Urinalysis and other Body Fluids - Misc. Body Fluid Analysis

ANALYSIS OF URINE AND OTHER BODY FLUIDS MISCELLANEOUS BODY FLUID ANALYSIS OUTLINE • • Introduction • Gastric Fluid Analysis o Utilities of Analysis o Cells of the Stomach o Gastric Acid Composition o Collection o Chemical Stimulants o Acid Output o Physical Examination of Gastric Juice o Chemical Examination o Microscopic Examination o Clinical Significance Vaginal Secretion Analysis o Utilities of Analysis o Vaginitis o Specimen Collection and Handling o Color and Appearance o Diagnostic Test o Other Diagnostic Test o Vaginal Disorders GASTRIC ACID COMPOSITION • • • • • INTRODUCTION • Gastric fluid is examined to determine differential diagnosis of gastric to duodenal ulcers and vaginal secretion is examined for vaginal infections and for forensic testing. Other than microscopic analysis, there are new diagnostic tests such as DNA probe testing and point of care testing that have been developed. DNA probe test is significantly more sensitive than wet mount microscopy. COLLECTION • GASTRIC FLUID ANALYSIS UTILITIES OF ANALYSIS • • • • • • Determine whether the patient can secrete gastric acid Useful in patient with Pernicious anemia and ulcer. Measure the amount of acid produced by a patient with symptoms of Peptic ulcer, and suspected Duodenal ulcer To support a hypersecretory state Determine the completeness of Vagotomy Used for differential diagnosis of gastric from duodenal ulcer Parietal cells → HCl and intrinsic factor Chief cells → pepsinogen Specialized G cells → gastrin Foveolar Cells → Mucus-producing cells Patient Preparation: o Should fast o with no medications o Should not swallow excessive amount of saliva during collection o Should be resting and relaxed METHODS OF COLLECTION • CELLS OF THE STOMACH • • • • Hydrochloric Acid (HCl) - Major role is in digestion Electrolytes - All the electrolytes found on other body fluids Mucus o Secreted by specialized cells of the: o Gland necks in the fundus and body of the stomach o Cells of the surface epithelium Digestive and Non-Digestive Enzymes o Pepsin - catalyzes the degradation of Proteins to Proteoses o Gastric lipase - dietary lipid digestion when pancretic function is not well developed or when it is compromised o Non-digestive enzymes - LDH,ALT,AST, ALP, Isocitrate Dehydrogenase , Ribonuclease Miscellaneous Substances o Small amounts of albumin o Gamma globulins o Intrinsic factor o Soluble blood group subs. • Tube or Intubation Method o Proper Position ▪ Sitting - Best recovery ▪ Lie on left side - bedfast patient o Kinds of Evacuation/Gastric Tubes ▪ Levin tube - passed through the nose ▪ Rehfuss - passed through the mouth ▪ Lavacuator tube - for evacuating gastric contents & stilling an irrigant (mouth) ▪ Ewald’s tube - for aspirating large amounts of gastric contents quickly (mouth) ▪ Edlich tube - for aspirating large amounts of gastric contents quickly (mouth) Tubeless Method / Diagnex Blue Test o Principle ▪ Ion exchange resin) that is coupled with a blue dye ( azure blue ) ▪ Qualitative TEST MEALS • • • • • • • Ewald’s Test Meal - Toasted bread, water or tea without sugar Boa’s - Oatmeal and small amount of salt Reigel Test Meal - Broiled beef steak, mashed potato, bouillon soup Heckman’s - Egg albumin, Distilled water and methylene blue Dock’s - Shredded wheat bread or biscuit Moter - Spinach or raisin+ water Salzer Motility Test - Roast beef or Broiled lamb chop, milk, rice, 1 soft broiled egg CHEMICAL STIMULANTS • • • • Histamine - exerts unpleasant systemic effects on blood vessels