sputum, sweat, gastric fluid
DESCRIPTION
AUBTRANSCRIPT
2/25/2013
1
Miscellaneous Body Fluids:
Sputum, Sweat, Gastric Fluid
Erika Gayle M. Lipana, RMT
SPUTUM
• Secretion of the goblet cells (lining the respiratory tract)
• No goblet cells in the alveoli • DUST CELLS oHallmark of sputum oMacrophages with carbon deposits
SPUTUM:
How to induce release?
1. Use of nebulized saline or distilled water 2. Chest percussion 3. Postural drainage 4. Aerosolized 15% NaCl and 10% glycerin
SPUTUM: Preservation
1. Refrigeration 2. Use of 10% formaldehyde (cannot
be used for bacteriologic purpose because of its bacteriostatic effect)
SPUTUM COLLECTION
FIRST MORNING SPECIMEN is the
BEST!
SPUTUM COLLECTION:
Obtaining a sputum sample • Mouth should be free from
foreign objects 1. Remove food. Gum or tobacco 2. Remove dentures 3. Gargle prior to collection
• Early morning specimen is the best
• Induce sputum if necessary 1. Nebulized hypertonic saline or distilled
water 2. Chest percussion 3. Postural damage
• Cough into sterile cup
Patient should be
instructed to cough up the
sputum which is then
collected in clean, sterile,
wide mouth bottle or
disposable plastic
containers. NEVER USE
PAPER CUPS!
2/25/2013
2
SPECIMEN COLLECTION: Special Circumstances
• Tuberculosis is suspected 1. Sputum collected in negative pressure
room
2. Early morning gastric aspirate 3. Bronchoscopy with bronchial lavage 4. 3 day successive collection (morning
sample only)
• Anaerobic culture specimen 1. Tracheal aspiration 2. Thoracentesis (insertion of a hollow needle
into the pleural cavity through the chest wall in order to withdraw fluid, blood pus, or air)
3. Direct lung puncture
• Viral culture specimens 1. Patient gargles and expectorates with
nutrient broth 2. Nasopharyngeal swab transported in viral
medium
SPECIMEN COLLECTION: Special Circumstances
• Fixation of sputum for cytology (prevents air drying) 1. Patient expectorates into a jar of 70% ethanol 2. Spread fresh sputum on slide and spray pap’s fixative
• Culture specimen transport to laboratory 1. Sputum gram stain assesses the sample for adequacy. 2. Anaerobic culture transported in an air tight container (should be
immediately for immediate plating) I. Bring to laboratory as quickly as possible II. Refrigerate sample if transport is delayed III. Consider washing specimen of oral flora
i. Rinse several times with saline ii. Discard supernatant (non-viscous saliva)
3. Aerobic culture specimen 4. Tuberculosis culture (maybe stored at room temperature for up to
48 hours)
SPECIMEN COLLECTION:
Preparation of sputum for laboratory examination
SPUTUM: Physical Characteristic
• QUANTITY o Very few in amount
or NOTHING AT ALL!
• CONSISTENCY o Watery (sialic acid is responsible for
sputum’s viscosity) o Blood-gelatinous sputum (Currant-
Jelly) • Klebsiella pneumoniae infection • Pneumococcal pneumonia
o Stringy Mucoid Sputum (may also appear frothy)
• Follows asthma exacerbation o Cloudy, mucoid sputum
• Chronic bronchitis o Three layered appearance
(stagnant, purulent sputum) • Bronchiectasis • Lung abscess
SPUTUM: Physical Characteristic
• Reaction o Slightly acidic o pH 6.5-7.0
• Turbidity o Frothy sputum or serous (air bubble, hemoglobin)
• Pulmonary eddema o Mucoid
• Bronchiectasis
• TB with cavities
o Foamy, clear materials • Saliva • Nasal secretions
SPUTUM: Physical Characteristic
2/25/2013
3
• Odor o Normally: ODORLESS o Abnormally:
• Sweetish o In pulmonary tuberculosis with cavities, bronchiectasis,
bronchomoniliasis • Putrid or foul
o Usually due to Fusobacteria & Spirochetes found in mouth, or anaerobic infections within the lung, lung abscess and necrotizing bronchogenic carcinoma
• Cheesy odor o In necrosis or malignant tumors and perforating
emphysema • Fecal Odor
o Rupture sunphrenic or liver abscess and in enteric gram negative products.
