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of: o gastrointestinal (GI) bleeding o causes of diarrhea and steatorrhea o liver and biliary duct disorders o detection of pathogenic bacteria and o maldigestion/malabsorption syndromes parasites o inflammation
PHYSIOLOGY Normal fecal specimen contains: o bacteria (many of which make up the normal flora of the intestines o cellulose o other undigested foodstuffs o GI secretions BACTERIAL METABOLISM produces the strong odor associated with feces and intestinal gas (flatus)
o o o o
bile pigments cells from the intestinal walls electrolytes water
CARBOHYDRATES especially oligosaccharides resistant to digestion pass through the upper intestine unchanged but are metabolized by bacteria in the lower intestine, producing large amounts of flatus excessive gas production: LACTOSE-INTOLERANT INDIVIDUALS when the intestinal bacteria metabolize the lactose from consumed milk or lactose-containing substances
ALIMENTARY TRACT where digestion of ingested proteins, carbohydrates and fats take place SMALL INTESTINE primary site for the final breakdown and reabsorption of these compounds
DIGESTIVE ENZYMES SECRETED INTO THE SMALL INTESTINE BY THE PANCREAS trypsin chymotrypsin amino peptidase lipase
BILE SALTS provided by the liver aid in the digestion of fats
* A deficiency in any of these substances causes the inability to digest, and, therefore, to reabsorb certain foods
hard stools DIARRHEA DIARRHEA increase in daily stool weight above 200 g increased liquidity frequency: more than 3X/day can be classified based on: a. negligible electrolytes Secretory diarrhea = <50 mOsm/kg. Duration of the illness o ACUTE: less than 4 weeks o b. GASTRIC. increased electrolytes . PANCREATIC AND INTESTINAL SECRETIONS 9000 mL/day DIGESTIVE TRACT 500 to 1500 mL LARGE INTESTINE 150 mL FECES WATER AND ELECTROLYTES readily absorbed in both intestines fecal electrolyte content similar to plasma LARGE INTESTINE can absorb approximately 3000 mL of water DIARRHEA occurs when amount of water reaching the large intestine exceeds 3000 mL water is excreted with the solid fecal material CONSTIPATION provides time for additional water to be reabsorbed from the fecal material small. LIVER. CHRONIC: more than 4 weeks Mechanism Osmotic gap = 290 – [2 (fecal Na+ + fecal K+) Osmotic diarrhea = >50 mOsm/kg.EXCESS UNDIGESTED OR REABSORBED MATERIAL appear in feces patient exhibits symptoms of maldigestion and malabsorption INGESTED FLUID. SALIVA.
causing: o cramping o diarrhea o bloating o constipation o flatus triggered by: o food o chemicals o emotional stress o exercise RAPID (ACCELERATED) GASTRIC EMPTYING (RGE) DUMPING SYNDROME hypermotility of the stomach shortened gastric emptying half-time. sorbitol. cholerae Salmonella Shigella Staphylococcus Campylobacter Protozoa Cryptosporidium Incomplete breakdown or reabsorption of food presents increased fecal material to the large intestine.MECHANISM ACTION CAUSATIVE AGENTS OTHER CAUSES Drugs Stimulant laxatives Hormones Inflammatory bowel disease o Crohn disease o Ulcerative colitis o Lymphocytic colitis o Diventiculitis Endocrine disorders o Hyperthyroidism o Zollinger-Ellison syndrome o Vipoma Neoplasms Collagen vascular disease Secretory Increase in secretion of water and electrolytes which override the reabsorptive ability of the large intestines E. coli Clostridium V. mannitol) Laxatives Magnesium-containing antacids Antibiotic administration Altered Motility Vagotomy Diabetic neuropathy Complication of menstruation Hyperthyroidism IRRITABLE BOWEL SYNDROME (IBS) both hypermotility and constipation are seen a functional disorder in which the nerves and muscles of the bowel are extra-sensitive. causing the small intestines to fill too quickly with undigested food from the stomach hallmark of Early Dumping Syndrome (EDS) healthy individuals: gastric emptying half-time range of 35-100 minutes (varies with age and gender) RGE: less than 35 minutes caused by disturbances in the gastric reservoir or in the transporting function normal gastric emptying is controlled by the FUNDIC TONE. resulting in the retention of water and electrolytes in the large intestine Conditions of enhanced motility (hypermotility) or slow motility (constipation) Osmotic Entamoeba histolytica Disaccharidase deficiency (lactose intolerance) Malabsorption (Celiac sprue) Poorly absorbed sugars (lactose. DUODENAL FEEDBACK and GI HORMONES .
