Blood

Learning objectives:
Composition of blood.
Functions of blood.
How plasma is separated from the blood cells.
Hematocrit /PCV and its clinical significance
ESR and its clinical significance
Plasma proteins types , functions
Functions of lymph

Study of components and functions of blood is known as

HEMATOLOGY.
Blood is a homogenous fluid connective tissue which is
in constant circulation throughout the body.
In a normal adult, the volume of blood is about 70 ml/kg
body weight and in an infant it is about 90 ml/kg body
weight.
On an average in a normal adult weighing about
70 kg, the volume of blood present is about 5 liters.

The functions of blood :

Respiratory
Excretory
Nutritive
Protective
Regulation of body temperature
pH regulation.

Packed Cell Volume(PCV)/ hematocrit:

Definition
Principle
Normal value
Significance
Erythrocyte Sedimentation Rate(ESR):
Definition
Principle
Normal values
Significance

Rouleaux formation

Westergrens
tube

Plasma

Is the fluid part of blood in which formed elements

(cellular components) are suspended.
The normal proportion of plasma in blood is about 55%.
About 91 93% of plasma is made up of water.
The remaining 7 9% is contributed by organic and
inorganic constituents.

Inorganic constituents of plasma

positively charged ions
Sodium

normal sodium level of plasma is about 150 mEq/L of water

Potassium
normal potassium level of plasma is about 5 mEq/L of
water.
Calcium
its concentration is about 9 to 11 mg%.

Negatively charged ions in plasma:

Chloride
Normal level is about 110 mEq/L of water.
Bicarbonate
normal level is about 24 mEq/L of water .

Plasma reflects the overall inorganic composition of extra

cellular fluid (ECF) in the body.

The organic constituents are

Plasma proteins- 6 8 g%
Glucose- 60 90 mg% (fasting)
Urea- 15 40 mg%
Cholesterol - about 150 to 250 mg%
Creatinine- about 0.3 -1.3 mg%

Non nucleated
Central pallor
Biconcave disc
Elastic - can squeeze through
narrow capillaries
Normal count
Diameter 6.8 8.8 m
Surface area - 140m2

ANISOCYTOSIS
Variations in size
Microcytes:
Decrease in the red cell size. Red cells are smaller than 7m in
diameter.
Found in:
Iron deficiency anemia.
Thalassaemia N
Lead poisoning.
Anemia of chronic disease
Macrocytes: Morphology:

Increase in the size of a red cell. Red cells are larger than 9m
in diameter. May be round or oval in shape.
Found in:
N
Folate and B12 deficiencies (oval)
Liver disease (round)
Reticulocytosis (round) POIKILOCYTOSIS

Variations in shape
Spherocytes

Normochromic

Hypochromic

Erythropoiesis
Definition: A process of formation of a mature RBC from its
precursor stem cells. Duration: 6-7 days
Sites of erythropoiesis:

Mesoblastic stage (first 3 months of intrauterine life )mesoderm of yolk sac(area vasculosa)
Hepatic stage: third month to fifth month of fetal life- Liver
and spleen form blood cells Myeloid stage : 5th month of IUL
onwards - bone marrow form blood forming organ In adultsBone marrow is the sole source for erythropoiesis

Bone marrow:
Types red and yellow
At birth all bone marrows are red in nature- source for
erythropoiesis
As age advances, red bone marrow replaced by yellow
bone marrow
At the age of 20,

Red bone marrow persist in vertebrae, sternum, ribs, bones

of skull and pelvis.

Functions of red bone marrow

Production of RBCs, WBCs and Platelets.
Destruction of senile RBCs (by the reticuloendothelial cells).
For any laboratory investigation a sample of the red bone
marrow can be obtained from one of the following regions:
In males ----Sternal puncture.
In female----Iliac crest.
In child ------Tibial tuberosity

Erythropoiesis
(Basophilic erythroblast)
(Orthochromatic
erythroblast)
The differentiation and proliferation of RBC.
Common features during erythropoiesis
Cell size change
Staining property
Accumulation of Hb
Disappearance of nucleoli and nucleus
Mitotic cell division

Reticulocyte:
Is an immature erythrocyte.