SPUTUM: Physical Characteristic
• COLOR Normally, the color is greatly influenced by pus, as well as nature of the disease and the sputum itself.
o Colorless or transluscent or opaque • When made of mucus only
o White or yellow • When pus is present, seen in advance pulmonary
tuberculosis, chronic bronchitis, jaundice and lobar pneumonia
o Gray • When pus and epithelial cells are present
o Bright green or greenish • When bile is present as in jaundice, rupture of the liver
abscess into the lungs and infection caused by Pseudomonas aeruginosa
SPUTUM: Physical Characteristic
• COLOR o Red or bright red
• When there is fresh blood or new hemorrhage. If blood streaks are present, it is indicative of pulmonary tuberculosis or bronchiectasis
o Anchovy sauce or rusty brown • When old blood is present, seen in pneumonia, pulmonary
gangrene, rupture of amoebic abscess of the liver into the lung or pigmented cells in chronic passive congestion, due to cardiac pigment after hemorrhage from the lung pulmonary infarction.
o Prune-juice • Pneumonia and chronic cancer of the lungs
o Rusty red • Lobar pneumonia
SPUTUM: Physical Characteristic
• COLOR o Olive green or grass green
• Cancer
o Black • Indicates inhalation of dust or dirt, carbon, charcoal, in cases like anthracosis and heavy smokers.
o Yellow green
• Due to destruction of neutrophils and release of verdo peroxidase
SPUTUM: Physical Characteristic
• Cheesy masses o Fragments of necrotic tissue,
pulmonary tissue or bits cartilaginous rings, from pin-point to pin size.
o Present in so-called nummular sputum from a tuberculosis cavity, pulmonary gangrene, abscess of the lungs and actinomyccosis.
• Curschmann’s spiral o Seen in bronchial asthma o Yellowish-white, spirally twisted
mucoid strands
SPUTUM: Macroscopic Structures
• Bronchial cast o These are branching
tree-like casts of the bronci, seen in lobar pneumonia, fibrinous bronchitis and diphtheria
• Dittrich’s bodies o Yellow of gray caseous
masses, seen in asthma, putrid bronchitis
o Pinhead o Emits a foul odor when
crushed
SPUTUM: Macroscopic Structures
2/25/2013
4
• Lung stone o Bronchioliths or pneumoliths o Small calcified nodules or stagnant
contents of cavities or dilated bronchi or calcified tuberculosis tissue. Sometimes the core is a small foreign body or a fungal growth.
• Foreign bodies o Include concretions formed in the
bronchi made of calcium carbonate and phosphate and aspirated substances such as: pollen, seeds, dust
• Parasites o Echinococcus granulosus, Toxaplasma
canis, paragonimus westermanii
SPUTUM: Macroscopic Structures
Must be treated first with KOH or NaOH to dissolve the mucus. • Elastic fibers
o Normally present in the walls of the alveoli, bronchioles and the blood vessels
• Curschmann’s spiral o Yellow, wavy threads o Usually coiled into balls,
seen in bright colorless wit central lines.
SPUTUM: Microscopic Examination
• Crystals o Indicates stasis and decomposition of the sputum in the
body or in a n old specimen that is often unsatisfactory
• Charcot Leyden crystals
o Seen in bronchial asthma, arises from the disintegration of eosinophil
o Stains black in hematoxylin and red with eosin o Often octahedral and/or hexagonal in shape
• Hematoidin
o Rhombic and brownish red o Arranged in rosettes o Resulted down from breaking down of old blood
and are found in pulmonary infections, lung abscess, pulmonary infarction
SPUTUM: Microscopic Examination
SPUTUM: Microscopic Examination
• Crystals o Cholesterol crystals
• Colorless, thin, rhombic plates with notched corner. This indicates stasis with fatty degeneration of exudates and are often in lung abscess and emphysema
o Fatty acid crystal • Long, colorless needles,
arranged in seeves. • Also indicates stasis with
fatty degeneration of exudates and are often in lung abscess and emphysema
SPUTUM: Microscopic Examination
• Heart failure cell o Blood pigmented cells, chiefly
hemosiderin o Appears as round grayish or
colorless o Diffuse staining o Found in congestive heart failure
• Carbon-Laden crystals o Contain carbon and are less
important o Appears as angular black
granules both intracellular and extracellular
o Seen in anthracosis, heavy tobacco smokers and in people living in smoky atmosphere
SPUTUM: Microscopic Examination
2/25/2013
5
• Myelin globules o With little or no clinical significance o Colorless, round, oval or ear-shaped globules of various
sizes
o Reported in order to minimize confusions with more important structures like Blastomyces.
