Checklist for suspected anemia
Symptoms, pre-existing conditions, risk factors and possible causes by systems and organs. Tick applicable items; mark possible causes as differential possibilities to be clarified.
1. Anemia symptoms
- Fatigue
- Decreased performance
- Exertional dyspnea
- Dizziness
- Palpitations
- Syncope
These symptoms can occur in different forms of anemia and are not specific for a particular cause.
Gastrointestinal system
Esophagus
Symptoms
- Difficulty swallowing
- Pain when swallowing
- Weight loss
Risk factors / history
- Smoking
- High alcohol consumption
- Chronic reflux / Barrett’s esophagus
Possible causes
- Esophageal carcinoma with blood loss
- Erosive esophagitis with blood loss
Stomach
Symptoms
- Upper abdominal pain: mainly epigastric, possibly food-related
- Nausea
- Vomiting blood
- Melena
Risk factors / history
- Helicobacter pylori infection
- NSAID use
- Alcohol consumption
- Previous stomach surgery / gastric bypass
Possible causes
- Gastric ulcer or duodenal ulcer with blood loss
- Gastritis
- Gastric carcinoma with blood loss
Small intestine
Symptoms
- Chronic diarrhea
- Bloating
- Abdominal pain
- Weight loss
- Symptoms after gluten-containing foods, for example wheat, rye or barley
Risk factors / history
- Known celiac disease
- Celiac disease in first-degree relatives
- Type 1 diabetes
- Autoimmune thyroid disease
Possible causes
- Celiac disease with reduced iron absorption
- Crohn’s disease with inflammation, blood loss and/or malabsorption
Colon / rectum
Symptoms
- Changed bowel habits
- Blood in the stool
- Abdominal pain
- Tenesmus: painful urge to defecate, possibly without adequate evacuation
- Weight loss
Risk factors / history
- Older age
- Family history of colorectal cancer
- Chronic inflammatory bowel disease
- Smoking
- Obesity
Possible causes
- Colon or rectal carcinoma with chronic blood loss
- Ulcerative colitis with blood loss and inflammatory anemia
- Crohn’s disease with colonic involvement
- Bleeding angiodysplasias
- Diverticular bleeding
Anus
Symptoms
- Bright red bleeding with bowel movements
- Pain during or after bowel movements
- Itching / oozing
- Constipation / hard stool
- Frequent diarrhea
Predisposing factors / history
- Known hemorrhoids / anal fissures
- Straining
- Low-fiber diet
Possible sources of bleeding
- Hemorrhoidal disease with recurrent bleeding
- Anal fissure with bleeding
A pronounced anemia caused solely by an anal fissure is unusual. Other sources of bleeding must be considered.
Gynecologic system
Uterus
Symptoms
- Heavy menstrual bleeding
- Prolonged menstrual bleeding
- Intermenstrual bleeding
- Painful menstrual bleeding
Possible causes / history
- Uterine fibroids / adenomyosis
- Copper IUD
- Known coagulation disorder
Cardiovascular system
Heart
Symptoms
- Exertional dyspnea
- Orthopnea
- Reduced exercise capacity
- Leg edema
Risk factors / history
- Known heart failure
- Coronary heart disease
- Arterial hypertension
- Valvular heart disease / cardiomyopathy
Possible anemia mechanisms in heart failure
- Iron deficiency
- Renal anemia with concomitant renal insufficiency
- Blood loss, possibly promoted by antithrombotic medications
CHD or hypertension alone do not explain an anemia. Cardiac diseases and anemia can cause similar symptoms and exacerbate each other.
Urinary system
Kidneys
Symptoms
- Edema
- Pruritus
Risk factors / history
- Known renal insufficiency
- Diabetes mellitus
- Arterial hypertension
Possible causes
- Renal anemia due to reduced erythropoietin production in chronic renal insufficiency
- Additional iron deficiency
- Blood losses during dialysis treatment
Musculoskeletal system
Joints
Symptoms
- Joint pain
- Joint swelling
- Morning stiffness
Risk factors / history
- Known rheumatologic disease
- Family history
- Regular NSAID use
Possible causes
- Anemia of chronic inflammation, for example in rheumatoid arthritis
- Iron deficiency due to NSAID-induced gastrointestinal bleeding
- Drug-induced suppression of hematopoiesis
Blood and lymphatic system
Erythrocytes / spleen
Symptoms / signs
- Jaundice
- Dark urine
- Splenomegaly
- Feeling of pressure in the left upper abdomen
- Recurrent pain crises
History / family history
- Gallstones / cholecystectomy at a young age
- Known autoimmune disease
- Sickle cell disease / thalassemia
- Anemias in the family
Possible causes
- Autoimmune hemolytic anemia
- Hereditary spherocytosis
- Sickle cell disease
- Thalassemia
- Hypersplenism with increased sequestration and accelerated cell breakdown
Bone marrow / lymph nodes
Symptoms / signs
- Petechiae / purpura
- Unusual bruising
- Mucosal bleeding
- Recurrent infections
- Fever / night sweats
- Weight loss
- Lymph node enlargement
- Bone pain
Possible causes/ history
- Leukemia
- Myelodysplastic neoplasm
- Aplastic anemia
- Bone marrow infiltration, for example in lymphoma or metastatic tumor
- Therapy- or toxin-induced bone marrow damage
- Anemia in tumor-related chronic inflammation
Nutrition
Nutrient intake
- Unbalanced diet
- Low food intake
- Vegetarian/vegan diet without adequate iron supply
- Malnutrition
Possible causes
- Iron deficiency due to insufficient intake
- Vitamin B12 deficiency
- Folate deficiency
- Combined nutrient deficiency
A vegetarian or vegan diet does not necessarily lead to anemia. What matters is the actual nutrient supply and, if applicable, supplementation.
Overall
Blood loss
- Recent trauma
- Recent surgery
- Frequent blood donations
Possible causes
- Acute post-hemorrhagic anemia after trauma or surgery
- Occult internal bleeding
- Iron deficiency due to repeated blood losses or frequent blood donations
Medications
- Anticoagulants / platelet aggregation inhibitors
- NSAIDs
- Medications potentially causing bone marrow damage
Possible causes / mechanisms
- Bleeding facilitated by anticoagulants or platelet aggregation inhibitors
- Gastrointestinal mucosal damage and bleeding under NSAIDs
- Drug-induced bone marrow suppression
- Drug-induced hemolysis
In bleeding under anticoagulant therapy, the underlying source of bleeding must also be sought.
Note on analysis
Assess the symptoms and risk factors together. Individual entries do not prove a cause. Multiple causes can also be present simultaneously. An unchecked box does not automatically mean that the respective finding has been excluded. The listed possible causes are suspicions and not confirmed diagnoses.
Comorbidity: An anemia can occur as an accompanying condition in various diseases. Therefore, in addition to diagnosing and treating the anemia, the underlying disease should also be identified and treated.
Confirmation and classification: Anemia is determined based on the hemoglobin value. Blood count, erythrocyte indices and reticulocytes help with classification. Further laboratory tests depend on the suspected cause.
Important: Lack of symptoms does not rule out anemia. A pronounced anemia should not be attributed solely to known hemorrhoids or anal fissures.