and smooth muscles Histalog/Betazole - histamine isomer with preferential effect on gastrin secretion Pentagastrin - stimulant of choice resembling gastrin; more rapid response than Histalog Insulin - used to determine completeness of vagotomy CHEMICAL EXAMINATION • ACID OUTPUT • • Basal Acid Output (BAO) o Total gastric secretion during unstimulated, fasting state o Duration of collection: ▪ 1 hour collection ▪ 2 hour collection Maximum Acid Output (MAO) o Total gastric secretion after gastric stimulation o Duration of collection ▪ 1 hour collection ▪ 2 hour collection • • • PHYSICAL EXAMINATION OF GASTRIC JUICE • • • • • Color o Normal: Colorless or Pale Gray and translucent with mucus o Variations : ▪ Green: Old Bile ▪ Yellow: Fresh Bile ▪ Red: Blood (Small volume) ▪ Coffee Ground: Old Blood (Large Volume) Volume o Fasting State: 20-50mL o Abnormal Fasting State: >50mL o After A Test Meal: 20-60 up to 120mL o After Alcohol Test Meal or Chemical Stimulant: 45150mL Odor o Normal: Usually odorless or slightly sour o Variations ▪ Foul Odor: Necrotic Lesions ▪ Fecaloid: Intestinal obstruction and regurgutation ▪ Rancid: Increase lactic acid, Benign stenosis ▪ Ammoniacal: Uremia ▪ Putrid: Malignant Stenosis Viscosity and character o Normal : it separates into 3 layers on standing, namely ▪ Top layer ▪ Center layer ▪ Bottom layer pH : 1.6 – 2.4 Total Acidity : HCl + Combined Acids o N.V. : 40 – 70 mEq/L o Phenolphthalein Test ▪ Rgt : Alcoholic Phenolphthalein ▪ End Result: Deep Pink o Topfer’s Test ▪ Titrant : 0.1 N NaOH ▪ Indicator : Phenolphthalein ▪ End Result: Salmon Pink Free HCl o NV : 20 – 40 mEq/L o Topler’s ▪ Titrant : 0.1 N NaOH ▪ (+) Result: Canary Yellow o Boa’s ▪ Titrant : Resublimed Resorcinol, Cane Sugar Alc. ▪ (+) Result: Rose Red o Gunzberg’s ▪ RGT : Phloroglucin, Vanillin, 95% Ethyl Alcohol ▪ (+) Result: Purple Red Free HCl, Organic Acids and Acid Salts o Rgt : Na ALIZARIN o (+) Result: Violet with Bluish Tinge Lactic acid test o Tests: ▪ Modified Uffelmann’s: FeCl3 + phenol Yellow ▪ Strauss: FeCl3 + ether Yellow ▪ Kelling’s: FeCl3 Yellow MICROSCOPIC EXAMINATION • • • • • • Pus Cell or WBC - Stomach Abscess, Chronic gastritis, Ulcer RBC - Ulcer, Trauma Yeast Cell - present in large number in patient with retained gastric contents (pyloric obstruction) Bacteria - Mycobacterial species in patient with PTb, H. pylori Food Residue - Pyloric obstruction Parasites - occur rarely: Patient with reflux of Duodenal contents: Giardia lamblia troph or cysts, Strongyloides larvae, Ascaris or Hookworm ova can also be found CLINICAL SIGNIFICANCE • • • Hyperchlorhydria o Seen in peptic ulcer ( duodenal , gastric ) Hypochlorhydria o Chronic gastritis, and stomach CA Achlorhydria o Pernicious anemia, Advanced gastric ulcer and Pellagra-Niacin Deficiency VAGINAL SECRETION ANALYSIS UTILITIES OF ANALYSIS • • to diagnose infections and complications of pregnancy for forensic testing in sexual assault patients VAGINITIS • Characterized by abnormal vaginal discharge or odor, pruritus, vaginal irritation, dysuria, and dyspareunia. • • o Secondary to bacterial vaginosis (BV), vulvovaginal candidiasis, or trichomoniasis; Can also occur with non-infectious conditions such as vaginal atrophy, allergies, and chemical irritation SPECIMEN COLLECTION AND HANDLING • • • • • • • The specimen is collected by swabbing the vaginal walls and vaginal pool to collect epithelial cells along with the vaginal secretions using one or more sterile, polyester tipped swabs on a plastic shaft or swabs. Cotton swabs should not be used → toxic to