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Clinical Microscopy
Fecalysis - Serous fluids
| Question | Answer |
|---|---|
| Stool weight of >200g/day with increased liquidity and frequency of >3x/day | Diarrhea |
| <4 weeks of diarrhea | Acute diarrhea |
| >4 weeks of diarrhea | Chronic diarrhea |
| Major mechanisms of Diarrhea | Secretory, Osmotic and Altered Motility |
| Used to differentiate the major mechanisms of Diarrhea | Fecal electrolytes, osmolarity and stool pH |
| Normal fecal osmolarity | 290 m0sm/kg |
| Normal fecal Na level | 30 mmol/L |
| Normal fecal K level | 75 mmol/L |
| Increased secretion of water and electrolytes | Secretory diarrhea |
| Caused by bacterial, viral and protozoan infections, laxatives, endocrine disorders, neoplasms, collagen vascular disease | Secretory diarrhea |
| Retention of water an electrolytes in the large intestine d/t incomplete breakdown or reabsorption of food | Osmotic diarrhea |
| Caused by maldigestion, malabsorption, disaccharidase def., laxative, antacids, amebiasis, antibiotics | Osmotic diarrhea |
| Enhanced (hypermotility) or slow (constipation) motility | Altered motility |
| Caused by irritable bowel syndrome (IBS), rapid gastric emptying (RGE) dumping syndrome | Altered motility |
| Fecal osmotic gap of secretory diarrhea | <50 m0sm/kg |
| Fecal osmotic gap of osmotic diarrhea | >75 m0sm/kg |
| Fecal screening test: Determine the cause of bloody stools in neonates (fetal blood or swallowed maternal blood during delivery) | Apt test (Apt-Downey Test) |
| APT test result: Pink solution | (+) Fetal blood (resistant to 1% NaOH); HbF is alkali resistant |
| APT test result: Yellow-brown supernatant | (+) Maternal blood (denatured); HbA is denatured by NaOH |
| Fecal screening test: Detects pancreatic enzyme called trypsin (digestive enzyme) | X-ray Film test (Gelatin test) |
| Gelatin test result: Clearing of film | (+) Trypsin |
| Gelatin test result: No clearing of film | (-) Trypsin; Absence of trypsin is seen in cystic fibrosis |
| Fecal screening test: Most valuable in assessing cases of infant diarrhea (Ex. Lactose intolerance) | Fecal Carbohydrates |
| Fecal screening test: Determination of clinitest and fecal pH | Fecal Carbohydrates |
| Fecal CHO result: Clinitest >0.5 g/dL | Carbohydrate intolerance |
| Normal stool pH | Fecal pH: 7-8 |
| Stool pH in CHO disorder | Fecal pH: ### |
| Fecal screening test: Immunoassay using an ELISA test; A sensitive indicator of exocrine pancreatic insufficiency | Elastase-1 |
| Fecal screening test: Differentiates malabsorption and maldigestion | D-Xylose test |
| Specimens for D-xylose test | 2-hr PP blood and 5-hr urine |
| Fecal screening test: Decrease blood and urine D-xylose (D-xylose is excreted in the feces) | Malabsorption |
| Fecal screening test: Normal urine D-xylose (D-xylose is not excreted in the feces but in the urine) | Maldigestion |
| The most frequently performed fecal analysis and the screen test for colorectal cancer; priniciple: pseudo peroxidase activity of Hgb | Guaiac Fecal Occult Blood test (gFOBT) |
| The significant blood result in gFOBT | gFOBT result: >2.5 mL blood/ 150g stool |
| gFOBT sample stool | center portion of the stool |
| Considering that a normal stool can contain up to 2.5mL of blood, a less sensitive chemical reactant is understandably more desirable to avoid false positive reactions | 1. Benzidine 2. Guaiac 3. O-toluidine |
| False positive FOBT | Avoid for 3 days: Red meat, melon, broccoli, cauliflower, horseradish, turnip Avoid for 7 days: Aspirin, NSAIDs other than paracetamol |
| False negative FOBT | Avoid 3 days: Vitamin C (>250mg/d) Failure to wait specified time after sample is applied to add the developer reagent |
| Other FOBT: It uses anti-hemoglobin antibodies; more sensitive to globin | Immunochemical (IFOBT/FIT) |
| Other FOBT: Conversion of heme to fluorescent porphyrins; NOT AFFECTED by reducing or oxidizing substances | Porphyrin-based FOBT |
| Microscopic examination of stools | 1. Fats 2. Muscle fibers 3. Fecal Leukocytes |
