del patrimonio emoglobinico totale per porre diagnosi generica di anemia. Per questo si è giunti alla convenzione di utilizzare semplicemente la concentrazione dell’emoglobina, assumendo che il volume totale ematico si mantenga costante.
Questa situazione non si verifica in due condizioni:
- l’emorragia acuta e la gravidanza.
Subito dopo un’ emorragia acuta, anche imponente, laconcentrazione dell’emoglobina può non subire variazionie può non essere la spia della condizione di anemia naturalmente presente. Nella donna in gravidanza c’è un aumento del volume totale plasmatico, che comporta una riduzione della concentrazione emoglobinica al di sotto dei limiti inferiori della norma senza che vi sia una riduzione del patrimonio emoglobinico totale e quindi anemia.
Tenute presenti queste eccezioni, si deve porre diagnosi generica di anemia quando la concentrazione dell’emoglobinanel sangue periferico è :
- inferiore a 12,0 g/dl nella donna
- inferiore a 13,0 g/dl nell’uomo.
Il numero di globuli rossi non deve essere utilizzato né per porre diagnosi di anemia nè per valutarne la gravità. Infatti, se è vero che una riduzione del numero degli eritrociti al di sotto della norma (4.500.000/µl nell’uomo e 4.200.000/µl nella donna) è sempre espressione di anemie, non è vero che avere un numero di globuli rossi superiore non esclude una possibile anemia; esistono infatti, e sono frequenti anemie con numero di globuli rossi normale o anche aumentato (anemia sideropenica e talassemia eterozigote). Nell’ambito delle anemie distinguiamo in base al livello emoglobinico:
- anemia lieve (Hb superiore a 10 g/dl)
- anemia moderata (Hb tra 8 e10 g/dl)
- anemia severa (Hb inferiore a 8 g/dl)
SINTOMI E SEGNI CLINICI
I sintomi e i segni clinici del paziente con anemia dipendono dallariduzione della concentrazione emoglobinicae dal meccanismo patogenetico che è alla base dell’ anemia. La riduzione della concentrazione dell’emoglobina è responsabile delpallore della cute e delle mucosee si traduce in una riduzione della capacità di trasporto di O2 nel sangue e in una conseguente ipossia tessutale, che è alla base dei sintomi che il paziente ha in quanto anemico.
Si possono definire questi sintomi “sintomi generali”perché comuni a tutte le anemie. La presenza e l’entità di questi sintomi dipendono dal grado di anemia e dal tempo in cui questa si è sviluppata. Una anemia ad inizio insidioso con lenta e progressiva riduzione del livello emoglobinico permette infatti all’individuo, che abbia un sistema cardiocircolatorio e respiratorio integri, di adattarsi fino a concentrazione diemoglobina pari a 7-8 g/dl (a volte anche inferiori ) senza presentare una sintomatologia apprezzabile. Accade così che gli unici disturbi presentati da pazienti con gravi anemie croniche (anemia sideropenica, anemia refrattaria, anemia emolitica cronica, ecc..) siano:
- una moderataastenia;
- esauribilitàfisica;
- dispneada sforzo;
- tachicardia;
- riduzione delle capacità diconcentrazione e della memoria.
La preesistenza di condizioni patologicheche riducono la riserva funzionale cardiaca e respiratoria determinerà la comparsa della sintomatologiaanche in anemia di grado moderato.Inoltre nelle persone anziane, la riduzione della concentrazione emoglobinica associata a ridotta portata circolatoria distrettuale può far emergere a livello clinico quadri di:
- insufficienza coronarica;
- insufficienza arteriosadegli arti inferiori;
- disturbi ipossiemici cerebrali.
La sintomatologia soggettiva e l’obiettività sono più eclatanti quando la riduzione del livello emoglobinico si instaura acutamente. Nell’anemia acutainfatti viene meno la possibilità di adattamento dell’organismo, e in particolare del sistema cardiovascolare alla nuova condizione, anche per riduzioni relativamente modeste della concentrazione emoglobinica.
Così il paziente che ha in atto unacrisi emolitica,o il paziente con anemia aplastica acuta, riferiranno al medico una transizione rapida da una condizione di completo relativo benessere a una condizione caratterizzata da:
- asteniaintensa;
- dispneaal minimo sforzo;
- cardiopalmo;
- cefaleapulsante;
- incapacitàdi applicarsi a qualsiasi attività sia fisica che intellettuale;
- vertigine;
- lipotimie, etc..
I segni clinici dell’anemia acutasaranno quelli di unapparato cardiocircolatorio ipercinetico:
- tachicardia;
- aumento dellapressione sistolica;
- riduzione dellapressione diastolica.
La valutazione dei sintomi e segni clinici generali permette quindi una prima fondamentale distinzione fra anemie acute e croniche.
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