Bacterial overgrowth Intestinal resection Celiac disease Tropical sprue Lymphoma o o o o Whipple disease Giardia lamblia infestation Crohn disease Intestinal ischemia Severity Stool characteristics .START Early Dumping 10-30 minutes following meal ingestion Late Dumping 2-3 hours after a meal SYMPTOMS Nausea Vomiting Bloating Cramping Diarrhea Diziness Fatigue Weakness Sweating Dizziness COMPLICATION Hypoglycemia CAUSES Gastrectomy Gastric bypass surgery Postvagotomy status Zollinger-Ellison syndrome Duodenal ulcer disease Diabetes mellitus STEATORRHEA increase in stool fat that exceeds 6 g/day due to absence of bile salts that assist pancreatic lipase in the breakdown and subsequent reabsorption of triglycerides detection is useful for the diagnosis of pancreatic insufficiency and small boweled disorders that cause malabsorption disease association: o Cystic fibrosis o Chronic pancreatitis o Carcinoma Steatorrhea may be present Maldigestion and Malabsorption 9000 mL/day D-Xylose Test urine D-Xylose is low Malabsorption D-XYLOSE a sugar that does not need to be digested but does need to be absorbed to be present in urine if low: Malabsorption if normal: Pancreatitis MALABSORPTION CAUSES o o o o o c. d.
FOUL ODOR. which may contain disinfectants. Collect specimen in a clean container. WHITE.SPECIMEN COLLECTION 1. Precaution: SPECIMEN MUST NOT BE CONTAMINATED WITH URINE OR TOILET WATER. 2. MAY FLOAT MUCUS-COATED STOOLS BLOOD-STREAKED MUCUS-streaked Diarrhea Constipation Intestinal constriction Biliary obstruction Steatorrhea Pancreatic disorders Intestinal inflammation or irritation Bacterial or amebic dysentery . RIBBONLIKE STOOLS WATERY CONSISTENCY SMALL. such as a bedpan or disposable container. especially Beets APPEARANCE SLENDER. FROTHY. HARD STOOLS BULKY. KITS FOR OCCULT BLOOD contain paper that can be floated in toilet bowl to collect the specimen RANDOM SPECIMENS for qualitative testing for blood microscopic examination for leukocytes. GRAY BLACK. muscle fibers and fecal fats container: PLASTIC OR GLASS CONTAINERS WITH SCREW-CAPPED TOPS TIMED SPECIMENS for quantitative testing for fecal fats most representative sample: 3-DAY COLLECTION o due to variability of bowel habits and transit time required for food to pass through the digestive tract container: PAINT CANS to accommodate specimen quantity and facilitate emulsification prior to testing MACROSCOPIC SCREENING first indication of GI disturbances: o changes in brown color o formed consistency COLOR BROWN PALE YELLOW. GREASY. Transfer specimen to laboratory container. TARRY Esopaghus bleeding Stomach bleeding Duodenal bleeding o all of these take 3 days to appear in stool Iron ingestion Charcoal ingestion Bismuth ingestion (antacids) RED GREEN Oral antibiotics (bilirubin to biliverdin) Ingestion of increased amounts of green vegetables Food coloring Normal: Stercobilinogen to Urobilin Blockage of the bile duct Diagnostic procedures that use barium sulfate Lower GI bleeding Medications Food.
fatty acids from soap and neutral fat hydrolysis o Normal: 100 small droplets. ONLY ONES COUNTED PARTIALLY DIGESTED FIBERS: striations in only one direction presence of MORE THAN 10 UNDIGESTED FIBERS are considered increased representative sample: RED MEAT IN DIET PRIOR TO COLLECTION. breakdown of neutral fats by bacterial lipase and hydrolysis of neutral fats may lower neutral fat count determine whether maldigestion or malabsorption causes steatorrhea SOAPS and FATTY ACIDS o do not stain with Sudan III o second slide mixed with acetic acid and heated stained droplets: free fatty acids. such as CYSTIC FIBROSIS. coli STAIN Methylene blue Dried smear Wright’s Gram’s TOXIN-PRODUCING BACTERIA USUALLY DO NOT CAUSE THE APPEARANCE OF FECAL LEUKOCYTES Staphylococcus aureus Vibrio spp. <4µm/hpf . which enhances the muscle fiber striations slide is examined for 5 minutes number of RED-STAINED FIBERS WITH WELL-PRESERVED STRIATIONS are counted UNDIGESTED FIBERS: visible striations running both vertically and horizontally. Wet preparation ADVANTAGES Faster Provide permanent slides Observation of Gram (+) and Gram (-) bacteria DISADVANTAGES More difficult to interpret All slide preparations: FRESH SPECIMEN 3 neutrophils/hpf: INVASIVE CONDITION OIO: finding of neutrophils has approximately 70% sensitivity for the presence of invasive bacteria Lactoferrin Latex Agglutination Test o detects fecal leukocytes and remains sensitive in refrigerated and frozen specimens o LACTOFERRIN: granulocyte secondary granule MUSCLE FIBERS Indicative of pancreatic insufficiency. Sudan IV.MICROSCOPIC EXAMINATION OF FECES FECAL LEUKOCYTES primarily neutrophils seen in infections that affect intestinal mucosa such as ULCERATIVE COLITIS and BACTERIAL DYSENTERY PRELIMINARY TEST to determine causative agent INVASIVE BACTERIAL PATHOGENS CAUSE THE APPEARANCE OF FECAL LEUKOCYTES Salmonella Shigella Campylobacter Yersinia Enteroinvasive E. Oil Red O NEUTRAL FATS (TRIGLYCERIDES) o stained by Sudan III as large orange-red droplets often located near the edge of cover slip o >60 droplets/hpf: steatorrhea o SPLIT FAT STAINING total fat content. examined within 24 hours QUALITATIVE FECAL FATS specimens suspected of steatorrhea: MICROSCOPIC EXAMINATION FOR EXCESS FECAL FAT o monitoring patients undergoing treatment for malabsorption disorders stains: Sudan III (routine). BILIARY OBSTRUCTION and GASTROCOLIC FISTULAS emulsify a small amount of stool in 10% alcoholic eosin.
