Stool Analysis and Other Body Fluid Analysis

Stool Analysis and Other Body Fluid Analysis

Stool Analysis

Fecal : end product of body metabolism Early detection of gastrointestinal bleeding,

liver and biliary duct disorders, malabsorption syndromes, & detection parasites

Normal contains bacteria, cellulose & undigested foodstuffs, GI secretions, bile pigments, cells from intestinal walls, electrolytes & water

Fecal Specimen Collection

Clean, dry, widemouth, leakproof, tight-fitting lid

Not contaminated with urine or water Within 2 hours after collection

Name:

Date :

Time:

Macroscopic Examination of Feces

1. Inspection lead a diagnosis: parasitic infestation obstructive jaundiceDiarrheaMalabsorptiongastrointestinal bleeding etc

2. Noted: quantity, form, consistency, color, parasites, mucus and pus

Normal 100-200 g/ day Diarrhea: watery Steatorrhea: mushy, foul-smelling, gray stool

floats on the water Constipation: small, firm, scybala Bleeding from upper GIT: black, tarry

consistency Bleeding from lower GIT: red

Macroscopic Examination of Feces

Macroscopic Examination of FecesAppearance Possible cause

Black Upper GIT bleeding, iron th/,bismuth (antacids)

Red Lower GIT, beets & food coloring, rifampin

Pale yellow, white, gray

Bile duct obst, barium

Yellow Rhubarb

Green Biliverdin, green vegetables, antibiotics

Bulky Steatorrhea

Ribbonlike Intestinal constriction

Mucus Constipation, malignancy, colitis

Mucus:

Translucent gelatinous: constipation or colitis

Bloody mucus: neoplasm or inflammatory process

Mucus + pus and blood: ulcerative collitis, bacillary dysentry, ulcerating diverticulitis and intestinal TB

Macroscopic Examination of Feces

Pus:Chronic ulcerative colitisChronic bacillary dysenteryAbscessesAmebic colitis

ParasitesHelminths: Ascaris lumbricoides

Macroscopic Examination of Feces

Fat

Sudan III, Sudan IV, Oil Red O Stain

Specimen + 2 drops 95% ethanol + stain

Fatty acid: lightly stained flakes or needle like crystal (not stained)

Neutral fats: large orange or red droplets

Soap: not stained well-defined amorphous flakes or rounded mass or coarse crystal

Microscopic Examination of Feces

A. CARBOHYDRATE : LUGOL AMYLUM / CH + IODIUM BLUE

B. 30 % ACETIC ACID RED MUSCLE

DEXTRINDEXTRIN

REAGENS

VEGETABLE

CONECTIVE TISSUE

C. FAT SUDAN III RED BALL STRUCTURE

VV

KK

LLEE

(BACKGROUND : RED COLOUR)

AMOEBAERY / LEUKO

COLOURLESS

Microscopic Examination of Feces

Meat fiberSpecimen + 10% alcohol solution of eosin, wait 3 minmuscle fiber: rectangular fibers with clearly evident cross-striation

LeukocytesSpecimen + Loeffler methylene blue, wait 3 minutes>3 neuthropil/HPF: invasive contion

Microscopic Examination of Feces

Parasites

S. haematobiumS. mansoni

Microscopic Examination of Feces

Ascaris

Enterobius

TaeniaS. japonicum Trichiuris

Stool for Occult Blood

Simple, inexpensive screening test for colorectal cancers

Microscopic bleeding in the intestine cannot detected by naked eye.

Principle:

Hb H2O2 Benzidine O-tolidineguaiac

Pseudo-peroxidase Blue color

Not specific for blood Peroxidase enzyme (horseradish and

turnips): false positive result Blood in red meat: positive result Cimetidine (blue pigment): confusion Vitamin C: false negative result

Stool for Occult Blood

Physiologic system to supply nutrients to nervous tissue, move metabolic waste & mechanical barrier to cushion the brain & spinal cord against trauma

Produce 500 ml/day Ultrafiltration and secretion through the choroid

plexus Obtained by lumbar puncture, cisternal puncture,

lateral cervical puncture or ventricular cannulas

Cerebrospinal Fluid

Formation of Cerebrospinal Fluid

Specimen Collection

Routinely by lumbar puncture between 3rd, 4th or 5th vertebrae

Collected in 3 sterile tubes:

1. Tube 1: chemical & serologic tests

2. Tube 2: microbiology

3. Tube 3: cell count Examination should be performed immediately

(<1 hr)

Gross Examination

Normal CSF:clear and colorlessviscosity similar to water

Turbidityleukocyte >200cells/µLerithrocyte > 400cells/µL

Clot formationtraumatic tap, complete spinal block, suppurative and tuberculous meningitis

Viscousmetastatic mucin-producing adenomacarcinomascryptococcal adenocarcinomas

Xanthochromiapink, orange or yellowdue to RBC lysis or Hb breakdownbilirubin, protein >150mg/dL, carotinoids, melanin, rifampicin therapi, contamination of detergent or methiolate disinfectan

Gross Examination

Microscopic Examination

Total Cell Count Leukocyte: normal 0-5 cells/µL Use Improve Neubauer counting chamber

Differential Count Performed on a stained smear Normal: primarily lymphocytes & monocytes

adult: lymphocytes : monocytes = 70:30children: monocytes more prevalent

Neutrophilia: bacterial meningitis

Chemical Analysis

Total ProteinDerived from plasma, concentration<1% blood level (15-45 mg/dL)elevated CSF protein:Increased permeability of BBB (meningitis, hemorrhage)Decreased resorption at arachnoid villi Mechanical obstruction (tumor)Increase intrathecal immunoglobulin synthesis (Guillain-Barre synd, multiple sclerosis)

Glucose

derived from blood glucose

fasting CSF glucose 50-80mg/dL

60% plasma values

Hypoglycorrhacia:

bacterial, tuberculous and fungal meningitis

Chemical Analysis

Enzymes

1. Lactate Dehydrogenase (LDH)

Normal < 40U/L

elevated in bacterial meningitis

2. Creatine Kinase (CK)

Normal < 5 U/L

elevated in demyelinating disease, seizures, stroke, malignant tumors, meningitis & head injury

Chemical Analysis

Microbiological Examination

Gram stain Bacterial Meningitis

group B Streptococcus and Gram negative rods Viral meningitis

Enteroviruses (polioviruses) Fungal meningitis

Cryptococcus (in AIDS patients) Tuberculous meningitis

Differential Diagnosis of MeningitisBacterial Viral Tubercular Fungal

WBC count elevated elevated elevated Elevated

Cell present neutrophil Lymphocytes Lymphocytes & monocytes

Lymphocytes & monocytes

Protein elevated

marked moderate Moderate to marked

Moderate to marked

Glucosa decreased normal decreased Normal to decrease

Synovial Fluid

Viscous liquid found in the joint cavities Ultrafiltrate of plasma combined with

hyaluronic acid produced by the synovial cell Normal: < 3.5mL Functions:1. Acts as lubricant and adhesive2. Provides nutrients for the avascular articular

cartilage

Synovial Fluid

Specimen Collection

Arthrocentesis Steril, disposable needles and plastic syringe Specimen:

1. EDTA: cell count & diff count

2. Na-Heparinized : chemical & immunologic test

3. Plain: microbiologic test & crystal examination Oxalate, Li-heparin and EDTA avoided

Gross Examination

Color evaluated in a clear glass tube against a white

background Normal: colorless to pale yellow noninflammatory/ inflammatory dis: straw to yellow

(xanthochromia) Septic: yellow, brown, green

Clarity Related to the number and type of particles

within synovia Normal: transparent Translucent: leukocytes Opaque: massive crystals Milky opalescent: abundance of cholesterol

crystal

Gross Examination

Microscopic Examination

Total Cell Count 1 hour after arthrocentesis Hemacytometer or automated cell counter Incubated with hyaluronidase Normal: <150-200/ µL

Differential CountNormal: Neutrophils 20% Lymphocytes 15% Monocytes & macrophages 65% Eosinophilia 2%Elevated: Neutrophils: inflammatory, Gout & RA Lymphocytes: early RA, chronic infection Monocytes: viral arthritis Eosinophilia: RA, metastatic carcinoma, parasitic inf

Microscopic Examination

Crystal Examination Gout: crystal deposition in articular tissue 1. monosodium urate monohydrate (MSU)

2. calcium pyrophosphate dihydrate (CPPD)3. apatite4. basic calcium phosphate (BCP)