| Microscopic examination: Increased fats in stool (>6g/day) | Steatorrhea |
| Microscopic examination of feces for fat globules | Screening test |
| Fecal fat determination | Definitive test |
| Qualitative fecal fat test: Stool suspension + 95% Ethanol +Sudan III -> Orange droplets (Neutral fats/ Triglycerides) | Neutral fat stain (Triglycerides) |
| Qualitative fecal fat test: Emulsified + 36% Acetic acid + Sudan III -> Orange droplets (Fatty acids) | Split fat stain (Fatty acids) |
| Quantitative fecal fat test: Gold standard for fecal fat determination. For definitive diagnosis of steatorrhea, titration with NaOH | Van de Kamer titration |
| Van de Kamer titration samples | 3 day stool (72 hours) |
| Van de Kamer test result: 1-6 g fats/day | Normal value of fecal fat |
| Van de Kamer test result: >6 g fats/day | Steatorrhea |
| A rapid test to estimate the amount of fat excretion (similar to microhematocrit test) | Acid Steatocrit |
| A sample is microwaved-dried and analyzed | Hydrogen nuclear magnetic resonance spectroscopy |
| Microscopic examination: Abnormal excretion of muscle fibers in feces | Creatorrhea |
| Determination of creatorrhea | The patient should include red meat in the diet Emulsified stool + 10% Eosin -> coverslip & stand for 3 minutes Count the number of undigested fibers (HPF) |
| Creatorrhea: No striations | Completely digested |
| Creatorrhea: Striation in one direction | Partially digested |
| Creatorrhea: Striation in both directions | Undigested |
| Creatorrhea: Abnormal >10 undigested muscle fibers; commonly found on ___________ & ____________ | 1. Biliary obstruction 2. Cystic fibrosis |
| Microscopic examination: >3 neutrophils/hpf = invasive condition | Fecal leukocytes |
| Pathogens that causes diarrhea with WBCs | Salmonella, Shigella, Yersinia, Enteroinvasive E. coli, Campylobacter |
| Pathogens that causes diarrhea w/o WBCs | Toxin producing (S. aureus, V. cholerae), virus, parasites |
| Determination of fecal leukocytes: Stool + Loeffler's methylene blue | Wet preparation |
| Determination of fecal leukocytes: Stool + Wright's or Gram stain | Dried preparation |
| Determination of fecal leukocytes: Lactoferrin found in secondary granules of neutrophils = (+) invasive bacterial pathogen | Lactoferrin latex agglutination test |
| Bristol Stool Chart: Separate hard lumps like nuts (hard to pass) | Type 1 |
| Bristol Stool Chart: Sausage-shaped but lumpy | Type 2 |
| Bristol Stool Chart: Like a sausage but with cracks | Type 3 |
| Bristol Stool Chart: Like a sausage or snake, smooth and soft | Type 4 |
| Bristol Stool Chart: Soft blobs with clear-cut edges (passed easily) | Type 5 |
| Bristol Stool Chart: Fluffy pieces with ragged edges, a mushy stool | Type 6 |
| Bristol Stool Chart: Watery, no solid pieces, entirely liquid | Type 7 |
| What color is normal stool (urobilin/stercobilin)? | Brown, formed |
| What color is upper GI bleeding, iron, charcoal, bismuth, melanoma (rare) in stool? | Black (Melena = denatured) |
| What color is lower GI bleeding, beets, food coloring, rifampin in stool? | Red (Hematochezia = fresh) |
| What color is bile duct obstruction, barium sulfate in stool? | Pale yellow, white, gray (alcoholic) |
| What appearance is bile duct obstruction, pancreatic disorders, steatorrhea in stool? | Bulky/ frothy |
| What appearance is cystic fibrosis (increase mucus) in stool? | Butter-like |
| What appearance is colitis, dysentery, malignancy, constipation in stool? | Mucus-streaked, blood-streaked |
| What appearance is intestinal obstruction or constriction in stool? | Slender, ribbon-/noodle-like |
| What appearance is cholera in stool? | Rice watery |
| What appearance is typhoid in stool? | Pea-soup |
| What appearance is constipation in stool? | Hard/ scybalous (goat droppings) |
| It contains bacteria, cellulose, undigested foodstuff, GI secretions, bile pigments, cells, electrolytes, water. | Feces |
| Around _________ of stool is passed per day | 100-200 g |
