URINALYSIS & BODY FLUIDS (HLD 22403)

PLEURAL , PERICARDIAL AND PERITONEAL ANALYSIS

By Mr. Hanan

PLEURAL FLUID ANALYSISPLEURAL FLUID ANALYSIS

Routine examination of Pleural fluid.Routine examination of Pleural fluid.

• Physical examinationPhysical examination

• Chemical examinationChemical examination

• Immunological examinationImmunological examination

• Cytological examinationCytological examination

• Specimen collection ProceduresSpecimen collection Procedures

Introduction

• Pleural fluid is obtained from the pleural cavity, located between the parietal pleural membrane lining the chest wall and the visceral pleural membrane covering the lung.

• Pleural effusions may be transudative or exudative.

Transudates & Exudates

• Exudates are fluids, cells, or other cellular substances that are slowly discharged from blood vessels usually from inflamed tissues.

• Transudates are fluids that pass through a membrane or squeeze through tissue or into the extracellular space of tissues. Transudates are thin and watery and contain few cells or proteins.

Differences Between Transudate & Differences Between Transudate & ExudateExudate

Characteristics TransudateCharacteristics Transudate

• Transudate - Transudate - Clear,Straw – yellow Clear,Straw – yellow

• Sp gravity :< 1.018 Sp gravity :< 1.018

• Protein :< 2g/dl Protein :< 2g/dl

• Inflammatory cells :Low Count Inflammatory cells :Low Count

EXUDATEEXUDATE

• Appearance: Appearance: cloudy may be clottedcloudy may be clotted

• Color: yellow to redColor: yellow to red

• Sp gravity :> 1.018Sp gravity :> 1.018

• Protein:> 2G/DLProtein:> 2G/DL

• Inflammatory cells: High countInflammatory cells: High count

Specimen Collection

Specimen Collection

• Fluids for laboratory diagnosis are collected by needle aspiration.

• EDTA tube is used for cell counts and the differential.

• Sterile heparinzed evacuated tubes are used for microbiological and cytology.

• Chemistry test can be run on clotted specimen in plain tube or on heparinized tubes .

Specimen Collection

Physical ExaminationPhysical Examination

• Volume: Measure and record the volume Volume: Measure and record the volume of fluid received.of fluid received.

• Appearance, color, clot formation: Appearance, color, clot formation:

• Note color whether clear or cloudy, or Note color whether clear or cloudy, or whether clot is formed on standing whether clot is formed on standing

Chemical ExaminationChemical Examination

• Chemical test that are performed are Chemical test that are performed are usually compared with plasma chemical usually compared with plasma chemical concentrations because the fluids are concentrations because the fluids are plasma filtrates. Therefore blood specimen plasma filtrates. Therefore blood specimen are usually obtained at the time of are usually obtained at the time of collection.collection.

• Protein estimationProtein estimation

• Glucose estimationGlucose estimation

NEUBAUER COUNTING NEUBAUER COUNTING CHAMBERCHAMBER

Count in the four cornersCount in the four corners

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Count in the four cornersCount in the four corners

Cells in one corner squareCells in one corner square

MESOTHELIAL CELLSMESOTHELIAL CELLS

BENIGN MESOTHELIAL BENIGN MESOTHELIAL CELLSCELLS

FOAMY MACROPHAGESFOAMY MACROPHAGES

INFLAMMATORY PLEURAL INFLAMMATORY PLEURAL FLUIDFLUID

Microbiology Examination

• Microorganism that area usually associated with pleural effusions are

• Staphylococus aureus , Enterobacteriaceae, Mycobacterium tuberculosis.

• Gram stain, cultures (both areobic and anerobic) acid fast and mycobacteria cultures are performed. Serological testing of pleura fluid is used to differentiate effusions of immunologic origin from non inflammatory processes. Test for antinuclear antibody(ANA)and rheumatoid factor (RF) are most frequently done.

