[Music] welcome back guys now in this video let's discuss about macro CTIC anemias macro citic anemas so what exactly are this microtic anemas you already know it so what is the normal volume of the RBC the normal volume of the RBC is 80 to 100 fol if the mean corpuscular volume if it is greater than 100 fol L okay if it's greater than 100 fol L then it is called as macrocytic anemias now what are the causes of the macroy anemas why macro cytic anemas let's write the causes here the causes are number one causes vitamin B9 deficiency vitamin B12 deficiency okay B9 that's a folate deficiency B12 that cobalamine deficiency deficiencies next it can be seen in persons who are alcoholics alcoholics and it can be seen uh in a patients who are having liver disease okay uh the persons who are using certain drugs like five fluo urasil Methotrexate okay which are folate and antagonistic drugs so these are the points which I want you to know the causes causes see why vitamin B9 deficiency and vitamin B12 deficiency see these are the two most important things why bamin B9 and B deficiency B9 B2 deficiency is going to cause the megaloblastic anemas how is see vitamin B9 B12 the folate and cobalamine are very important for the production of DNA precursors important for synthesis of DNA cursors okay so for the production of the DNA precursors or simply we can say for the production of the DNA you require the vitamin B9 and b12 if vitamin B9 and b12 if they are deficient okay if they are deficient that causes improper DNA synthesis the DNA synthesis is not happening no DNA production without DNA production do you think cell division is going to occur the cell division is not occurring so RBC production continuous cell division is not occurring sir okay so the point which I want you to know is see actually you require cell divisions okay you require cell divisions for the production of mature cells from the blastic from the immature cells which are called the blastic cells the immature cells hematop Bois is happening right from the hoptic stem cell to the mature RBC see one thing which I I want you to appreciate here is so the immature cells are bigger cells and the mature cells are becoming smaller cells the more the number of cell division the cell size will gradually reduce okay now here because of the vitamin B9 and B12 deficiency the DNA precursors are not synthesizing no DNA replication without DNA replication cell division is not happening properly so the main problem here is a cell division the cell division is not occurring properly as the cell division is not occurring properly you are going to left with the immature cells okay what you are having mainly in the bone marrow and that's coming into the uh bloodstream is the immature cells are coming okay it's the immature cells coming so immature cells are definitely small large okay the immature cells are definitely larger when compared to the normal so that's why the name Mega sorry I that's why the name macrocytic RBS okay macro means bigger macrocytic means bigger cells are there which bigger cells the rbcs see not only this is true for the rbcs but even true for the wbcs also okay even true for the wbcs even the WBC size will increase greatly increase okay so if you look at the WBC they're also not properly dividing so you're going to have bigger um WBC what you will see is for example say this is the WBC in a mature neutrophil in a mature neutrophil you'll be having three to fops okay three to fops of nucleus but in an immature WBC you are going to have multilobated nucleus more than pH Lopes okay more than phop is going to be seen such type of neutrophils are called as hyper segmented neutrophils okay the such neutrophils are called as hypers segmented neutrophils now whenever you see such hypers segmented neutrophils definitely it is macrocytic anemia that to see if a macrocytic anemia if it is due to vitamin B9 and B12 deficiency if the macro citic anemia if it is due to vitamin B9 and B12 deficiency that is called as megaloblastic anemia okay megaloblastic in the name itself it say mega means bigger blastic means immature cells megaloblastic anemia so hypers segmented neutrophils are seen in megaloblastic anemia vitamin B9 B12 deficiency immature cells bigger cells okay so this thing apart from this what else I have to teach you is see how folet how you will get the folate you will get the folate um like via green leafy vegetables or from some fruits you'll get it so folate once it enters into your body it's going to be methylated okay it's going to become methy Tetra hydrolate okay it's become methy Tetra hydrolate see if you want to send this folate to DNA production or we should say what kind of folate is required for the DNA production it's normal Tetra hydrolate okay Tetra hydrolate is required not methy so this methylated group need to be donated who will accept this methylated group this methy group is accepted by vamin B12 so now methy group is here that's the ch3 group is with there with the vitamin B12 now this tetrahydrofolate is going for the DNA synthesis okay DNA precursor synthesis now this vitamin B12 it is a methy donor it will also donate to whom it will donate it will donate it to homosysteine the biochemistry the homoy by acting the by by receiving by accepting this mythy group okay by accepting that mythy group it will become methionin okay methionin sir one important thing and what I want you to know here is Sir in B12 deficiency anemias and in fet deficiency anemia see this is vamin B9 this is vitamin B12 so what changes are going to be