Stool AnalysisStool AnalysisWhat is the stool or feces?

5. Epithelial cells that have been shade

1. Waste residue of indigestible material (cellulose during the previous 4 days) 2. Bile pigments and salts

3. Intestinal secretions, including mucus 4. Leukocytes that migrate from the bloodstream 6. Bacteria and Inorganic material(10-20%) chiefly calcium and phosphates. Undigested and unabsorbed food.

Random CollectionRandom Collection1. Universal precaution2. Collect stool in a dry,clean

container3. uncontaminated with urine or other

body secretions, such as menstrual blood

4. Collect the stool with a clean tongue blade or similar object.

5. Deliver immediately after collection

Ova and parasites Ova and parasites collectioncollection

1. Warm stools are best for detecting ova or parasites. Do not refrigerate specimen for ova or parasites.

2. If the stool should be collect in 10 % formalin or PVA fixative, storage temperature is not critical.

3. Because of the cyclic life cycle of parasites, three separate random stool specimens are recommended.

Enteric pathogen Enteric pathogen collectioncollection1. Some coliform bacilli produce antibiotic

substances that destroy enteric pathogen.Refrigerate specimen immediately.

2. A diarrheal stool will usually give accurate results.

3. A freshly passed stool is the specimen of choice.

4. Stool specimen should be collected before antibiotic therapy, or as early in the course of the disease.

5. If blood or mucous is present, it should be included in the specimen

Interfering factors1. Patients receiving tetracyclines, anti-

diarrheal drugs, barium, bismuth, oil, iron , or magnesium may not yield accurate results.

2. Bismuth found in toilet tissue interferes with the results.

3. Do not collect stool from the toilet bowl.A clean, dry bedpan is the best.

4. Lifestyle, personal habbits, environments may interfere with proper sample procurement.

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Normal values in Normal values in stool Analysisstool AnalysisMacroscopic examination Macroscopic examination

Normal valueNormal valueAmount 100-200 g / dayColour BrownOdour Varies with pH of stool and depend on bact-

erial fermentationConsistency Plastic, not unusual to see fiber, vegetable skins.Size and shape FormedGross blood,Mucous,Pus, Parasites None

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Normal values in Normal values in stool analysisstool analysis

Microscopic examination Microscopic examination Normal valuesNormal values

Fat (Colorless, neutral fat (18%)and fatty acid crystals and soaps)Undigested food None to small amountMeat fibers, Starch, TrypsinNoneEggs and segments of parasites

NoneYeasts NoneLeukocytes None

Normal values in Normal values in stool analysisstool analysisChemical examinationChemical examination Normal Normal

valuesvaluesWater Up to 75 %pH 6.5-7.5Occult blood NegativeUrobilinogen 50-300 g/24hrPorphyrins Coporphyrins:400-1200g/24hr

Uroporphyrins:10-40 mg/24hrNitrogen <2.5 g/24hr

Normal values in Normal values in stool analysisstool analysisChemical examinationChemical examination Normal Normal

valuesvaluesBile Negative in adults:positive in childrenTrypsin 20-950 units/g( positive in small amounts

in adults; present in greater amounts in normal children.Osmolarity used 200-250 mOsm with serum osmol-arity to calculate osmotic gapSodium 5.8-9.8 mEq / 24hr

Normal values in Normal values in stool analysisstool analysisChemical examinationChemical examination

Normal valuesNormal valuesChloride 2.5-3.9 mEq / 24 hrPotassium 15.7-20.7 mEq /24 hrLipids ( fatty acid) 0-6 g / 24 hr

Clinical Clinical ImplicationsImplications1.1. Fecal consistency may be altered in Fecal consistency may be altered in

various disease statesvarious disease statesa. Diarrhea mixed with mucous and red

blood cells is associated with

1. Typhus 2. Typhoid 3. Cholera

4. Amebiasis 5. Large bowel cancer

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อมบีาฝังตัวในลำาไส้มะเรง็ทางเดินอาหารขนาดใหญ่

Clinical Clinical ImplicationsImplications

b. Diarrhea mixed with mucus and white blood cells is associated with

1. Ulcerative colitis 2. Regional enteritis

3. Shigellosis 4. Salmonellosis

5. Intestinal tuberculosisวณัโรคลงทางเดินอาหาร / ฝีในท้อง

โรคทางเดินอาการอักเสบประจำาถ่ินแผลในโคลอน (ขอบเรยีบ)

Clinical Clinical ImplicationsImplications

C. ”Pasty” stool is associated with a high fat content in the stool:

1. A significant increase of fat is usually detected on gross examination2. With common bile duct obstruction, the fat gives the stool a putty- like appearance.3. In cystic fibrosis, the increase of neutral fat gives a greasy, “butter stool” appearance.