| Human feces contains around __ water and __ solids | 75% 25% |
| The odor of feces is due to the presence of | indole and skatole |
| Gastric test: Developed by Squibb. A blue-colored dye azure-A is complexed with an ion-exchange resin. Azure A is released in proportion to free HCL, which is absorbed in the blood and excreted in urine | Diagnex Tubeless test (Diagnex Blue test); the amount of dye excreted in urine is an indicator of gastric HCL secretory activity |
| The specimen of choice of Diagnex blue test | Urine |
| What term is used to define the failure to produce a pH <6.0 following gastric stimulation (pernicious anemia)? | Anacidity |
| What term is used to define the gastric pH >3.5 and does NOT fall after gastric stimulation (no free HCL) (pernicious anemia)? | Achlorhydria |
| What term is used to define the gastric pH >3.5 but FALLS after gastric stimulation (decreased free HCL) (stomach cancer)? | Hypochlorhydria |
| What term is used to define the increased free HCL (ZES, Peptic ulcer)? | Hyperchlorhydria |
| What term is used to define the normal free HCL? | Euchlorhydria |
| What is the volume of a normal (fasting specimen) gastric fluid? | 20-50mL |
| What is the volume of a abnormal (fasting specimen) gastric fluid? | >50mL |
| What is the volume of gastric fluid after Ewald's test meal? | 20-60 mL up to 120 mL |
| What is the volume of gastric fluid after alcohol test meal or histamine stimulation? | 45-150mL |
| What is the color of a normal gastric fluid? | Pale gray, slightly mucoid |
| What is the color of large amounts of bile? | Yellow-green |
| What is the color of small amounts of fresh blood? | Red |
| What is the color of large amounts of blood? | Coffee ground |
| Gastric stimulants: | 1. Test meals 2. Chemical stimulants 3. Sham Feeding (Fictitious feeding) |
| Test meals: Bread, weak tea/water | Ewald's test meals |
| Test meals: Oatmeal | Boa's test meals |
| Test meals: Beef steak & mashed potato (increased acid) | Riegel's test meals |
| Chemical stimulants: | 1. Pentagastrin 2. Insulin 3. Histalog (Betazole) 4. Histamine |
| Chemical stimulant: Most preferred | Pentagastrin |
| Chemical stimulant: To assess vagotomy procedure (surgical division of vagus nerve) | Insulin |
| Normal BAO/MAO ratio | 10% |
| Pernicious BAO/MAO ratio | 0 |
| Duodenal ulcer BAO/MAO ratio | 17% |
| Zollinger-Ellison syndrome BAO/MAO ratio | 72% |
| Method of collection for gastric fluid | Gastric aspiration |
| Gastric tube passed thru the nose | Levin |
| Gastric tube passed thru the mouth | Rehfuss tube |
| Other gastric tube passed thru the mouth | Lavacuator tube, Ewald's tube, Edlich tube |
| The total gastric secretion during unstimulated, fasting state | Basal Acid Output (BAO) |
| BAO duration of collection which consists of four 15 minute specimens, but a single 1-hour can be used | 1 hour collection |
| BAO duration of collection for insulin hypoglycemia test | 1 hour collection |
| The total gastric secretion after gastric stimulation | Maximum Acid Output (MAO) |
| MAO duration of collection (at 15 minutes intervals) - when Pentagastrin and histamine are used | 1 hour collection |
| MAO duration of collection for insulin hypoglycemia test and when histalog is used | 2 hour collection |
| Cells in the stomach that produce HCL and intrinsic factor | Parietal cells |
| Cells in the stomach that produce pepsinogen | Chief cells |
| Cells in the stomach that produce gastrin | Specialized G cells |
| Cells in the stomach that produce mucus that protects the stomach wall from acid | Foveolar cells |
| Presence of anti-parietal cell antibodies and anti-intrinsic factor antibodies causes | Pernicious anemia |
| Presence of non-beta islet cell and adenoma of the pancreas causes | Zollinger-Ellison Syndrome (ZES) |
| It contains concentric striations of collagen-like material and seen in benign conditions and associated with ovarian & thyroid carcinomas | Psammoma bodies |
| What is the color of a normal ascitic fluid? | Clear, pale yellow |
| What is the appearance of ascitic fluid in a microbial infection? | Turbid |
