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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