Immunological StudiesImmunological Studies

• ANA (Anti Nuclear Antibodies) titres are ANA (Anti Nuclear Antibodies) titres are useful in diagnosing effusion due to SLE, useful in diagnosing effusion due to SLE, and rheumatoid factor is commonly and rheumatoid factor is commonly present in pleural effusion associated with present in pleural effusion associated with sero - positive rheumatoid arthritissero - positive rheumatoid arthritis

ACID FAST BACILLIACID FAST BACILLI

CANDIDA IN PLEURAL FLUID CANDIDA IN PLEURAL FLUID

Cytological Studies

• Distinguishing characteristics of malignant cells may include nuclear and cytroplasmic irregularities , hyperchromic nucleoli, cellular clumps and abnormal nuclear to cytoplasmic ratios.

Abnormal mitosisAbnormal mitosis

SMALL CELL CA SMALL CELL CA

ATYPICAL PLASMA CELLS ATYPICAL PLASMA CELLS

Pathophysiology of Pericardial Effusion:Pathophysiology of Pericardial Effusion:

• The pericardial space normally contains 15-50 mL of The pericardial space normally contains 15-50 mL of fluid, fluid, • Lubrication------ for the visceral and parietal layers Lubrication------ for the visceral and parietal layers • Originate from the visceral pericardium an ultra filtrate of Originate from the visceral pericardium an ultra filtrate of

plasma. Total protein levels are generally lowplasma. Total protein levels are generally low• The cause of abnormal fluid production underlying The cause of abnormal fluid production underlying

etiology secondary to pericarditis.etiology secondary to pericarditis. 1.Transudative ---obstruction of drainage (lymphatic)1.Transudative ---obstruction of drainage (lymphatic) 2. Exudative -------inflammatory2. Exudative -------inflammatory infectious infectious malignantmalignant autoimmune processes within the autoimmune processes within the pericardium.pericardium.

CAUSES OF PERICARDIAL FLUID CAUSES OF PERICARDIAL FLUID ACCUMULATIONACCUMULATION

• Infectious Infectious – Viral (coxsackievirus A and B, hepatitis, HIV) Viral (coxsackievirus A and B, hepatitis, HIV) – Pyogenic (pneumococci, streptococci, staphylococci, Neisseria, Pyogenic (pneumococci, streptococci, staphylococci, Neisseria,

Legionella species) Legionella species) – Tuberculous Tuberculous – Fungal (histoplasmosis, coccidioidomycosis, Candida) Fungal (histoplasmosis, coccidioidomycosis, Candida) – Other infections (syphilitic, protozoal, parasitic)Other infections (syphilitic, protozoal, parasitic)

• Noninfectious Noninfectious – Acute idiopathic Acute idiopathic – Uremia Uremia – Neoplasia Neoplasia

• Primary tumors (benign or malignant, mesothelioma) Primary tumors (benign or malignant, mesothelioma) • Tumors metastatic to pericardium (lung and breast cancer, Tumors metastatic to pericardium (lung and breast cancer,

lymphoma, leukemia)lymphoma, leukemia)

ROUTINE EXAMINATIONROUTINE EXAMINATION

Physical examination:Physical examination:

• Colour. Clot formation. Specific gravity: Colour. Clot formation. Specific gravity: Altered colour is seen in Bacterial Altered colour is seen in Bacterial pericarditis,Tuberculosis, SLE, pericarditis,Tuberculosis, SLE, Rheumatoid pleuritis, Lymphoma, Rheumatoid pleuritis, Lymphoma, carcinoma.carcinoma.

Chemical examination:Chemical examination:

• Includes test for glucose and proteins Includes test for glucose and proteins • Glucose- decreased in rheumatoid Glucose- decreased in rheumatoid

inflammation& purulent infection.inflammation& purulent infection.• Lactate- elevated in bacterial infectionLactate- elevated in bacterial infection• pH- decreased in pneumonia not pH- decreased in pneumonia not

responding to antibiotics.responding to antibiotics.• Amylase-elevated in pancreatitis, Amylase-elevated in pancreatitis,

esophageal rupture and malignancy.esophageal rupture and malignancy.

