AUBF LECTURE M10 CHAP12: SEROUS FLUID

SEROUS FLUID
Closed cavities of the body

Pleural​: lung cavity

Pericardial​: heart
Peritoneal​: abdominal cavity

All body cavities are lined by a thin membrane that has 2 parts:

1. Parietal membrane​: lines the body cavity

2. Visceral membrane​: the outer lining of the organ

Serous fluid ​- in the space between the 2 membranes

- provides l​ ubrication ​between the parietal and visceral membranes
➢ Lubrication​: necessary to p ​ revent the friction​ between the two membranes that
occurs as a result of movement of the enclosed organs (expansion & contraction of
lungs)
Formation

● Serous fluid​: formed as ultrafiltrates of plasma, derived from the capillary network of the
membrane.
● Production a ​ nd ​reabsorption​: hydrostatic pressure & colloidal pressure (oncotic pressure)
from the capillaries that serve the cavities and the capillary permeability.
● Effusion​: disruption of the mechanisms of serous fluid formation and reabsorption that causes
an i​ ncrease in fluid between membranes
: accumulation of fluids in the tissue spaces
❏ Primary causes​ are:
➢ Increased hydrostatic pressure (congestive heart failure)
➢ Decreased oncotic pressure (hypoproteinemia)
➢ Increased capillary permeability (inflammation and infection)
➢ Lymphatic obstruction (tumors)

Pathologic Causes of Effusions

Increased capillary hydrostatic pressure Congestive heart failure

Salt and fluid retention

Decreased oncotic pressure Nephrotic syndrome

Hepatic cirrhosis
Malnutrition
Protein-losing enteropathy

Increased capillary permeability Microbial infections

Membrane inflammations
Malignancy

Lymphatic obstruction Malignant tumors, lymphomas

Infection & inflammation
Thoracic duct injury

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 AUBF LECTURE M10 CHAP12: SEROUS FLUID

Specimen Collection & Handling

● Collected by ​needle aspiration f​ rom the respective cavities

● Aspiration procedures
❏ Thoracentesis​: pleural
❏ Pericardiocentesis​: pericardial
❏ Paracentesis​: peritoneal
● Abundant fluid of ​>100 mL i​ s usually collected
● Tubes
❏ EDTA tube​: cell counts and the differential
❏ Sterile heparinized​ or ​sodium polyethanol sulfonate (SPS) evacuated tubes​:
microbiology and cytology
❏ Plain tubes​ or h ​ eparin tubes​: chemistry tests on clotted specimens
● Centrifugation​: concentration of large amounts of fluid for better recovery of microorganisms
and abnormal cells
● pH specimens​: maintained anaerobically in ice
● Chemical tests on serous fluids are frequently compared with plasma chemical concentrations =
fluids are essentially plasma ultrafiltrates
❏ Blood specimens should be obtained at the time of collection

Transudates and Exudates

Categorization of Effusion

Transudate Effusions Transudate: fluid Occur during various Examples:

pushed through the systemic disorders that Changes in the
capillary due to high disrupt fluid filtration, hydrostatic pressure
pressure within the fluid reabsorption, or - Congestive heart
capillary. both. failure
- Hypoproteinuria,
associated with
the nephrotic
syndrome

Exudate Effusions Exudate: fluid that Occur during Examples:

leaks around the cells inflammatory processes Infection
of the capillaries caused that result in damage to Inflammations
by inflammation. blood vessel walls, body Hemorrhages
cavity, membrane Malignancies
damage, or decreased
reabsorption by the
lymphatic system.

