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WEEK 5: FECAL ANALYSIS March 14, 2018

Analysis of Urine and Other Body Fluids Lecture Hand-Outs

Learning Objectives: KEY TERMS

 Describe the composition and formation of normal feces Acholic stools: Pale, gray or
 Classify the condition of diarrhea according to the physiologic mechanisms clay-colored stools. They
involved. occur when production of
 Differentiate between Secretory and Osmotic diarrhea using fecal normal fecal pigments-
osmolality.
Stercobilin, Mesobilin and
 Differentiate steatorrhea from diarrhea and discuss the physiologic
Urobilin is partially or
conditions that result in steatorrhea.
completely inhibited.
 Describe the macroscopic characteristics of normal feces
 List the major causes of abnormal fecal color, consistency and odor. Constipation: Infrequent
 Compare and contrast the following methods for the detection of blood on
and difficult bowel
feces. (Slide test, Quantitative chemical tests, Immunologic assays,
movements, compared with
Radiometric assays.
an individual’s normal bowel
movement pattern. The
fecal material produced
FECAL FORMATION:
consists of hard, small, often
 100-200 g of fecal material excreted per day (NORMAL) spherical mass.
o Consist of undigested foodstuff (e.g., cellulose)
Diarrhea: An increase in the
o Sloughed intestinal epithelium, NF bacteria in GUT.
volume, liquidity, and
o Bile pigment, electrolytes, water
frequency of bowel
Small intestine: movements compared with
the normal bowel
 Fxn: digestion and absorption of foodstuffs movement pattern of an
Large intestine: individual.

 Fxn: Absorbs water, sodium and chloride. Disaccharidase


o Apprx 9000mL of fluid from GIT from food, water, saliva, Deficiency: a lack of
gastric secretions, bile, pancreatic secretions and sufficient enzymes
intestinal secretions. (disaccharidases) to
o 500-1500mL only enters to the large intestine per day. metabolize disaccharides in
o It only Excrete 150ml of fluid in normal feces. the small intestine. These
o Has a limited ability to absorb liquid (up to 2700mL) deficiencies can be
hereditary or acquired (e.g.,
Scybala: Hard Feces resulting diseases or drug
therapy).
 A fecal specimens from constipated individuals are typically small,
Malabsorption: Inadequate
hard, often spherical masses that are often difficult and painful to
intestinal absorption of
pass.
processed foodstuffs despite
Intestinal bacteria in the large intestines results in the production of normal digestive ability.
intestinal gas or “Flatus”. And normally produced at a rate of about 400 to Maldigestion: an inability to
700mL/day. convert foodstuff in the
gastrointestinal tract into
Increased gas production can result in foamy and floating stools. (normal)
readily absorbable
but be seen to Px with lactose intolerance and steatorrhea.
substances.
WEEK 5: FECAL ANALYSIS March 14, 2018
Analysis of Urine and Other Body Fluids Lecture Hand-Outs

Classification of Diarrhea:

*Differentiating secretory and Osmotic diarrhea requires determination of Causes of steatorrhea


fecal osmolality, fecal sodium and fecal potassium levels* Maldigestion Decreased
pancreatic
 Using the fecal sodium and potassium “calculated” fecal osmolality is enzyme
determined using this equation. Pancreatitis
Cystic fibrosis
Calculated fecal osmolality= 290-2x(Na+fecal + K+FECAL)
Pancreatic cancer
 Reference range: Zolinger-ellison
o >50 mOsm/kg = OSMOTIC DIARRHEA syndrome
Ileal resection
o Within <50 mOsm/kg = SECRETORY DIARRHEA
Decresed bile acid
“Both maldigestion and malabsorption present abnormally in osmotic micelle formation
diarrhea that increased quantity of foodstuff to the large intestine causes Hepatocellular
dse
retention of large quantities of water and electrolytes in the intestinal
Bile duct
lumen and excretion of a watery stool. obstruction
Bile acid
Intestinal hypermotility: deconjugation
Malabsorption Dmg intestinal
 When the transit time for intestinal contents is too short to allow mucosa
normal intestinal absorption to occur. Celiac dse
 Stimulated by intestinal distention. E.g., dietary fiber. Tropical dse
 Parasympathetic nerve activity= increased intestinal motility. Abetalipoproteine
 Sympathetic nerve activity= decreased intestinal motility. mia
 Both osmotic and secretory diarrhea increased lumen fluid cause’s Lymphatic
intestinal distention. obstruction
Lymphoma
 When severe, diarrhea decreases the blood volume (hypovolemia)
and distrupts the acid-base balance of the body. The large fluids loss Whipple’s dse
and accompanying electrolyte depletion (Na,HCO3,K) can result
metabolic acidosis.
WEEK 5: FECAL ANALYSIS March 14, 2018
Analysis of Urine and Other Body Fluids Lecture Hand-Outs

STEATORRHEA:
 Fecal fat excretion that exceeds 7g/day
 Common feature of patients with malabsorption syndromes
 Characteristic: Pale, Greasy, Bulky, Spongy or Pasty and extremely foul smelling.
 May float or foamy because of large amounts of gas with them.