appreciated that I will explain you okay within a minute I will explain you see now after this let's start with the B9 deficiency okay folate deficiency so from where you will get the vitamin B9 you'll get the vitamin B9 from fruits and vegetables fruits and vegetables so if you're not taking proper diet you will get vamin B deficient or if you're using drugs like five FL Flo urasil okay five florasil are Methotrexate see these are folate antagonistic drugs these are fet antagonists okay so mythri used in the treatment of ectopic pregnancy mythri used in the treatment of cancers F FL uras used in the treatment of cancers using these drugs can also cause vitamin B9 deficiency vitamin B9 deficiency so what are the uh Clinical Laboratory findings we be seen okay what are the clinical and laboratory findings okay laboratory finding the patient is having vitamin B9 deficiency yes the patient is going to have magal blastic anemia okay Matic carb is M blastic anemia is seen no doubt means in the lab what you will see big rbcs Megalo blasts are going to be seen with Hyper segmented neutrophils okay hypers segmented neutrophils can be more than F Lopes apart from this these things already you know it apart from this what else see vitamin B9 is not there okay vitamin B9 is not there when vitamin B9 is not there okay so mythy group is not going to vitamin B12 when methy group is not going to vitamin B12 the conversion of homoy to meth is not going to happen so which levels are going to be elevated in the blood so the homo levels the homo levels are going to be elevated that's the important question okay homoy levels so homos levels are elevated okay and methy melanic acid okay methyl melic acid levels are maintained normal why I'm talking about the methyl Melo acid levels now here because see in B12 deficiency later on I'm going to explain about the second type of megaloblastic anemia that is is B2 deficiency anemia so in B12 deficiency anemia methy melano acid levels are going to be elevated okay so don't forget about it methyl mic acid levels are going to be elevated okay in where in B2 deficiency not in FID deficiency okay not in folate deficiency okay so lab findings are going to be yeah of course serum folate levels okay serum folate levels are going to be reduced normal meic acid levels okay so these patients are going to have what else clinical features because of this megaloblastic anemia okay because of this megaloblastic anemia uh the patient is going to have hypoxic symptoms easy fatigability okay nausea easy like you know getting tired very easily the pale conjuctiva can be seen these things and glossitis can be seen okay glossitis can be seen okay atrophy glossitis so these things are see now let's talk about the B12 deficiency anemia see why someone can get B12 deficient okay see usually people won't get B12 deficients very rare because we have sufficient stores of B12 in the liver okay in the liver there are sufficient stores of B12 usually no one will get vitamin B2 deficiency until unless they are a pure vegans okay not even vegetarian pure vegans they are not at all touching the Animal product okay now you can ask me why I'm talking about the animal products now because between B12 is one vitamin cobalamine is a vitamin you'll only get from animals okay so those people who are completely avoiding the animal sources at least they have to take milk okay milk butter ghee kind of thing okay so those people who are completely avoiding the animal products they can get vitamin B12 deficient okay they can get vitamin B12 deficient because vitamin B12 is a animal derived protein animal derived protein so how Vitamin B12 is absorbed see our salv glands okay our Sal glands produces something called as AR binder okay protein called as AR binder see now this AR binder okay now this AR binder is going to bind with okay AR binder is going to bind with vitamin B12 okay vitamin B12 so this is called as vitamin B12 arbind complex now this vitamin B12 arbent complex when it is coming into the deum okay it's coming into the deam now in the deinum whatever the proteines that are getting produced is going to cleave now it's going to cleave the vitamin B12 and arbin complex now vitamin B12 is free now this vitamin B12 is going to bind with intrinsic factor okay intrinsic factor Factor so vitamin B12 in the deod where is binding with it's binding with the intrinsic factor now you can get a question from who is producing this intrinsic factor so this intrinsic factor is produced by paral cells paral cells now where are these paral cells the paral cells are present in the stomach so in the stomach in the gastric mucosa there are cells called as a paral cells now those parel cells of course it produces acid parel cells produce acid as well as intrinsic factor now this intrinsic factor is going to B with the B B12 so this is called as B12 intrinsic factor complex now this B12 intrinsic factor complex is going to be absorbed in terminal alium okay so only vitamin B12 is absorbed only vitamin B12 is absorbed in the presence of intrinsic factor without intrinsic factor vitamin B12 absorption is not going to happen it's not going to happen Okay so this is something normal physiology now why someone get vitamin B2 deficiency okay one reason is if they are a pure vegan completely avoiding the animal products that can lead to vitamin B2 deficiency or diseases like Mal absorption syndromes okay Mal absorption syndromes um anything like crons ulcerative colitis cronn ulcera colitis or parasitic infections like dorium okay dum latum see this dilum