Size is about 8 9. (1.12 to 1.16 times bigger than RBC)

Is also non-nucleated like red blood cell.
Has reticulum, which is remnant of RNA.
Normal % in adult will be around 0.5
1.0. In newborn infant it is more (2 6).
Reticulum gets stained when the cells are treated with brilliant
cresyl blue - supra vital stain (stains the cells in living condition
outside the body)
Reticulocytosis occurs in conditions like
Hemolytic anemia.
Anemias after treatment with vitamin B12, folic acid and iron.
After hemorrhage.
Erythroblastosis foetalis
Regulation of Erythropoiesis:

Importance
Must Not fall
To supply oxygen from lungs to tissues
Must Not rise
Blood viscosity may increase
May impede blood flow

Factors affecting Erythropoiesis

Tissue Oxygenation
Vitamins
Metals
Proteins

Hormones
Tissue Oxygenation Crucial
Regulator of Erythropoiesis
High altitudes
Cardiac Failure
Lung diseases
All conditions have one common problem
Erythropoietin
Glycoprotein
Mol weight 34000
Sites of production
KIDNEYS, liver and spleen
Stimulants of Erythropoietin production

Hypoxia decreased oxygen to kidney

Vitamins
Vit B12 & Folic acid (maturation factors)
Essential for formation of thymidine triphosphate
Essential building block of DNA
Vit.C, pyridoxine.
Iron
Hormones- Testosterone , Growth hormone, Thyroid hormone,
Cortisol, Adrenocorticotrophic hormone (ACTH)
Learning objectives:
Iron in erythropoiesis
Iron deficiency anemia
Maturation factors in erythropoiesis
Megaloblastic anemia : cause

clinical features
Treatment
The lifespan of RBCs
Site of destruction
Process of destruction.
Applied aspect- jaundice.
Iron :
Daily requirement
Adult man 10mg/day
Menstruating women 20mg/day
Pregnant and lactating woman- 40 mg/day
Children - >10mg/day

Iron is required for

Hemoglobin, myoglobin, cytochromes, peroxidase, catalase etc
Total body iron 4-5 gms About 65% - Hb
4%- Myoglobin
1%- heme compounds (promote oxidation)
15-30% in stores
Dietary sources of iron :
Leafy vegetables, fish , pulses, dried fruits , cereals, meat.
There are 2 types of iron in the diet; haem iron and non-haem
iron
Haem iron is present in Hb containing animal food like meat, liver
& spleen
Non-haem iron is obtained from cereals, vegetables & beans

Site of absorption: duodenum (small intestine) Gastric HCl

release Fe+++ from food.
Ascorbic acid, cysteine favor conversion of ferric(Fe +++ )to
ferrous(Fe++) form
The dietary phenols & phytic acids compounds bind with iron
decreasing free iron in the gut & forming complexes that are not
absorbed.
Apotransferrin + iron (diet) transferrin
Transferrin bind to epithelial receptor absorption by pinocytosis
released as plasma transferrin.
Iron deficiency anemia: Causes(etiology):
CHRONIC BLEEDING :

menorrhagia
peptic ulcer
stomach cancer
ulcerative colitis
intestinal cancer
Haemorrhoids
DECREASED IRON INTAKE
INCREASED IRON REQUIRMENT ( PREGNANCY,
LACTATION)
Features:
Fatigue, dizziness, palpitation, dry, pale skin, spoon shaped nails
(koilonychia), hair loss pica (apetite for non food substances such as
an ice, clay)
Peripheral blood :

Decreased number of erythrocytes

Erythrocytes are smaller and paler
Decreased amount of Hb
MCV,MCH,MCHC are decreased.

KOILONYCHIA

Pale RBC with more central pallor

Depigmentation of upper lip

Depapillated tongue

Erosion of lower lip

Treatment:
Administration of ferrous(Fe++) - oral /intramuscular route
Maturation factors: vitamin B12 and folic acid :
Vitamin B12:
Daily requirement is about 1 g.
Is stored in the liver to the extent of 1000 g.
Is absorbed at the ileum part of small intestine.
Absorption in the intestine requires Intrinsic factor secreted by
the parietal cells of stomach.


Folic acid sources
Folic acid daily requirement is about 75 100 g.
Both vit.B12 and folic acid required for the formation of
thymidine triphosphate, the essential building blocks of DNA.
lack of vitamin B12 or folic acid - abnormal and diminished
DNA- failure of nuclear maturation and cell division.
The erythroblastic cells of the bone marrow -fail to
proliferate rapidly, produce larger than normal red cells
called macrocytes.


