Anemia

Causes

• Folic acid deficiency
  • Alcohol causes folatemalabsorption.
  • Due to cirrhosis capacity to store and release folate is decreased.
  • Ethanol impairs release of folate from liver.
• Other nutritional deficiency: Ex: Pyridoxine
• Chronic GI bleed
• Hepatic dysfunction
• Direct toxic effect of alcohol on erythropoiesis (So in alcoholics normoblasts are vacuolated).
• Zieve's syndrome:
  • Hyperlipidemia
  • Jaundice
  • Transient spherocytichemolytic anemia
  • Spur cell hemolytic anemia

Thrombocytopenia

• Causes
  • Cirrhosis leads to decreased TPO production
  • Congestive splenomegaly
  • Folic acid deficiency
  • Direct marrow suppression
• Thrombocytopenia resolves in 5-12 days with cessation of ethanol ingestion.

Platelet dysfunction

• Causes
  • Inhibition of prostaglandin synthesis
  • Alterations in storage pool of nucleotide
  • Membrane stabilization

Haemostatic derangement

• Low levels – Increases fibrinolytic potential of endothelial cells by increasing levels of urokinase receptors
• Moderate levels– Reduction in the response of platelet to agonists (By reduction in activity of phospholipase A2 with concurrent fall in thromboxane synthesis)
• High levels – Inhibition of platelet aggregation in dose dependent fashion(By blocking the activity of phospholipase A2 and cyclooxygenase activity)
• Regular heavy drinking causes cirrhosis with subsequent coagulopathy
• Potential of fibrinolytic system becomes lower with increasing alcohol consumption

Investigations

• Peripheral smear: 
  • Macrocytosis/ Dimorphic anemia (if there is coexisting iron and folic acid deficiency)
  • Thrombocytopenia- as platelet production is affected
• Bone marrow: 
  • Megaloblastic changes
  • Multinuclear erythroblasts 
  • Vacuolated pro-erythroblasts and granulocyte precursors
  • Decreased megakaryocytes
  • Vacuolization of periphery of megakaryocytes