มพีงัผืดเกิดขึ�นในถงุนำ�าดี

Stool OdorStool OdorNormal value Varies with pH of

stool and diet. Indole and sketole are the substances that

produce normal odor formed by intestinal bacteria putrefaction and fermentation.

Clinical implication.1. A foul odor is caused by degradation

of undigested protein.2. A foul odor is produced by excessive

carbohydrate ingestion.3. A sickly sweet odor is produced by

volatile fatty acids and undigested lactose

Stool pHStool pHNormal value : Neutral to acid or alkalineClinical implication1. Increased pH ( alkaline)

a. protein break down b. Villous adenoma

c.Colitis d.Antibiotic use2. Decreased pH ( acid)

a. Carbohydrate malabsorptionb. Fat malabsorptionc. Disaccharidase deficiency

มกีารหมกัคารโ์บไฮเดรตโดยแบคทีเรยีได้กรดแลกติก

มกีารยอ่ยไขมนั หมกักรดไขมนัได้กรดคีโตนส์ทำานองเดียวกับคารบ์มาลแอบสอรบ์

สลายโปรตีนมากๆ จะมยูีเรยีและแอมโมเนียทำาใหเ้ป็นด่าง

มะเรง็ต่อมเมอืกท่ีวลิไลทางเดินอาหารสว่นปลายอักเสบ

Stool colorStool colorNormal value : BrownClinical implication:1. Yellow to yellow-green : severe diarrhea2. Green : severe diarrhea เขยีวเพราะนำ�าดีดดูกลับไมทั่น ไมม่เีวลาใหแ้บคทีเรยียอ่ย bile

Black: resulting from bleeding into the upper gastrointestinal tract (>100 ml blood) การท่ีมเีลือดออกในทางเดินอาหารสว่นบนเหล็กจะถกูกรดออกซไิดซไ์ด้สดีำา3. Tan or Clay colored : blockage of the common bile duct.4. Pale greasy acholic (no bile secretion) stool found in pancreatic insufficiency.

การบลอกทำาใหไ้มม่นีำ�าดี สอึีเลยไมม่สีี

แสดงถึงการท่ีไขมนัไมถ่กูยอ่ย

Stool color(con)4. Maroon-to-red-to-pink : possible result of bleeding from the lower gastrointestinal tract (eg. Tumors, hemorrhoids, fissures,inflammatory process)5. Blood streak on the outer surface of usually indicates hemorrhoids or anal abnormalities.6. Blood in stool can arise from abnormalities higher in the colon. In some case the transit time is rapid blood from stomach or duodenum can appear as bright or dark red or maroon in stool.

เนื�องอก , รดิสดีวง , รอ่งตดูแหก , มกีารอักเสบ

รดิสดีวง , รูก้นผิดปกติ

Blood in StoolBlood in StoolNormal value : NegativeClinical Implication :1. Dark red to tarry black indicates a loss of 0.50 to 0.75 ml of blood from the upper GI tract. 2. Positive for occult blood may be caused by

a. Carcinoma of colon b. Ulcerative colitis

c. Adenoma d. Diaphramatic hernia

e. Gastric carcinoma f. Diverticulitis

g. Ulcers

มะเรง็ของโคลอน แผลขอบเรยีบท่ีโคลอนใสเ้ล่ือนท่ีกระบงัลม

มะเรง็กระเพาะอาการ ลำาไสพ้นักันทำาใหเ้น่าตาย

Mucous in StoolMucous in StoolNormal value : Negative for mucousClinical Implication:1. Translucent gelatinous mucous clinging to the surface of formed stool occurs in

a. Spastic constipation b. Mucous colitis

c. Emotionally disturbed patientsd. Excessive straining at stool

2. Bloody mucous clinging to the surface suggests

a. Neoplasm b. Inflammation of the rectal canal

เบง่แรงๆ เมอืกจากการอักเสบอารมย์

เก็บอึนานไป ไมช่อบถ่าย

เนื�องอก ภาวะอักเสบท่ีไสต้รง

Mucous in Stool Mucous in Stool (con)(con)