Neisseria gonorrhoeae, Wood in a wooden shaft → toxic to Chlamydia trachomatis Calcium alginate →inactivate herpes simplex virus (HSV) for viral cultures Specimens must be kept at room temperature to preserve the motility of Trichomonas vaginalis and the recovery of N. gonorrhoeae Specimens for T. vaginalis should be examined within 2 hours of collection Specimens for C. trachomatis and herpes simplex virus must be refrigerated • • • COLOR AND APPEARANCE • • Normal Color: o White with a flocculent discharge Abnormal Color: o Increased thin, homogeneous white-to-gray discharge → bacterial vaginosis o White “cottage cheese”–like discharge → Candida infections o increased yellow-green,frothy, adherent discharge → T. vaginalis o yellow, opaque cervical discharge → C. trachomatis DIAGNOSTIC TEST • pH • • Normal: usually 4.5 (3.2 to 4.5) ↑ 4.5 pH : bacterial vaginosis, trichomoniasis, desquamative inflammatory vaginitis (DIV), atrophic vaginitis. MICROSCOPIC • • • • Initial Screening test: Saline wet mounts & KOH mounts Confirmatory Test: Gram stain Squamous Epithelial Cells o 25 to 70 μm in diameter o polygonal “flagstone” appearance o originate from the linings of the vagina and female urethra o present in significant numbers Clue Cells • abnormal variation of the squamous epithelial cell o distinguished by coccobacillus bacteria attached in clusters on the cell surface o diagnostic of bacterial vaginosis caused by G. vaginalis White Blood Cells o measure 14 to 16 μm in diameter o exhibit a granular cytoplasm o present in rare to scanty number o > 3+ WBCs: vaginal candidiasis, atrophic vaginitis, or infections with Trichomonas, Chlamydia, N. gonorrhoeae, or Herpes simplex Red Blood Cells o approximately 7 to 8 μm in diameter o distorted in vaginal specimens o not usually seen but might be present during menstruation or due to a desquamative inflammatory process o distinguished from yeast cells by KOH (RBCs are lysed) Parabasal Cells o round to oval shaped o 16 to 40 μm in diameter o nucleus to cytoplasm ratio is 1:1 to 1:2 o marked basophilic granulation or amorphic basophilic structures (“blue blobs”) in the surrounding cytoplasm. o located in the luminal squamous epithelium of the vaginal mucosa o Increased numbers: Desquamative inflammatory vaginitis ( if present with >WBCs) o Basal Cells o located deep in the basal layer of the vaginal stratified epithelium o round and measure 10 to 16 μm in diameter o nucleus to cytoplasm ratio of 1:2. o Not normally seen o If present: desquamative inflammatory vaginitis (with >WBCs) Bacteria o Normally present: o Lactobacillus spp ▪ the largest portion of vaginal bacteria ▪ large gram - positive,nonmotile rods on Gram stain ▪ produce lactic acid (maintains the vaginal pH at 3.8 to 4.5) o Other bacteria ▪ anaerobic streptococci, ▪ diphtheroids, ▪ coagulase-negative staphylococci ▪ a –hemolytic streptococci. o Maybe replaced by: ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ Mobiluncus spp. (thin, curved, gram-negative, motile rods) Prevotella spp. Porphyromonas spp. Bacteroides spp. (anaerobic gram-negative rods) Gardnerella vaginalis (short, gram-variable coccobacilli) Peptostreptococcus spp. (gram-positive cocci) Enterococcus spp. (gram-negative cocci) Mycoplasma hominis Ureaplasma urealyticum • Point of Care Tests: o The OSOM Trichomonas Rapid Test (Genzyme Diagnostics, Cambridge, MA) is an immunochromatographic strip test that detects T. vaginalis antigen from vaginal swabs in 10 minutes. o The OSOM BVBLUE test (Genzyme Diagnostics, Cambridge,MA) detects vaginal fluid