Macrocyte has a fragile membrane and is often irregular,
large, and oval instead of the usual biconcave disc.
Normal oxygen carrying capacity but short life span
Deficiency may be due to deficiency of intrinsic factor
(pernicious anemia) vitamin B12in the diet.
delayed maturation of RBC, decreased cell division
This type of anemia is called as megaloblastic anemia.
Pernicious anemia: vitamin B12 deficiency due to lack of
intrinsic factor
Changes seen in
Blood peripheral blood smear
Bone marrow
Central nervous system (CNS)


Peripheral nervous system (PNS)
Gastro intestinal tract (GIT)
a. Peripheral blood smear changes are:
Size of red blood cells will be more than normal
(macrocytes).
More hemoglobin will be present per cell mean corpuscular
hemoglobin (MCH) increases. (Normal is 28-32 pg.)
Mean corpuscular volume (MCV) is more than normal. (Normal
is 78-94 3)
The average volume of RBC occupied by hemoglobin alone is
known as mean corpuscular hemoglobin (MCHC) and normally
this will not get affected. (Normal range is 32 38 g %)
Red blood cell count will be markedly decreased.


decreased red blood cell count, along with decrease in
leucocytes and platelet count pancytopenia.
b. Bone marrow changes are:
Instead normal normoblastic type, it will be megaloblastic
type.
There will be hyperplasia(abnormal increase in number of
cells ) of bone marrow.
Red bone marrow can be observed in the shafts of long bones
even in the adult Gastro intestinal tract changes are:
No hydrochloric acid secretion in the stomach
Atrophy of gastric mucosa.
Tongue becomes more smooth and glistening.


Central nervous system changes are:
Tracts in the spinal cord are affected especially in the
lateral white matter area of spinal cord and lead to sub acute
combined degeneration of the cord (both ascending and
descending tracts are affected).
Peripheral nervous system changes are:
Degeneration of myelin sheath in the nerves leads to
numbness and tingling sensation.

Treatment:
Injection of cobalminMegaloblastic bone marrow to normal
Reticulocytosis in a week after treatment
Folic acid administration corrects the anemia due to folic
acid deficiency
Life span of RBCs 120days
Site of destruction of RBCs:

Reticuloendothelial cells (macrophages) of

Bone marrow(littoral cells)
Spleen and
Liver (kupffer cells)
Excreted in to the bile in to the intestine as bilinogens
Most of the colorless bilinogens formed in the colon by
the fecal flora are oxidized there to stercobilinogen
(colored compounds) and are excreted in the feces

Normal excretion of stercobilinogens in feces80240mg/day

the rest enters the portal blood, to be excreted in the bile
or in the urine.-as urobilinogens.
Amount excreted per day 0.5-2mg
Jaundice is yellow discoloration of skin, mucus membrane
and sclera of eyes.

Normal serum bilirubin level- 0.2-0.8 mg%

>0.8mg%- hyperbilirubinemia
When it exceeds 2mg% - clinical jaundice

RBC Indices
RBC indices include:
Mean Corpuscular Volume (MCV)
Mean Corpuscular Hemoglobin (MCH)
Mean Corpuscular Hemoglobin
Concentration (MCHC)
RBC Distribution Width (RDW)

MCV
Mean corpuscular volume
MCV is the volume of single RBC
MCV =
PCV in liter
RBC (millions/cubic mm)
Expressed in femtoliter (fL) or cubic microns(m3)
If 80-94 fL, normal range, RBCs considered normocytic
If < 80 fL are microcytic
If > 94 fL are macrocytic
MCH
MCH is average amount of hemoglobin in a single RBC.
MCH =
Hb x 10
RBC (millions)
Expressed in picograms(pg)
40

Normal value- 28-32 pg

MCHC
MCHC is average hemoglobin concentration in a single RBC
MCHC = Hb in gm% x 100
PCV (%)
Normal range 35-38%
If MCHC is normal, cell described as normochromic
If MCHC is less than normal, cell described as hypochromic
There are no hyperchromic RBCs
RDW
Most automated instruments now provide an RBC Distribution
Width (RDW)
An index of RBC size variation
Normal range is 11.5% to 14.5% for both men and women
41

Anemia
Learning objectives:
Definition
Features of anemia
Classification : based on

Etiology

morphology

Based on etiology:
Hemorrhagic anemia- loss of blood
Dietary deficiency anemia- iron, vitamin B12 deficiency
Dyshemopoietic anemia- aplastic anemia
Hemolytic anemia malaria, erythroblastosis fetalis

Based on morphology :
Normocytic normochromic anemia Microcytic
hypochromic anemia Macrocytic normochromic anemia.