o Resembles fat droplets and yeast-like fungi o Large structures show peculiar concentric or irregular
spiral markings o Abundant in the scanty morning sputum of health persons
and may be found in closely packed sputum o Absent or scarce in specimens with inflammatory exudates.
SPUTUM: Microscopic Examination
• Actinomyces hominis o Small and yellowish structures
with sulphur granules which can be seen with unaided eye
o Similar structure with Actinomyces bovis under LPO
o consist of a network of threads having more or less radial arrangement
o Seen better by running small amount of eosin in alcohol solution and glycerin under the cover glass
o Seen in Actinomycotic pulmonary infection
SPUTUM: Microscopic Examination
• Moulds and yeasts o Hyphae are rods usually jointed
or branched and often arranged in meshwork (mycelium)
o Spores are highly refractive spheres and ovoid
o Seen in pneumomycosis specifically infection by Aspergillus fumigatus
o Grows in sputum upon long standing of tuberculosis specimen
• Creola Bodies o Cluster of ciliated columnar cells
found in the sputum of asthmatic patients.
SPUTUM: Microscopic Examination
• Blood Cells o Leukocyte
• Major blood present in sputum • Markedly increased when pus is
present • Eosinophil are commonly seen in
allergic patients (asthma) and can be demonstrated by Wright’s stain
o Erythrocytes • Present in lung hemorrhage,
pulmonary tuberculosis, and Paragonimus westermanii infection
• Detected by Guaiac or benzidine tests or presence of blood derivatives such as hemosiderin
SPUTUM: Microscopic Examination
SWEAT • The common eccrine glands function in
the regulation of the body temperature. They are innervated by cholinergic nerve and are a type of exocrine gland. Sweat has been analyzed for its multiple inorganic and organic contents, but with one notable exception, has not proven a clinically useful model. The exception is the analysis of sweat for chloride and sodium levels in the diagnosis of CYSTIC FIBROSIS
CYSTIC FIBROSIS • Also known as mucoviscidosis • An autosomal, recessive inherited disease that
affects the exocrine glands and causes electrolyte and mucous abnormalities
2/25/2013
6
CYSTIC FIBROSIS Methods/ Diagnosis • Pilocarpine NitrateIontophoresis by Gibson and
Cooke
Principle: Pilocarpine is introduced into skin by iontophoresis to stimulate locally increased sweat gland secretion. The resulting sweat is absorbed by filter paper or gauze, diluted with water and analyzed for sodium and chloride determination
METHODS/ DIAGNOSIS:
Pilocarpine NitrateIontophoresis by Gibson and Cooke
• Site of Iontophoresis o Sweat should only be collected
from the arms or legs o The area for stimulation must
be free from skin lesion o The skin should be cleaned with
distilled water, washed followed by drying with paper tissue
• Gauze pad o Place a weighed gauze pad on patient’s back overnight, that pad is
sealed tightly to prevent evaporation and removed in the morning. The pad is then weighed, diluted with water and analyzed for sodium and chloride
• Macro duct collection COLOR
Methods/ Diagnosis
Brown Ochronosis
Red Rifampin overdose
Blue Occupation exposure to copper
Blue-black Idiopathic Chronhidrosis
Sodium • It should approximate the chloride concentration,
so it is measured to provide better quality control
* Discrepancies for sodium and chloride is influenced by air bubbles (decrease concentration) and temperature fluctuations
Electrolytes • Use the osmometer method for measuring sweat
electrolytes provides a means for evaluation of young infants without subjecting them to the Rigos traditional sweat collection method
• The test should be performed on infants older than 8 days because newborn infants consistently have high electrolyte concentrations
• Because the sweat osmolarity is measured on an undiluted sample, cre must be taken to include the water that condences on the plastic cover or values will be falsely elevated
2/25/2013
7
Electrolytes
Reference Ranges:
SODIUM CHLORIDE
Normal < 70 mEq/L < 50 mEq/L
Abnormal > 90 mEq/L > 60 mEq/L
Equivocal 70-90 mEq/L 50-60 mEq/L
Electrolytes Test for Sweat Chloride AgNO3 Method Cotlove Chloridometer Test Results: Adults generally have higher sodium and chloride concentrations in their sweat than children. Also, sweat test results in adults can vary widely. This is especially true in women, because the amount of salt in their sweat can vary with the phase of their menstrual cycle. Enough sweat must be collected to get accurate results. Normal values may vary from lab to lab. Sweat chloride must be measured to diagnose cystic fibrosis. Some labs also measure sodium. Normal and abnormal sweat sodium values vary slightly from sweat chloride values.
