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Referral Guidelines for Macrocytosis The differential diagnosis of red cell macrocytosis (mean corpuscular volume >98fl) includes B12 and folate deficiency, excess alcohol consumption / liver disease including fatty liver, cytotoxic drugs, reticulocytosis, hypothyroidism and myelodysplastic syndrome. Uncomplicated B12 or folate deficiency does not require routine referral for Haematology outpatient assessment Appropriate investigation in primary care prior to referral: B12 and folate levels ( intrinsic factor if B12 deficiency) Blood film examination and reticulocyte count Liver and thyroid biochemistry Immunoglobulins and protein electrophoresis Drug (cytotoxics)/ Alcohol history and appropriate lifestyle modification Referral for specialist opinion should be considered for: Suspected myelodysplastic syndrome (based on blood film report) MCV >100 fl with accompanying cytopenia (excluding B12/folate deficiency) Persistent unexplained MCV >104 fl confirmed on repeated fbc over months. Often macrocytosis is evident over many months or even years without progression or obvious illness and with no clear cause. These patient may only need 6 or 12 month checks.