Polarized light microscope 1. MSU: Gout, septic arthritis

2. CPPD: degenerative arthritis, hypo-Mg, hemochromatosis

Microscopic Examination

Synovial Fluid CrystalCrystal Shape

Monosodium urate Needles

Ca pyrophosphate Rods

cholesterol Notched rhombic plates

apatite Small needles

coricosteroid Flat, variable shape plates

Chemical Analysis

GlucoseNormal: <10 mg/dL

ProteinNormal: 1.38 g/dL

Uric acid Lipids:

1. cholesterol-rich psedochylous: chronic RA2. lipid droplets: trauma3. chylous effusion: RA, SLE, filariasis,

pancreatitis, trauma

Immunologic & Microbiological Examination

1. Immunologic studies Rheumatoid Factor (RF) Complement

2. Microbiological Examination Gram’s stin Ziehl-Neelson Culture

Pleural Fluid

Pleural cavity: between mesothelium of visceral and parietal pleura

Normal: small amount of fluid Plasma filtrate derived from capillaries of the parietal

pleura, reabsorbed through the lympatics and venules of the visceral pleura

Effusion: accumulation of fluid Specimen collection: Thoracentesis In EDTA tube: cell counts & differential

Transudates & Exudates

Transudates: increased hydrostatic pressure or decreased oncotic pressure

Congestive heart faillure Hepatic cirrhosis HypoproteinemiaExudates:

Increase capillary permeability or decreased lymphatic resorption

Infections: Tb, bacterial, viral pneumonia Neoplasms: metastatic Ca Extrapleural sources: pancreatitis, ruptured esophagus

Gross Examination

Transudates Exudates

Color Pale yellow to straw

Turbidity Clear Turbid/milky/ bloody

Odor - Fecalent: anaerobic inf

Microscopic ExaminationTransudates Exudates

Cell counting < 1000/µL > 1000/µL

Differential count :Mesothelial cell

Neutrophilia (>50%)

Lymphocytosis (>50%)

Eosinophilic (>10%)

negative

10% case

30% case

Cong heart failure, trauma

Tb, empiema, rheumatoid Bacterial pneu, pancreatitisTb, viral inf, malignancy, SLEparasitic/fungal inf, drug rx, rheumato

Chemical Analysis

Transudates Exudates

Protein <3.0 g/dL >3.0 g/dL

Glucose = serum =serum

LDH PF/S <0.6

<200 IU/L

PF/S >0.6

>200 IU/L

Amylase ≤ serum ≤ serum

pH >7.4 >/<7.3

Pericardial Fluid

Normal: 10-50 mL Produced by transudative process Effusion: Inflammatory, malignant,

hemorrhagic processes Obtained: pericardiotomy,

pericardiocentesis

Pericardial Fluid

Gross Examination Normal: pale yellow and clear Infection: turbid effusion Uremia: clear & straw colored effusion Chylous effusion: milky appearance

Microscopic Examination Leukocyte count:

>10 000/µL: bacterial, TB, malignant

Chemical Analysis Protein

>3.0g/dL: exudates Glucose

<40mg/dL: bacterial, TB, malignant pH

<7.10: rheumatic & purulent condition7.20-7.40: malignant, uremia, TB

EnzymesLD >300U/dL & fluid/serum LD ratio>0.6: exudates

Pericardial Fluid

Peritoneal Fluid

Ultrafiltrate of plasma Peritoneal effusion: ascites Normal: <50mL Specimen collection:EDTA

Gross Examination Transudates: pale yellow & clear Exudates: cloudy/ turbid Acute pancreatitis & cholecystitis: green Malignancy & TB: bloody Chylous & pseudochylous: milky fluid

Peritoneal Fluid

Microscopic Examination Bacterial peritonitis:

leukocyte >500/µL, >50% neutrophil Eosinophilia (>10%): chronic inflammatory process

Chemical Analysis Protein: little value Low glucose: TB peritonitis & malignancy Elevated amylase: pancreatitis, gastrointestinal

perforation Elevated alkaline phosphatase: intestinal

perforation Elevated urea/ creatinine: ruptured bladder

Peritoneal Fluid

References

1. Clinical Diagnosis and Management by Laboratory Methods.Henry JB. 20th ed. 2001. WB Saunders co: Philadelphia London

2. Urinalysis and Body Fluid. Strasinger SK. 2nd ed.1989. F.A. Davis Co: Philadelphia

3. Basic Medical Laboratory Techniques. Estridge BH, Reynolds AP, Walters NJ. 4th ed. 2000. Delmar: Africa Australia