Produced by conditions
that directly involve the
membranes of the
particular cavity

● Classifying a serous fluid as a transudate or exudate can provide valuable initial diagnosis step
and aid in the course of further laboratory testing
❏ Because it is usually ​not necessary to test transudate fluids

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 AUBF LECTURE M10 CHAP12: SEROUS FLUID

● Laboratory Tests
❏ Appearance
❏ Total protein
❏ Lactic dehydrogenase
❏ Cell counts
❏ Spontaneous clotting
● Most reliable differentiation​: determining the ​fluid blood ratios for protein​ and ​lactic
dehydrogenase

General Laboratory Procedures

● Tests usually performed on ​ALL s​ erous fluids

❏ Evaluation of the appearance
❏ Differentiation between transudate and exudate
● Effusion of exudative origin​ = examined for the p ​ resence of microbiologic and cytogolic
abnormalities
● RBC a​ nd ​WBC = ​ N​ OT ​routinely performed on serous fluid
❏ They provide little diagnostic information
● WBC​: ​>1000 u/L RBC​: ​>100 000 u/L = to indicate an e
​ xudate
● Serous fluid cell counts: m​ anually by Newbauer chamber
❏ Include a count of all ​nucleated cells
● Serous fluid cell counts: e ​ lectric cell counters
❏ Inclusion of ​tissue cells and debris
● Differential cell counts​: routinely performed on serous fluids preferably on W ​ right’s stained​,
cytocentrifuged specimens​ or on s​ lides prepared ​from the sediment of centrifuged specimens
● Smears​: must be examined not only for WBC, but also for normal and malignant tissue cells.
❏ Any suspicious cells = cytology laboratory or pathologist

Laboratory Differentiation of Transudates and Exudates

Transudates Exudates

Appearance Clear Cloudy

Fluid: Serum Protein Ratio <0.5 >0.5

Fluid: Serum LD Ratio <0.6 >0.6

WBC Count <1000 u/L >1000 u/L

Spontaneous clotting No Possible

Pleural Fluid: Cholesterol <45 to 60 mg/dL >45 to 60 mg/dL

Pleural Fluid: Serum Cholesterol Ratio <0.3 >0.3

Pleural Fluid: Bilirubin Ratio <0.6 >0.6

Serum-ascites albumin gradient >1.1 <1.1

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 AUBF LECTURE M10 CHAP12: SEROUS FLUID

PLEURAL FLUID

● Obtained from the pleural cavity, located between the parietal pleural membrane lining the chest
wall and the visceral pleural membrane covering the lungs
● May be either transudative or exudative
● Pleural fluid cholesterol:​ ​>60 mg/dL
Pleural fluid: serum cholesterol ratio​: ​>0.3
Pleural fluid: serum total bilirubin ratio: > ​ 0.6
= fluid is an ​exudate
● Normally contains l​ ess than 30 ml​ of fluid.
● Pleural effusions occur when fluid accumulates around the lungs.
❏ Thoracentesis​: performed to r​ emove​ this ​excess fluid​.

Appearance

● Normal ​and t​ ransudate​: c​ lear ​and p

​ ale yellow
● Turbidity​: ​presence of WBCs = ​ indicates ​bacterial infection​, t​ uberculosis​, or an i​ mmunologic
​disorder​, such as rheumatoid arthritis
● Presence of blood​: h ​ emothorax (​ traumatic injury), membrane damage such as occurs in
malignancy, or traumatic aspiration
❏ Traumatic tap​: streaked and uneven
● Hemothorax vs hemorrhagic exudate
❏ Blood from ​hemothorax​: the fluid hematocrit is more than ​50% of the whole blood
hematocrit, ​because the effusion comes from the inpouring of blood from the injury
❏ A chronic membrane disease effusion contains both blood and increased pleural fluid,
resulting in a much ​lower hematocrit
● Milky pleural fluid​: ​presence of chylous material​ from thoracic duct leakage or to
pseudochylous material produced in chronic inflammatory conditions
❏ Chylous material​: high concentration of ​triglycerides
❏ Pseudochylous material​: higher concentration of ​cholesterol
➔ Sudan III staining​: strongly positive with ​chylous material