| What is the color of a bile/pancreatic/ gall bladder disorders ascitic fluid? | Green |
| What is the color of a trauma, infection, malignant ascitic fluid? | Blood-streaked |
| What is the appearance of ascitic fluid in a lymphatic trauma and blockage? | Milky |
| What is the wbc count of a normal ascitic fluid? | <500 cells/ul |
| What is the wbc count of bacterial peritonitis, cirrhosis ascitic fluid? | >500 cells/ul |
| What is the wbc is predominant in bacterial peritonitis of ascitic fluid? | Neutrophils |
| What is the wbc is predominant in malignancy of ascitic fluid? | Malignant cells |
| Ascitic fluid test significance: >100,000 RBCs/uL indicates blunt trauma injury (intra-abdominal bleeding) | Peritoneal lavage |
| Ascitic fluid test significance: Malignancy of GI origin | CEA |
| Ascitic fluid test significance: Malignancy of ovarian origin | CA 125 |
| Ascitic fluid test significance: Decrease tubercular peritonitis, malignancy | Glucose |
| Ascitic fluid test significance: Increase pancreatitis, GI perforation | Amylase |
| Ascitic fluid test significance: Increase GI perforation | ALP |
| Ascitic fluid test significance: Ruptured/ punctured bladder | BUN/Creatinine |
| Ascitic fluid test significance: Bacterial peritonitis | Gram stain and culture |
| Ascitic fluid test significance: Tubercular peritonitis | Adenosine deaminase, Acid-fast stain |
| Ascitic fluid test significance: Bacterial infections (M. tuberculosis) | PCR |
| What is the color of a normal, transudate pericardial fluid? | Clear, pale yellow |
| What is the appearance of an infection, malignant pericardial fluid? | Blood-streaked |
| What is the color of a cardiac puncture, anticoagulants pericardial fluid? | Grossly bloody |
| What is the appearance of a chylous and pseudochylous material pericardial fluid? | Milky |
| What is wbc predominant on bacterial endocarditis in pericardial fluid? | Neutrophils |
| What is wbc predominant on metastatic carcinoma in pericardial fluid? | Malignant cells |
| Pericardial fluid test significance: Bacterial endocarditis | Gram stain and culture |
| Pericardial fluid test significance: Tubercular effusion | Acid-fast stain |
| Pericardial fluid test significance: Tubercular effusion | Adenosine deaminase (ADA) |
| Pericardial fluid test significance: Metastatic carcinoma | CEA |
| Tumor marker for effusions significance: Colon cancer | CEA |
| Tumor marker for effusions significance: Ovarian/ metastatic uterine cancer | CA-125 |
| Tumor marker for effusions significance: Breast cancer | CA 15-3, CA 549 |
| Tumor marker for effusions significance: Lung cancer, breast cancer, urinary bladder cancer | CYFRA 21-1 (CYtokeratin FRAgment) |
| Pleural fluid test significance: Decreased rheumatoid inflammation, purulent infection | Glucose |
| Pleural fluid test significance: Increase bacterial infection | Lactate |
| Pleural fluid test significance: Increase chylous effusions | Triglyceride |
| Pleural fluid test significance: Decrease pneumonia not responding to antibiotics, decrease esophageal rupture, decrease complicated parapneumonic effusion (loculated/associated w/ empyema) | pH |
| Pleural fluid test significance: Malignancy, tuberculosis (>40u/L) | Adenosine deaminase (ADA) |
| Pleural fluid test significance: Increase pancreatitis, esophageal rupture, malignancy | Amylase |
| Pleural fluid test significance: M. tuberculosis | PCR |
| What cell is predominant in pneumonia, pancreatitis, pulmonary infarction? | Neutrophils |
| What cell is predominant in pneumothorax, hemothorax, allergic reactions, parasitic infections? | Eosinophils |
| What cell is predominant in TB, viral infection, autoimmune disorders, malignancy, sarcoidosis? | Lymphocytes |
| What cell is predominant in normal and reactive forms have no significance (decreased in TB)? | Mesothelial cells (lines serous membranes) |
| What cell is predominant in tuberculosis? | Plasma cells |
| What cell is predominant in primary adenocarcinoma, small cell carcinoma, and metastatic cancer? | Malignant cells |
