FECALYSIS

FECAL EXAMINATION

> Macroscopic
> Microscopic
> Chemical analyses
o Detection of GI malignancies/bleeding
o Liver and biliary duct disorder
o Maldigestion/malabsorption syndrome
o Inflammation
o Causes of diarrhea and steatorrhea
> Detection and id of bacteria and parasite

WHAT IS A FECES?

> Human feces is called as stool.

> Faeces / feces is plural of latin term “faex” meaning residue.
> It is the waste residue of indigestible materials of an animal’s digestive tract expelled through the anus
during defecation.
> Meconium is newborn’s first feces.
> Scatology or coprology is the study of feces.

PHYSIOLOGY
> Bacterial metabolism:
o Produces strong odor and flatus
o Lactose intolerance leads to excessive gas production
> Small intestine:
o Major site for final breakdown and reabsorption of compounds
> Digestive enzymes:
o Trypsin, chymotrypsin, lipase, and amino peptidase and lipase
DIARRHEA

− Increase daily stool (above 200g)

− Increased liquidity and frequency of more than three times per day.
− Classification:
o Illness duration
o Mechanism
o Severity
o Stool characteristics

MAJOR MECHANISM
− Secretory
− Osmotic
− Intestinal hypermotility.

SECRETORY DIARRHEA
− Secretory - bacterial, viral, and protozoan infections produce increased secretion of water and
electrolytes, which override the reabsorptive ability of the large intestine

− MECHANISM:
o Usually caused by an organism that produces a toxin that stimulates adenylase cyclase enzyme
that leads to crampy diarrhea & secretion of intestinal fluid
− Stools are characterized as watery and voluminous with no rbc, wbc & mucus
− CAUSATIVE AGENT
o Vibrio cholerae
o Etec (traveler’s bacterial diarrhea)
o giardia lamblia
INVASIVE DIARRHEA
− Mostly caused by bacteria
− MECHANISM:
o Invasive organisms destroys the mucosal lining of the intestines producing pus, blood and mucus
in stool.
− Stool may contain wbc, rbc, & specks of mucus; and sometimes the organism.
− Patient is experiencing tenesmus.
− CAUSED BY:
o Shigella dysenteriae
o Entamoeba histolytica
o Eiec
o Campylobacter jejuni
o yersinia enterocolitica
OSMOTIC DIARRHEA
− Osmotic- incomplete breakdown or reabsorption of food presents increased fecal material to the large
intestine, resulting in the retention of water and electrolytes in the large intestine
− MECHANISM:
o Usually caused by inefficient reabsorption of an osmotic substance due to an enzyme deficiency
− Stool samples are watery & gaseous with no wbc, rbc & mucus
− Positive for the substances not reabsorbed (lactose; a reducing sugar, fat globules and muscle fibers)
− CAUSES:
o Lactose intolerance
o Pancreatic insufficiency

DIFFERENTIAL FEATURES FOR DIARRHEA

LABORATORY OSMOTIC SECRETORY

TEST DIARRHEA DIARRHEA

Osmotic gap >50 Osm/kg <50 Osm/kg

Stool Na <60 mml/L >90 mmol/L

Stool output in 24 <200 g >200 g

hours

pH <5.3 >5.6

Reducing Positive Negative

substances

COMMON FECAL TEST FOR DIARRHEA

SECRETORY OSMOTIC
 Stool cultures Microscopic fecal fats

Ova and parasite Muscle fiber detection

examination
Qualitative fecal fats
Rotavirus immunoassay
Trypsin screening
Fecal leukocytes
Microscopic fecal fats

Muscle fiber detection

Quantitative fecal fats

Clinitest

D-xylose tolerance test

Lactose tolerance test

Fecal electrolytes

Stool pH

Fecal osmotality

ALTERED MOTILITY
− Altered motility describes conditions of enhanced motility (hypermotility or slow motility (constipation)
− Both can be seen in irritable bowel syndrome (ibs),
o A functional disorder in which the nerves and muscles of the bowel are extra sensitive, causing
cramping, bloating, flatus, diarrhea, and constipation

STEATORRHEA

− Increase fat in stool (>6g/day)

o Absence of bile salts that assist pancreatic lipase in the breakdown and subsequent reabsorption
of triglycerides
− CONDITIONS ASSOCIATED:
o Pancreatic disorders:
o Cystic fibrosis
o Chronic pancreatitis
o Carcinoma that decrease the production of pancreatic enzymes
D-XYLOSE TEST:
− Distinguish steatorrhea in maldigestion and malabsorption condition
− D-xylose is a sugar that does not need to be digested but does need to be absorbed to be present in the
urine
− A normal d-xylose test indicates pancreatitis

SPECIMEN COLLECTION
− Container:
o Any clean, nonbreakable, leakproof container
− The type and amount depends on the type of test ordered
o For fecal occult blood, wbcs or qualitative fat, only a small specimen is required
o Quantitative fecal fat analysis  72-hour specimen
− The technologist must be aware of contaminants such as urine, water or paper