Differentiation Between Chylous and Pseudochylous Pleural Effusions

Chylous Effusion Pseudochylous Effusion

Cause Thoracic duct damage Chronic inflammation

Lymphatic obstruction

Appearance milky/ white milky/ green tinge

Leukocytes Predominantly lymphocytes Mixed cells

Cholesterol crystals Absent Present

Triglycerides >110 mg/dL <50 mg/dL

Sudan III staining Strongly positive Negative/weakly positive

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 AUBF LECTURE M10 CHAP12: SEROUS FLUID

Hematology Tests

● Differential cell count​: most diagnostically significant hematology test performed on serous
fluids
● Primary cells associated with pleural fluid
❏ Macrophages​: ​64% to 80%​ of a nucleated cell count
❏ Neutrophils​: ​1% to 2%
❏ Lymphocytes​: ​18% to 30%
❏ Eosinophils
❏ Mesothelial cells
❏ Plasma cells
❏ Malignant cells

Significance of Cells Seen in Pleural Fluid

CELLS SIGNIFICANCE

Neutrophils Pancreatitis
Pulmonary infarction

Lymphocytes Tuberculosis
Viral infection
Autoimmune disorders
Malignancy

Mesothelial cells Normal and reactive forms have no clinical significance

Decreased mesothelial cells are associated with tuberculosis

Plasma cells Tuberculosis

Malignant cells Primary adenocarcinoma and small-cell carcinoma

Metastatic carcinoma

● Lymphocytes​: normally noticeably p ​ resent in both transudates and exudates​ in a variety of

forms, including small, large, and reactive
❏ More prominent nucleoli and cleaved nuclei may be present
❏ Elevated lymphocyte counts​: effusions resulting from t​ uberculosis​, v​ iral infection​s,
malignancy​, and ​autoimmune disorders​ such as rheumatoid arthritis and systemic lupus
erythematosus.
● Increased eosinophil levels​ (​>10%​): trauma resulting in the p ​ resence of air​ or b
​ lood
(​pneumothorax ​and ​hemothorax​) in the pleural cavity.
❏ Seen in a ​ llergic reactions​ and ​parasitic infections
● Mesothelial cells​: lines the membranes of serous cavities
❏ Pleomorphic
❏ Resemble lymphocytes, plasma cells, and malignant cells, frequently making identification
difficult.
❏ “​Normal​” mesothelial cells: single small or large round cells; abundant blue cytoplasm;
round nuclei with uniform dark purple cytoplasm
❏ “​Reactive​” mesothelial cells: clusters; have varying amounts of cytoplasm, eccentric nuclei,
and prominent nucleoli; and be multinucleated, thus more closely resembling malignant cells
❏ Increase in mesothelial cells​: not a diagnostically significant finding, but they may be
increased in ​pneumonia a ​ nd ​malignancy

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 AUBF LECTURE M10 CHAP12: SEROUS FLUID

❏ Lack of mesothelial cells:​ ​tuberculosis​, which results from exudate covering the pleural
membranes.
➔ Tuberculosis​: increase in the presence of pleural fluid plasma cells
● Primary concern in examining all serous effusions​: ​detection of malignant cells
● Malignant pleural effusions​: contain large, irregular adenocarcinoma cells, small or oat cell
carcinoma cells resembling large lymphocytes, and clumps of metastatic breast carcinoma cells

Chemistry Tests

● The ​most common chemical test​ performed on pleural fluid are:

❏ Glucose
❏ pH
❏ Adenosine deaminase (ADA)
❏ Amylase

Significance of Chemical Testing of Pleural Fluid

TEST SIGNIFICANCE

Glucose Decreased in rheumatoid inflammation, tuberculosis

Decreased in purulent infection

Lactate Elevated in bacterial infection

Triglyceride Elevated in chylous effusions

pH Decreased in pneumonia not responding to antibiotics

Markedly decreased with esophageal
rupture

ADA Elevated in tuberculosis and

malignancy

Amylase Elevated in pancreatitis, esophageal

rupture, and malignancy

● Decreased pleural fluid glucose levels​: tuberculosis, rheumatoid inflammation, and purulent
infections.
❏ Decreased Pleural fluid glucose​:​ < 60 mg/dL
● Pleural fluid pH​: ​lower than 7.2​ may indicate the need for ​chest-tube drainage​, in addition to
administration of antibiotics in cases of p ​ neumonia​.
❏ In cases of a ​ cidosis​, the pleural fluid pH should be compared with the ​blood pH​.
❏ Pleural fluid pH​ at least 0 ​ .30 degrees lower​ than the blood pH is considered significant.
❏ pH value ​as low as 6 ​ .0​ indicates an ​esophageal rupture​ that is allowing the influx of gastric
fluid.
● ADA levels:​ h ​ igher than 40 U/L​ are highly indicative of ​tuberculosis​.
● Elevated amylase levels​ are associated with p ​ ancreatitis​, and amylase is o
​ ften elevated first in
the pleural fluid.
❏ Pleural fluid amylase​, including s ​ alivary amylase:​ ​elevated ​in e
​ sophageal rupture​ and
malignancy​.

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Microbiologic and Serologic Tests

Microorganisms primarily associated with pleural effusions include:

★ Staphylococcus aureus,
★ Enterobacteriaceae,
★ Anaerobes,
★ Mycobacterium tuberculosis

Microbiological tests that are performed on pleural fluid when clinically indicated are:
★ Gram stains,
★ cultures (both aerobic and anaerobic),
★ acid-fast stains, and
★ Mycobacteria cultures

SEROLOGIC TESTS of pleural fluid

❖ Used to differentiate effusions of immunologic origin from noninflammatory processes
❖ Tests for antinuclear antibody (ANA) and rheumatoid factor (RF)​ are the ​most frequently
performed​.
➢ Detection of these tumor markers provide valuable diagnostic information in
effusions of malignant origin:
■ Carcinoembryonic antigen (CEA),
■ CA 125 (metastatic uterine cancer),
■ CA 15.3 and CA 549 (breast cancer), and
■ CYFRA 21-1 (lung cancer)

PLEURAL FLUID TESTING ALGORITHM

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 AUBF LECTURE M10 CHAP12: SEROUS FLUID

PERICARDIAL FLUID

● Small amount (​10 to 50 mL​) of fluid is found between the pericardial serous membranes
● Pericardial effusions​: result of changes in the membrane permeability due to
❏ Infection (pericarditis)
❏ Malignancy
❏ Trauma-producing exudate
● Transudates​: caused primarily by m ​ etabolic disorders​ such as uremia, hypothyroidism, and
autoimmune disorders
● Effusion​: suspected when c​ ardiac compression​ (​tamponade​) is noted during the physician’s
examination

Significance of Pericardial Fluid Testing

Test Significance

Appearance

Clear, pale yellow Normal, transudate

Blood-streaked Infection, malignancy

Grossly bloody Cardiac puncture, anticoagulant medications

Milky Chylous and pseudochylous materia

Additional testing

Increased neutrophils Bacterial endocarditis

Malignant cells Metastatic carcinoma

Carcinoembryonic Metastatic carcinoma

antigen

Gram stain and Bacterial endocarditis

culture

Acid-fast stain Tubercular effusion

Adenosine deaminase Tubercular effusion

Appearance

● Normal ​and t​ ransudate pericardial fluid​: ​clear a ​ nd pale yellow

● Turbid​: Effusions resulting from i​ nfection​ and ​malignancy
❏ Malignant effusions: ​frequently b ​ lood streaked​.
❏ Grossly bloody effusions​: associated with a ​ ccidental cardiac puncture​ and ​misuse of
anticoagulant medications​.
● Milky fluids:​ representing ​chylous ​and ​pseudochylous effusions ​may also be present.