1-8µm o Increased: 100 droplets measuring 6-75 µm CHOLESTEROL o stained by Sudan III after heating o forms crystals upon cooling CHEMICAL TESTING OF FECES OCCULT BLOOD Fecal Occult Blood Test (FOBT) detection of hidden blood most frequently performed fecal analysis bleeding >2. o Slightly elevated: 100 small droplets. fat and nitrogen in g/24h .5 mL/150 g of stool: pathologically significant but may not produce signs of bleeding early detection of colorectal cancer principle: PSEUDOPEROXIDASE ACTIVITY OF HEMOGLOBIN chromogens in order of decreasing sensitivity: o benzidine o ortho-tolidine o gum guaiac: routine commercial testing kits o Guaiac-impregnated filter paper: feces + H2O2 Contraindications: 3 days: o red meat o horseradish o melon o raw broccoli o cauliflower o radish o turnip o Vitamin C o Iron supplements 7 days o Aspirin o NSAIDs other than Acetaminophen Hemoquant o fluorometric test for hemoglobin and porphyrin Immunochemical Fecal Occult Blood Test (iFOBT) o specific for the globin portion of human hemoglobin and uses anti-human hemoglobin Ab’s QUANTITATIVE FECAL FAT TESTING confirmatory test for steatorrhea Van de Kamer titration (gold standard) 3-day specimen with a regulated intake of fat (100 g/d) fecal lipids are converted to fatty acids and titrated to a neutral endpoint with NaOH Coefficient of fat retention = (dietary fat – fecal fat) X 100 dietary fat ACID STEATOCRIT o rapid test to estimate amount of fat excretion o monitor therapy and screen for steatorrhea in pediatric populations NEAR-INFRARED REFLECTANCE SPECTROSCOPY (NIRA) o 48-72hr stool that does not require reagents after homogenization o reflectance of fecal surface + IR light between 1400 nM and 2600 nM o quantitates water.
bacterial enzymes Chymotrypsin: more resistant to intestinal degradation. carbohydrates and fats decrease (pancreatic insufficiency) is associated with chronic pancreatitis and cystic fibrosis steatorrhea occurs.APT TEST (FETAL HEMOGLOBIN) grossly bloody stools and vomitus: SWALLOWING MATERNAL BLOOD DURING DELIVERY material is emulsified in water to release Hb. Hb AS. CS and SS stool specimens should be tested when fresh FECAL ENZYMES supplied by the pancreas for digestion of dietary proteins. centrifuged. + 1% NaOH to pink Hb-containing supernatant in the presence of alkali-resistant fetal Hb.5 . whereas denaturation of the maternal Hb (Hb A) produces a yellow-brown supernatant after standing for 2 minutes the test can also distinguish fetal Hb from Hb A.0 o carbohydrate disorders: pH 5. the solution remains pink (Hb F). presence of undigested food in feces analysis focuses on TRYPSIN. enzyme form produced by pancreas o strongly resistant to degradation o 6% of secreted pancreated enzymes o pancreas-specific with concentrations 5X higher than in pancreatic juice o not affected by motility disorders and mucosal defects o measured using ELISA that provides a very sensitive indicator of exocrine pancreatic insufficiency CARBOHYDRATES an increase indicates OSMOTIC DIARRHEA by the osmotic pressure of unabsorbed sugar in intestine drawing in fluid and electrolytes may be present due to: o intestinal inability to absorb carbohydrates: CELIAC DISEASE o lack of digestive enzymes such as lactase: LACTOSE INTOLERANCE Carbohydrate malabsorption or intolerance (maldigestion): primarily analyzed by serum and urine tests o COPPER REDUCTION TEST (Clinitest tablet) in fecal specimen Detects congenital disaccharidase deficiencies as well as enzyme deficiencies due to nonspecific mucosal injury Infant diarrhea: fecal carbohydrate testing + pH determination o normal pH of feces: 7. more sensitive indicator of less severe cases of pancreatic insufficiency o remains stable in feces for 10 days at RT o also capable of gelatin hydrolysis but most frequently measured spectrophotometrically Elastase I: isoenzyme of elastase. CHYMOTRYPSIN and ELASTASE I Trypsin: (historically) absence has been screened for by exposing x-ray paper to stool emulsified in water o If present: it digests gelatin on the paper o Detects only severe cases of pancreatic insufficiency o False-negative results: intestinal degradation of trypsin and possibly trypsin inhibitors in feces.0 – 8.
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