3. Mucous with pus and blood is associated witha. Ulcerative colitis b. Bacilliary dysentery

c. Ulcerating cancer of colon d. Acute diverticulitis

e. Intestinal tuberculosis

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แผลท่ีเกิดจากมะเรง็โคลอน ลำาไสพ้นักันเฉียบพลัน

Fat in StoolFat in StoolNormal value : fat in stool will account for up to 20 % of total solids. Lipids are measured as fatty acids (0-6.0 g/24hr) Clinical Implication :

1. Increased fat or fatty acids is associated with the malabsorption syndromes

a. Nontropical sprue b. Crohn’s disease

c. Whipple’s disease d. Cystic fibrosis

e. Enteritis and pancreatic diseasesf. Surgical removal of a section of the

intestine

ลำาไสตี้บตันเนื่องจากผนังหนาขึ�นและมเียื่อมเีซนทรมีากขึ�น

Urobilinogen in StoolUrobilinogen in StoolNormal value : 125-400 Ehrlich units / 24

hr 75-350 Ehrlich units/100 g

Clinical Implication:1. Increased values are associated with

Hemolytic anemias2. Decreased values are associated with

a. Complete biliary obstructionb. Severe liver disease, infectious hepatitisc. Oral antibiotic therapy that alters intestinal bacteria florad. Infants are negative up to 6 months of age

Bile in StoolBile in StoolNormal value : Adults –negative

: Children may be positiveClinical ImplicationClinical Implication:1. Bile may be present in diarrheal stools.2. Increased bile levels occur in Hemolytic anemia

Trypsin in StoolTrypsin in StoolNormal value : Positive in small amounts

in 95 % of normal persons.Clinical Implication : Decreased amounts

occur ina. Pancreatic deficiencyb. Malabsorption syndromesc. Screen for cystic fibrosis

Leukocytes in StoolLeukocytes in StoolNormal value : Negative Clinical Implication1. Large amounts of leukocytes

a. Chronic ulcerative colitis b. Chronic bacilliary dysenteryc. Localized abscessd. Fistulas of sigmoid rectum or anus

2. Mononuclear leukocytes appear in Typhoid

ลำาไสก้ลืนกันบรเิวณซฺกมอยด์โคลอน หรอืท่ีทวาร

มฝีีหนอง

แผลลำาไสอั้กเสบเรื�อรงั ท้องเสยีเรื�อรงัจากการติดแบซไิล

Leukocytes in Stool (con)Leukocytes in Stool (con)3. Polymorphonuclear leukocytes appear in

a. Shigellosis b. Salmonellosisc. Yersinia d. Invasive Escherichia coli diarrheae. Ulcerative colitis

4. Absence of leukocytes is associated witha. Cholera b. Non specific diarrhea c. Viral diarrhea d. Amebic colitise. Noninvasive E.coli diarrhea f. Toxigenic bacteria Staphylococci spp., Clostidium Cholera

g. Parasites-Giardia,

Porphyrins in StoolPorphyrins in StoolNormal value : Coproporphyrin 400-1200 g / 24hr

Urophorphyrin 10-40 g / 24 hr. These values vary from Lab to Lab.

Clinical Implication:1. Increased fecal coproporphyrin is

associated with a. Coproporphyria (hereditary)b. Porphyria variegata c. Protoporphyria d. Hemolytic anemia

2. Increased fecal protoporphyrin is associated with a. Porphyria veriegata b. Protoporphyriac. Acquired liver disease

Stool ElectrolytesStool ElectrolytesNormal values : Sodium 5.8-9.8

mEq / 24 hr Chloride 2.5-3.9 mEq /

24 hr Potassium 15.7-20.7

mEq /24 hrClinical Implication :

1. Idiopathic proctocolitis Sodium and Chloride Normal Potassium

2. Cholera Sodium and Chloride