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 AUBF LECTURE M10 CHAP12: SEROUS FLUID

Laboratory Tests

● Tests performed on pericardial fluid​: determining whether the fluid is a transudate or an

exudate and include the f​ luid:serum protein​ and ​lactic dehydrogenase (LD) ratios​.
● WBC counts​: little clinical value
❏ A count of > ​ 1000 WBCs/µL​ with a ​high percentage of neutrophils​ = b ​ acterial endocarditis
● Cytologic examination of pericardial exudates for the p ​ resence of malignant cells ​is an important
part of the fluid analysis.
● Cells most frequently encountered​: result of m ​ etastatic lung​ or ​breast carcinoma​ and
resemble those found in pleural fluid.
● Bacterial cultures and Gram stains​: performed on c​ oncentrated fluids​ when e ​ ndocarditis​ is
suspected.
● Infections: f​ requently ​caused by previous respiratory infections
❏ Streptococcus
❏ Staphylococcus
❏ Adenovirus
❏ Coxsackievirus
● Effusions of tubercular origin​ are increasing ​as a result of AIDS​.
❏ Acid-fast stains and chemical tests for adenosine deaminase​: often requested on
pericardial effusions​.

PERITONEAL FLUID
● Ascites: ​accumulation of fluid​ between the peritoneal membranes.
❏ Ascitic fluid:​ ​common term​ for this fluid rather than peritoneal fluid
● Hepatic disorders, ​such as c​ irrhosis​ =
​ ​frequent causes of ascitic transudates
● Most frequent causes of exudative fluids:
❏ Bacterial infections (peritonitis)​: often as a ​result of intestinal perforation o ​ r a​ ruptured
appendix
❏ Malignancy
● Normal Saline: ​introduced into the peritoneal cavity as a lavage to d ​ etect abdominal injuries
that have not yet resulted in fluid accumulation.
● Peritoneal lavage:​ sensitive test to ​detect intra-abdominal bleeding in blunt trauma cases
❏ Results of the RBC count can be used along with radiographic procedures to aid in
determining the need for ​surgery
❏ RBC > 100,000/mL​ = indicative of b ​ lunt trauma injuries
● To detect infection:
❏ Cell counts​ and ​differentials ​may also be requested on fluid from p ​ eritoneal dialysis
● To detect allergic reactions to the equipment or introduction of air into the peritoneal
cavity:
❏ Eosinophil count

Transudates VS Exudates

● Serum-ascites albumin gradient (SAAG): r​ ecommended over the​ fluid:serum total protein
and ​LD rations​ to detect transudates of hepatic origin
● Fluid and serum albumin levels​ are measured concurrently
❏ The fluid albumin level is then ​subtracted​ from the serum albumin level.
➔ A ​difference (gradient) of 1.1 or greater​ suggests a ​transudate effusion of hepatic
origins.
➔ Lower gradients​ are associated with e ​ xudative effusions.

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➔ Example:

SIGNIFICANCE OF PERITONEAL FLUID TESTING

TEST SIGNIFICANCE

APPEARANCE

Clear, pale yellow Normal

Turbid Microbial infection

Green Bile, gallbladder, pancreatic disorders

Blood-streaked Trauma, infection or malignancy

Milky Lymphatic trauma and blockage

Peritoneal lavage >100,000 RBCs/uL indicates blunt trauma injury

WBC COUNT

<500 cells/uL Normal

>500 cells/uL Bacterial peritonitis, cirrhosis

Differential Bacterial peritonitis, malignancy

Carcinoembryonic antigen Malignancy of gastrointestinal origin

CA 125 Malignancy of ovarian origin

Glucose Decreased in tubercular peritonitis, malignancy

Amylase Increased in pancreatitis, gastrointestinal

perforation

Alkaline phosphatase Increased in gastrointestinal perforation

Blood urea nitrogen/ creatinine Raptured or punctured bladder

Gram stain and culture Bacterial peritonitis

Acid-fast stain Tubercular peritonitis

Adenoside deaminase Tubercular peritonitis

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 AUBF LECTURE M10 CHAP12: SEROUS FLUID