Cytological ExaminationCytological Examination

• Includes WBC countIncludes WBC count

• RBC count, RBC count,

• Differential countDifferential count

• Malignant cells.Malignant cells.

Microbiological ExaminationMicrobiological Examination

• Gram”s stain Gram”s stain

• AFB stains AFB stains

• Pericardial fluid culturePericardial fluid culture

Sample CollectionSample Collection

• Normally -10-50 ml Normally -10-50 ml

• Excess fluid ---pericardial effusion. Excess fluid ---pericardial effusion.

• Fluid is obtained by using a sterile needle Fluid is obtained by using a sterile needle under aseptic precaution called as under aseptic precaution called as pericardiocantisis.pericardiocantisis.

Peritoneal Fluid

• Accumulation of fluid between the peritoneal membrane is called ascites, and the fluid is commonly referred to as ascitic fluid rather than peritoneal fluid.

SPECIMEN COLLECTIONSPECIMEN COLLECTION

• Abdominal paracentesis: Abdominal paracentesis:

• The removal of 5 L of fluid is considered The removal of 5 L of fluid is considered large-volume paracentesis.large-volume paracentesis.

• Total paracentesis, ie, removal of all Total paracentesis, ie, removal of all ascites (even >20 L), ascites (even >20 L),

Routine ExaminationRoutine Examination

PHYSICAL EXAMINATION: PHYSICAL EXAMINATION: • Transparent and tinged yellow. Transparent and tinged yellow. • A minimum of 10,000 red blood cells/µL is required for A minimum of 10,000 red blood cells/µL is required for

ascitic fluid to appear pink, ascitic fluid to appear pink, • more than 20,000 red blood cells/µL is considered more than 20,000 red blood cells/µL is considered

distinctly blood tinged. distinctly blood tinged.

Bloody fluid from a traumatic tap is heterogeneously Bloody fluid from a traumatic tap is heterogeneously bloody, and the fluid will clot. bloody, and the fluid will clot.

Nontraumatic bloody fluid is homogeneously red and Nontraumatic bloody fluid is homogeneously red and does not clot because it has already clotted and lysed. does not clot because it has already clotted and lysed.

Neutrophil counts of more than 50,000 cells/µL have a Neutrophil counts of more than 50,000 cells/µL have a purulent cloudy consistency and indicate infection. purulent cloudy consistency and indicate infection.

CHEMICAL TESTING

• Chemical testing- is primarily glucose, amylase and alkaline phosphates determination.

• Glucose – low below serum levels in bacterial and tubular peritonitis and malinancy.

• Amylase-to ascertain cases of pancreaititis• Elevated alkaline phosphates-is highly

diagnostic of intestinal perforation.

Cytological examination:Cytological examination:

CytologyCytology• 58-75% sensitive Malignant Cells58-75% sensitive Malignant Cells

sediment is smeared on slides. sediment is smeared on slides.

• Papanicolaou stain and Leishman stains Papanicolaou stain and Leishman stains

• A cytospin preparation can be used for clear A cytospin preparation can be used for clear

fluid. fluid.

..

Cell count:Cell count: • Normal <500 leukocytes/µL Normal <500 leukocytes/µL < 250 polymorphonuclear < 250 polymorphonuclear

leukocytes/µL. leukocytes/µL. • A neutrophil count > 250 cells/µL - highly A neutrophil count > 250 cells/µL - highly

suggestive ofsuggestive of bacterial peritonitis. bacterial peritonitis.

• In tuberculous peritonitis &peritoneal carcinoma In tuberculous peritonitis &peritoneal carcinoma a predominance of lymphocytes usually occurs. a predominance of lymphocytes usually occurs.

Microbiological examination:Microbiological examination:

Culture/gram stain is performed when Culture/gram stain is performed when

bacterial periontitis is suspected.bacterial periontitis is suspected.

AFB stain may be done if required.AFB stain may be done if required.

MESOTHELIAL CELLSMESOTHELIAL CELLS

MALIGNANCY IN ASCITIC FLUIDMALIGNANCY IN ASCITIC FLUID