Lum is a fish tape form is a fish tape form see this dilum Lum where it will live it lives in the terminal alium okay it lives in the terminal alium as it's living in the terminal alium it interferes with the absorption of the vitamin B12 it's causing like you know elitis so inflammation so during that inflammatory conditions vitamin B2 absorption is not going to happen properly so that can lead to vitamin B12 deficiency anemia that's the one reason cron alcer colitis Dam infections are Auto imune conditions autoimmune condition see what is this autoimmune condition there is autoimmune condition called as pernicious anemia so what is this pernicious anemia in this condition sir antibodies okay the antibodies are produced against the antibodies are produced against paral cells paral cells now paral cells are getting damaged so when the paral cells are getting damaged so acid production goes down also the intrinsic factor levels goes down intrinsic factor production goes down now my question to you sir if the intrinsic factor is not there do you think V B12 is going to be absorbed so intrinsic factor is not there so this patient having severe deficiency of intrinsic factor without intrinsic factor that will cause B12 deficiency okay inic factor is not there so B12 is not getting absorbed so that's one of the cause of vitamin B12 deficiency okay so Cron's disease and alcer Colitis you know are inflammatory bubel diseases so absortion of the substances will decrease dilum Lum infection autoimmune conditions like pernicious anemia and vegans can get deficient in the vitamin B12 okay now if a patient is having vitamin B12 deficiency what are the laps that are going to be the same look at the laps so serum B12 levels are going to decrease one thing what about the homo levels see vitamin B12 is not there I have explained you vitamin B12 if is not there no one is giving the mythy group to the homo okay no one is giving the mythy group to the homos so homos is not getting converted into the methin so what happened to the homos levels the homos levels are elevated okay homos levels are elevated so even B12 deficiency okay even B12 deficiency homoy levels are elevated okay homos levels are elevated sir now here in this condition the methon acid okay the methon acid levels these are also elevated sir but in folate deficiency I have explained you in folate deficiency meth malonic acid levels are normal but here it's elevated why because you need to convert the meth milonic acid into sux Co so melonic acid biochemistry so it's converted it needs to be converted into suy coenzyme a methon COA the meth acid is it need to be converted to Su Co with the help of what with the help of vitamin B12 okay with the help of vitamin B12 the mthm malonic acid is converted into Su Co when vitamin B12 is not there what happened to the mthm malonic acid levels elevated so that's why meic acid levels are elevated this elevated meic acid okay this elevated methon acid levels are going to cause damage to the spinal cord or the mation of the spinal cord okay so this me this methon acid levels are going to cause a condition called as Subacute combined degeneration Subacute contain Subacute combined degeneration of spinal cord where especially the mation mainly the mation is getting damaged because of the accumulation of this metonic acid levels mainly the posterior column posterior column we know it right the posterior column of the spinal cord the poster in the posterior column of the spinal cord the fine touch vibration proprioception information is going in the posterior column that advanced Sensations are going in the posterior column of the spinal cord so the posterior column as it's getting damaged the patient is going to have a loss of proprioceptive information okay proprioceptive information and vibratory senses are affected because you know it the poster of the spinal card is highly highly mated because of the accumulation of the metonic acid levels the poster call of the spinal card is getting mainly affected that causes a Subacute combined degeneration of the spinal cord so in B12 deficiency okay in B12 deficiency the patient is having neurological symptoms that's the McQ in B12 deficiency the patient will experience neurological okay neurological symptoms but in B9 deficiency folic acid deficiency such kind of neurological symptoms are not seen okay such kind of neurological symptoms are going to be absent okay so what you will see here in B2 deficiency also same thing hypochromic hypers segmented neutrophils can be seen okay hypochromic RBS can be seen even these patients will be having atrophic glossitis okay atrophic glossitis can be seen in this patients also okay having said that we have discussed all the important points regarding the macro anemas that's both B12 deficiency and B9 deficiency how they are going to cause the magalo blastic anemias and how to differentiate between B9 deficiency and B12 deficiency again I'm telling you to differentiate between B9 and b12 you have to check the Mythic acid levels B12 deficiency increas the metonic acid levels in B9 deficiency meic acid levels are not elevated homoy levels are going to be elevated both in B9 deficiency as well as B2 deficiency neurological symptoms seen in B12 deficiency if it is a megaloblastic anemia hypers segmented neutrophils are seen if you see that word hypers segment neutrophils it is macrocytic megaloblastic anemias okay so with this macrocytic anemias are also completed in the next video we'll start with the normocytic anemas hope the video is helpful thank you