| Distribution of bloody pleural fluid is uneven. | Hemothorax |
| Distribution of bloody pleural fluid is even. | Hemorrhagic effusion |
| Hematocrit of bloody pleural fluid is >1/2 of whole blood hematocrit | Hemothorax |
| Hematocrit of bloody pleural fluid is <1/2 of whole blood hematocrit | Hemorrhagic effusion |
| This milky pleural fluid is caused by thoracic duct leakage. | Chylous effusion |
| This milky pleural fluid is caused by chronic inflammation. | Pseudochylous effusion |
| What is the appearance of a chylous effusion? | milky/ white |
| What is the appearance of a pseudochylous effusion? | milky/ green tinge/ gold paint |
| What is the predominant wbc in chylous effusion? | Lymphocytes |
| What is the predominant wbc in pseudochylous effusion? | Mixed cells |
| Cholesterol crystals in chylous effusion is ____ | Absent |
| Cholesterol crystals in pseudochylous effusion is _____ | Present |
| A milky pleural fluid that has >110 mg/dL of triglycerides | Chylous effusion |
| A milky pleural fluid that has <50 mg/dL of triglycerides | Pseudochylous effusion |
| Sudan III staining of chylous effusion | (+++) |
| Sudan III staining of pseudochylous effusion | (-/ weakly +) |
| What is the color of normal pleural fluid? | Clear, pale yellow |
| What is the appearance of a microbial infection in pleural fluid? | Turbid, white |
| What is the color of a rupture of amoebic liver abscess in pleural fluid? | Brown |
| What is the color of an aspergillosis in pleural fluid? | Black |
| What is the appearance of malignant mesothelioma (increase hyaluronic acid) in pleural fluid? | Viscous |
| What is the appearance of chylous material, pseudochylous material in pleural fluid? | Milky |
| What is the appearance of hemothorax, hemorrhagic effusion in pleural fluid? | Bloody |
| Method of collection of pleural fluid (<30ml) | Thoracentesis |
| Method of collection of pericardial fluid (<50ml) | Pericardiocentesis |
| Method of collection of peritoneal (ascitic fluid) (<100ml) | Paracentesis |
| Collection of 3P's (pleural, pericardial, peritoneal): EDTA | Cell counts and differential |
| Collection of 3P's (pleural, pericardial, peritoneal): Sterile heparin or SPS | Microbiology and cytology |
| Collection of 3P's (pleural, pericardial, peritoneal): Plain/heparin tubes | Chemistry (for pH testing, maintain samples anaerobically in ice) |
| Fluid total protein of transudate | <3.0 g/dL |
| Fluid total protein of exudate | >3.0 g/dL |
| Fluid:Serum protein ratio of transudate | <0.5 |
| Fluid:Serum protein ratio of exudate | >0.5 |
| Fluid:Serum LD ratio of transudate | <0.6 |
| Fluid:Serum LD ratio of exudate | >0.6 |
| Pleural fluid cholesterol (mg/dL) of transudate | <45-60 |
| Pleural fluid cholesterol (mg/dL) of exudate | >45-60 |
| Serum-ascites albumin gradient (SAAG) of transudate | >1.1 |
| Serum-ascites albumin gradient (SAAG) of exudate | <1.1 |
| Glucose of transudate | Equal to serum |
| Glucose of exudate | < serum level |
| Rivalta's test of transudate | negative |
| Rivalta's test of exudate | positive |
| Effusion test: Acetic acid + Water + Unknown fluid -> Heavy precipitation = Exudate | Rivalta's (Serosamucin clot) test |
| Effusion test: Recommended to detect transudates of hepatic origin. SAAG = Serum albumin - Peritoneal fluid albumin | Serum-Ascites Albumin Gradient (SAAG) |
| Fluid between parietal and visceral membranes. To provide lubrication between 2 membranes as surfaces move against each other | Serous fluid |
| Accumulation of fluid between the membranes. Classified as exudate or transudate | Effusion |
| Disruption of fluid production and regulation between membranes. Change in hydrostatic and oncotic pressure | Transudate |
| Examples of transudates | Hypoproteinemia Congestive heart failure Nephrotic syndrome |
| Direct damage to the membrane of a particular cavity | Exudate |
| Examples of exudates | Infection Inflammation Malignancy |
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