Comparison of Diarrhea and steatorrhea

Condition Fecal Fecal Volume Fecal Cause Clinical Features


Characteristics Frequency

Diarrhea Watery; odor Increased Increased Distruption in Water and electrolyte


normal or water and imbalance; acidosis;
unremarkable electrolyte hypovolemia
absorption

Steatorrhea Greasy; foul odor; Increased Normal or Maldigestion or Malnutrition; weight


spongy consistency increased malabsorption of loss
dietary fat

SPECIMEN COLLECTION:
 The specimen container must be cleaned and non-breakable container. That is sealable and leak proof are
acceptable.
 The type and amount of specimen collected vary with the test to be performed.
 For FOBT or qualitative fecal fat requires only a small amount of random collected specimen.
 Quantitative test for excretion usually require 2 or day fecal collection.
 Dietary restrictions may required before collection.

MACROSCOPIC EXAMINATION:

1. Color
 Normal color: Brown due to bile pigments
When conjugated bilirubin is secreted as bile into small intestine, it is hydrolyzed back to its unconjugated
form. The intestinal anaerobic bacteria subsequently reduce it to three colorless tetrapyrroles called
urobilinogens: Stercobilinogen, mesobilinogen, urobilinogen spontaneously oxidize in the intestine and
produce Urobilins: stercobilins, mesobilins, and urobilins.
2. Consistency and Form:
 Normal Consistency of stool is Formed
 Soft stool indicates increase in fecal water content.
 Ribbon-like stools indicate intestinal obstruction or lumen narrowing as a result of strictures.
3. Mucus
 A translucent Gelatinous substance, Not present in normal stool.
WEEK 5: FECAL ANALYSIS March 14, 2018
Analysis of Urine and Other Body Fluids Lecture Hand-Outs

 Indication of villous adenoma (tumor of the colon)


 Can also be seen in colitis, intestinal tuberculosis, Neoplasm, rectal inflammation, Ulcerative
diverticulitus, Bacillary dysentery, constipation.
4. Odor
 Normal odor of feces results from the metabolic by-products of the intestinal flora. If normal flora
is disrupted or the foodstuffs presented to the flora change dramatically, a change in fecal odor
may noticed.

Fecal reference Intervals


Physical Examination
Color Brown
Consistency Firm, formed
Form Tubular, Cylindrical
Chemical Examination
Total fat, Quantitative (72-hour specimen) <6g/day and <20% of stool
Osmolality 285-430 mOsm/kg H2O
Potassium 30-40 mEq/L
Sodium 40-110 mEq/L
Microscopic Examination
Fat, Qualitative Assessment
Neutral Fat Few fat globules present per High-power Field
Total Fat <100 fat globules (diameter ≤4 microns) per High-
power Field
Leukocytes (qualitative) None Present
Meat and Vegetable Fibers (qualitative) Few
WEEK 5: FECAL ANALYSIS March 14, 2018
Analysis of Urine and Other Body Fluids Lecture Hand-Outs

MICROSCOPIC EXAMINATION:

1. Fecal Leukocytes:

 Presence of leukocytes or pus in stools aids in the differential diagnosis of diarrhea.


 Intestinal wall is infected or inflamed
 Saline preparation , wright’s stain or methylene blue aids for the determination of leukocytes.

2. fecal fat, Qualitative

 Qualitative assessment performed through microscopy, and quantitative determination for definitive
diagnosis of steatorrhea.
 Sudan III is most routinely used stain for determination of fecal fats “ Orange-red Color”
 Sudan IV, oil red O other stains used for fat determination
o Consist of two parts staining procedure: 1. Neutral fat stain 2. Split fat stain.
o More than 60 droplets/hpf indicates steatorrhea
 Break down of neutral fats by bacterial lipase and spontaneous hydrolysis of neutral fats may lower
the neutral fat count.
a. Neutral fat stain= Homogenize 1 part of stool / 2 parts water , add 1 drop of 95% ethanol and 2
drops of sudan III in 95% ethanol.
b. Split fat stain= 1part stool/ 2part water, add 1 drop 36% acetic acid and add 2 drops sudan III heat
to almost boiling. Can be seen free fatty acid and fatty acids produce in hydrolysis of soap and
neutral fats.

*Soaps and Fatty acids do not stain directly with sudan III.