Appearance

● NORMAL: c​ lear and pale yellow

● EXUDATES​: turbid with bacterial or fungal infections.
● GREEN o ​ r ​DARK BROWN​: presence of bile
● BLOOD-STREAKED FLUID​: after trauma and with tuberculosis, intestinal disorders, and
malignancy.
● CHYLOUS o ​ r ​PSEUDOCHYLOUS MATERIAL​: present with trauma or lymphatic vessels
blockage

Laboratory Tests

● Normal WBC Count​: ​<350 cells/µL​,

❏ Count increases with ​bacterial peritonitis​ and ​cirrhosis​.
● Absolute neutrophil count​: ​>250 cells/µL o ​ r>​ 50% of the total WBC count​ = i​ nfection​.
● Lymphocytes​: predominant cell in t​ uberculosis​.

Cellular Examination

● Examination of ascitic exudates​ for the p ​ resence of malignant cells​ is important for
detecting tumors of primary and metastatic origin​.
● Malignancies​: most frequently of ​gastrointestinal​, p ​ rostate​, or o
​ varian origin​.
● Other cells present in ascitic fluid include:
❏ Leukocytes
❏ Abundant mesothelial cells
❏ Macrophages, including lipophages
● Microorganisms including b ​ acteria​, y​ east​, and T​ oxoplasma gondii​ may also be present
● Malignant cells of ovarian​, p ​ rostatic​, and c ​ olonic origin​, often containing mucin-filled
vacuoles, are frequently seen
● Psammoma bodies containing concentric striations of collagen-like material​ can be
seen in ​benign conditions​ a​ nd are also associated with o ​ varian a
​ nd ​thyroid malignancies

Chemical Testing

● Chemical examination of ascitic fluid consists primarily of ​glucose​, a ​ mylase​, and a ​ lkaline
phosphatase determinations​.
❏ Glucose​: ​decreased below serum levels​ in ​bacterial a ​ nd ​tubercular peritonitis a
​ nd
​malignancy​.
❏ Amylase​: determined on ascitic fluid to a ​ scertain cases of pancreatitis​,
➔ Elevated​ in patients with ​gastrointestinal perforations​.
● Elevated alkaline phosphatase level​: also highly diagnostic of ​intestinal perforation​.
● Blood urea nitrogen​ and ​creatinine ​in the fluid are requested when a r​ uptured bladder​ or
accidental puncture of the bladder​ during the p ​ aracentesis i​ s of concern.
● Bilirubin​: l​eakage of bile into the peritoneum​ is suspected following trauma or surgery.
❏ Bile ​contains primarily c​ onjugated bilirubin​; therefore, a test for total bilirubin is acceptable.
● Amylase ​or l​ ipase: ​to determine whether the pancreatitis or damage to the pancreas is
accounting for the a ​ ccumulation of these pancreatic enzymes​ in the ascitic fluid

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 AUBF LECTURE M10 CHAP12: SEROUS FLUID

Microbiology Tests

● Gram stains​ and ​bacterial cultures​ for both aerobes and anaerobes: performed when
bacterial peritonitis​ is suspected.
● Inoculation of fluid into blood culture bottles​ at the bedside ​increases the recovery of
anaerobic organisms​.
● Acid-fast stains​, ​adenosine deaminase​, and c ​ ultures for tuberculosis m​ ay also be
requested.

Serologic Tests

● Measurement of the tumor markers C ​ EA​ and ​CA 125​: valuable procedure for i​ dentifying the
primary source of tumors​ producing a ​ scitic exudates​.
❏ Presence of C ​ A 125 antigen​ with a n ​ egative CEA​ suggests the source is from the ​ovaries​,
fallopian tubes​, or ​endometrium

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