GASTRIC JUICE Composition: 99% H2O, 1% solid • 0.2-0.4% HCl
o production by the parietal cells (oxyntic cells); for the activation of Pepsinogen
• Gastrin o Hormone stimulating secretion of HCl
• Zollinger-Ellison o High secretion of gastrin due to gastrin-secreting
tumor oxygenating from the pancreas
• Digestive enzymes o Produced by the chief cells (Zymogen or peptic cells)
• Pepsin (protein)
• Lipase (fats) • Rennin (to curdle milk)
Composition:
• Electrolytes o H+ (1 million times greater than blood) o Na, Cl, Mg, Ca, Fe
• Mucin o From the goblet or mucous cells to prevent autodigestion of
the stomach
• Intrinsic factor of Castle o For the absorption of Vitamin B12 to prevent Pernicious
Anemia
Collection o Intubation (fasting patient) o Ewald’s or Boa’s Method (best evacuated tube)
GASTRIC JUICE
GASTRIC JUICE: Commonly Used Stimulants
• Pentagastrin o Stimulant of choice o Synthetic compound resembling gastrin
o Produce more rapid response o No discomfort o Specimens are collected at 15 minutes interval for 1 hour
following the administration
• Histalog o When used, collection must continue for 2 hours because
maximum output is delayed
• Histamine TUBELESS METHOD
o Diagnex blue test o Patient is given an Azure A dye
Gastric Juice: Physical Characteristics
Quantity 20-50 mL
Color Grayish or bile-stained; colorless
Odor Sloightly sour or odorless
Reaction Acidic (pH 1.6-1.8)
Specific Gravity 1.001- 1.010
Consistency Watery
Mucus Small amount
Sediment Normally non
2/25/2013
8
Gastric Juice: Chemical Characteristics
1˚ acidity = 0.00365% HCl
• Free HCl o 25˚-50˚ or 20-40 mEq/L o Tests:
• Topfer’s • Boa’s • Gunzberg
• Total acidity o 50˚-75˚
o Composed of free HCl, combined HCl, acid salts and organic acids like lactic acid, butyric acid and amino acids
o Tests: • Topfer’s • Phenolpthalein
• Combined HCl (Acid-metaprotein) o N.V. = 10-15˚
o Composed of HCl which combines loosely with the protein in the absence of free HCl
• Lactic acid o Normally absent o Indicates advanced gastric cancer o Maybe found in the stomach from the fermentation of CHO
or from the production of lactic acid-forming bacteria like Boas-oppler bacilli
• Occult blood o Normally none o Seen in peptic ulcers and gastric carcinoma
Gastric Juice: Chemical Characteristics
• Bile o Small amount
• Renin o Absence indicates organic disease o Tests:
• Reitman • Riegel
• Pepsin o Absence indicates organic disease o Tests:
• Bauer • Hammerschlag
Gastric Juice: Chemical Characteristics
Definition of Terms • Euchlorhydria
o Normal acidity
• Hyperchlorhydria o Increased free HCl around 60˚
o Seen in: Peptic ulcers like duodenal and gastric ulcers
• Hypochlorhydria o Decreased free HCl o Seen in: Gastric syphilis, Gastric cancer, Chronic gastritis
• Achlorhydria o Absence of free HCl o Seen in: Pernicious Anemia, Gastric cancer, pellagra
• Achylia gastrica o Absence of HCl and renin in gastric juice
• Anacidity o Inability to produce a pH less than 6.0 following gastric stimulation