 Fewer than 100 globules /hpf should not exceed <4um diameter = normal
 <100globules/hpf 1-6um= slightly increased
 >100 globules/ hpf with 6-80um =considered steatorrhea

3. Meat fibers:

 Undigested foodstuffs , such as meat and vegetable fibers can be identified microscopically in feces.
 Meat fiber: Rectangular with cross-striations
 Increased numbers of fecal meat fibers correlate w/ impaired digestion and the rapid transit of
intestinal contents.
 Helpful diagnosis and monitoring with Pancreatic insufficiency, such as cystic fibrosis.
 Can also be seen in biliary obstruction and Gastrocolic fistulas.
 The patient should be instructed to include red meat in their diet before collecting the specimen.,
within 24 hours.
 Emulsify stool and add 2drops 10% eosin in alcohol and stand for 3-5 mins.

4. Fecal Blood
 Fecal blood is a common and early symptom of colorectal cancer
 All individuals older than 50 years of age should annually screened for FOBT.
 Bleeding in Upper GIT – black colored stool/ mahogany-colored
 MELENA- Excretion of large amounts of fecal blood (50-100ml/day)
WEEK 5: FECAL ANALYSIS March 14, 2018
Analysis of Urine and Other Body Fluids Lecture Hand-Outs

 Belliding in Lower GIT- Bright red colored stool


 Greater than 2.5/150 g of stool blood considered pathological
 Bleeding in gums, esophageal varices, ulcers, hemorrhoids, inflammatory conditions and varius drugs
such as aspirin and and iron supplements that irritates the intestinal mucosa can cause blood in feces.
 a small amount of blood in feces is often not visually apparent and is referred to as “ Occult blood”

Guaiac-Based Fecal Occult blood test

 are based on the pseudoperoxidase activity of the heme moiety of hemoglobin. In the presence of an
indicator and hydrogen peroxide, the heme moiety catalyzes oxidation of the indicator, which in a color
change.

Ingested substances associated with erroneous Guaiac-based Fecal


Occult blood test.
False-Positive result False-Negative Results
Red or rare cooked meats and fish Ascorbic acid and iron supplement
Vegetables* such as turnips,
Broccoli, cauliflower, and
horseradish.
Fruits* cantaloupe, Bananas,
Pears, Plums
Drugs* Aspirin NSAID or any kind
acetamenophen
*adequate cooking can destroy peroxidase activity of vegetables and fruits.
WEEK 5: FECAL ANALYSIS March 14, 2018
Analysis of Urine and Other Body Fluids Lecture Hand-Outs

 Heme degredation can occur:


o Within the intestinal tract
o During storage of the fecal specimen
o After it has been applied to the gFOBT slide.

IMMUNOCHEMICAL FOBT

o A Poly clonal anti-human antibodies directed against the globin portion of undegraded human
hemoglobin.
o Highly specific, in Lower HIT

Fetal Hemoglobin in Feces (Apt Test)

 Presence of blood in the stoll, emesis, or gastric aspirate from a newborn infant
 The specimen must contain fresh “red” blood such as bloody, soiled or bloody diaper.
o Black tarry stools are not acceptable due to hemoglobin degradation to hematin
 1mL of NaOH is added to the alkaline tube with supernatant of feces, READ FOR 2 MINS (+)= pink color
change to yellow or brown (maternal hemoglobin present Hb A)
o Remain pink (fetal hemoglobin Hb F)

Quantitative Fecal Fat:


Preparation:
1. Patient must limit their fat intake to 100-150g of fat/day
2. Do not used laxatives or synthetic fat substitutes
3. Fat-blocking nutritional supplement not recommended to intake before the test.
4. Should not contaminated by mineral oils and lubricants or creams.
The feces collects all feces excreted for 3 days in large container (Paint cans)
Van de Kamer Titration: most routinely used for fecal fat measurement
Others: Gravimetric, Near infrared reflectance spectroscopy and nuclear magnetic resonance spectroscopy
 The fat content is reported as grams of fat or the coefficient of fat retention per 24 hours
 Reference value: 1-6g/d or a coefficient of fat retention of at least 95%.

Fecal enzymes:
 Proteolytic enzymes trypsin, chymotrypsin, and elastase I
 The enzymes supplied to the gastrointestinal tract by the pancreas are essential for digesting dietary
proteins, carbohydrates and fats.
 Chymotrypsin is more resistant to intestinal degradation and is a more sensitive indicator for pancreatic
insufficiency
 Fecal specimen is stable for up to 10 days at room temp.
 Chymotrypsin is capable of gelatin hydrolysis but is most frequently measured by spectrophotometric
methods
WEEK 5: FECAL ANALYSIS March 14, 2018
Analysis of Urine and Other Body Fluids Lecture Hand-Outs

 Elastase I an isoenzyme of elastase and produced by the pancreas


o Highly concentrations in pancreatic secretion and strongly resistant to degradation.
o Account for about 6% of all secreted enzyme
o Can be measured by immunoassay using ELISA kit sensitive test for pancreatic insufficiency
 Uses monoclonal antibodies against human pancreatic elastase 1 (more specific and not
affected by pancreatic enzyme replacement therapy)
o Can differentiate pancreatic with steatorrhea and nonpancreatic causes.