sialidase, an enzyme produced by the bacterial pathogens associated with bacterial vaginosis, such as Gardnerella, Bacteroides, Prevotella, and Mobiluncus. VAGINAL DISORDERS • • Trichomonas vaginalis o atrial flagellated protozoan o cause vaginal inflammation and infection in women o oval shaped, measures 5 to 18 μm in diameter o has four anterior flagella and an undulating membrane o nonmotile trichomonads can be mistaken for WBCs • • Yeast Cells o Candida albicans and non–Candida spp. cause most fungal infections o appear on a wet mount as both budding yeast cells (blastophores) or as hyphae, which are long filaments that grow and form a mycelium o Pseudohyphae - multiple buds that do not detach and form chains • OTHER DIAGNOSTIC TEST • • • • Gram stain - considered the gold standard in identifying the causative organisms for bacterial vaginosis. Culture - gold standard test for detecting yeast and Trichomonas Diamond’s medium - Special media required for T. vaginalis. DNA Testing- Affirm VPIII (Becton, Dickinson, Franklin Lakes, NJ), is available for differential diagnosis of G. vaginalis, Candida spp., and T. vaginalis Bacterial Vaginosis o most common cause of vaginitis o Occurs when there is an imbalance in the ratio of normal vaginal bacterial flora. o associated with new or multiple sex partners, frequent douching, use of intrauterine devices, pregnancy, and a lack of the protective lactobacilli. o risk factor for the premature rupture of membranes and preterm labor for pregnant women. o To diagnose: (three of the following four features must be present) ▪ thin, white, homogeneous discharge ▪ >4.5 pH ▪ (+) amine (Whiff) test ▪ presence of clue cells on microscopic examination Trichomoniasis o caused by the parasitic protozoon T. vaginalis o transmitted by sexual intercourse o associated with enhanced transmission rates of HIV o characterized by a green-to-yellow o frothy vaginal discharge, malodor, pruritus, irritation, dysuria, dyspareunia, and vaginal mucosa erythema o Male patients: asymptomatic o To diagnose: ▪ the wet mount examination and microscopically: (+) motile trichomonads ▪ > 4.5 pH ▪ (+) amine test ▪ culture using Diamond’s medium or the commercially available pouch system: negative wet mount ▪ DNA probe test system ▪ point of care rapid antigen detection test Candidiasis o caused by C. albicans, and also nonalbican species such as C. glabrata, C. parapsilosis, o C. tropicalis, and C. krusei common cause of vaginitis o Candida part of normal flora o To diagnose: ▪ the wet mount examination and microscopically: (+) motile trichomonads ▪ Normal pH (3.8▪ (-) amine test ▪ Microscopic examination of saline and KOH wet prep: budding yeast and pseudohyphae forms, large numbers of WBCs, lactobacilli, and large clumps of epithelial cells • • Desquamative Inflammatory Vaginitis o characterized by profuse purulent vaginal discharge, vaginal erythema, and dyspareunia o occur secondary to atrophic vaginitis in postmenopausal women o To diagnose: ▪ Wet mount and Gram stain microscopic examination: • > number of WBCs and RBCs, • occasional parabasal and basal cells, • reduced or absent lactobacilli that have been replaced by gram-positive cocci Atrophic Vaginitis o syndrome found in postmenopausal women o caused by thinning of the vaginal mucosa o To diagnose: ▪ Wet mount and Gram stain microscopic examination: • > number of WBCs and RBCs, • occasional parabasal and basal cells,squamous epithelial cells • decreased numbers of lactobacilli that have been replaced by gram-positive cocci and gram-negative rods