MACROSCOPIC EXAMINATION
− Color
− Consistency
− Form

MACROSCOPIC SCREENING: COLOR

BLACK/
PALE YELLOW,
TARRY
RED GREEN
WHITE, GRAY
> UGIT > LGIT > Bile duct > Biliverdin
> Iron therapy > Beets obstruction > Oral
> Charcoal intake > Barium antibiotics
intake > Rifampin intake > Green
> Bismuth intake vegetables
intake

o Normal color is brown

> Urobilinogen is converted to urobilin and stercobilin
o Pale color signifies biliary obstruction (acholic stool)
o Bleeding
> Ugit black (melena) stools
> Lgit red stools (hematochezia)

CONSISTENCY
FORMED

HARD

WATERY
FORM
> Cylindrical
o Normal
> Ribbon-like
o Intestinal strictures such as tumor blockage
> Small, round / scybalous
o Constipation
> Bulky and frothy
o Steatorrhea
> Mucoid
o Colitis, constipation

MACROSCOPIC SCREENING: CONSISTENCY

Bulky frothy Mucus and blood-

Ribbon-like stool
stool streaked stool

> Bile duct > Intestinal > Amoebic colitis

obstruction constriction > Dysentery
> Pancreatic due to > Malignancy
insufficiency malignancy
(colon cancer)
ODOR
− Basically depends on the pH of the stool and indole and skatole are the substances that produce normal
odor formed by intestinal bacterial fermentation and putrefaction.
− A foul odor is caused by degradation of undigested protein and excessive carbohydrate intake.
− Sickly sweet odor is produced by undigested lactose.

CHEMICAL EXAMINATION:
FECAL OCCULT BLOOD
> Hidden blood, not seen by microscopic
examination
> Normally found in small amount, 2.5ml/ 150
grams of stool.
> Screening test for colorectal cancer & git bleeding
➢ 2.5ml/ 150 grams of stool is significant!
> Principle:
o Based on the Pseudoperoxidase activity
of hemoglobin molecule reacting with
the chromogen
> Gum guiac is commonly used because it is not too
sensitive (avoids high false positive)
> Benzidine is the most sensitive chromogen
> O-tolidine
> Positive result: blue chromogen

− Substances that may also exhibit

Pseudoperoxidase activity/ reaction:
o Hemoglobin
o Myoglobin
o Vegetables
o Fruits
− Dietary restrictions 3 days before the examination
o Red meat
o Horse radish
o Melons
o Raw broccoli
o Turnip
o Vitamin c and iron

FALSE POSITIVE FALSE NEGATIVE

REACTION REACTION
 > NSAIDS > Vitamin C and Iron
> Contamination of intake
menstrual blood
> Hemorrhoids
> Non adherence to diet
advice

IMMUNOCHEMICAL FECAL OCCULT BLOOD TEST

− HEMOCCULT ICT (IFOBT)  specific for globin portion of human hemoglobin. Uses anti – human
hemoglobin antibodies.
− It does not require dietary or drug restrictions.
− It is more sensitive to lower GI bleeding that could be an indicator of colon cancer or other GI disease and
can be used for patients who are taking aspirin and other anti-inflammatory medications.

PORPHYRIN – BASED FECAL OCCULT BLOOD TEST

− HEMOQUANT – offers a porphyrin-based fobt fluorometric test for hemoglobin based on the conversion
of heme to fluorescent porphyrins. The test
− Measures both intact hemoglobin and the hemoglobin that has been converted to porphyrins.

CHEMICAL EXAMINATION: APT TEST

− Determines if infant’s stool or vomitus is fetal or maternal in origin
− PRINCIPLE:
o “fetal blood resist alkali denaturation (remains pink) while maternal blood is sensitive to alkali
denaturation (yellow brown).”
− Procedure:
o Specimen in emulsified with water, centrifuged then added with 1% naoh.
− Result:
o Maternal blood is denature = YELLOWISH BROWN
o Fetal flood is unchanged = PINK

QUANTITATIVE FECAL FAT TESTING

− Confirmatory test for steatorrhea
− Collection of 3-day fecal specimen
− Method: van de Kamer titration (gold standard)
− Rapid test: acid steatocrit

ACID STEATOCRIT

1. Dilute 0.5g of feces from a spot collection 1 to 4 with deionized water

2. Vortex for 2 minutes to homogenize the specimen
3. Add a volume of 5N perchloric acid equal to 20% of the homogenate and then vortex the mixture for 30
seconds Confirm the pH to be <1
4. Place the acid-homogenate mixture in a 75-L plain hematocrit capillary tube. Seal the end with wax
 5. Centrifuge the capillary tube horizontally at 13,000 rpm for 15 minutes in a microhematocrit centrifuge.
This separates fat as an upper layer overlying a solid fecal layer
6. Measure the length of the fat and solid layers using a magnifying lends
7. Calculate he ac1 teat
8. Calculate the fecal fat in grams per 24 hours
> The acid steatocrit in percent (fatty layer length in cm) [(fatty Layer length in cm) + (solid layer
length)] X 100
> The fecal fat for adults 1 quantitated as follow
> Fecal fat in grams per 24 hours = [10.45 X (acid steatocrit in percent as a whole number)] – 0.43
> An acid steatocrit value <31 is considered normal while a value >31% indicates steatorrhea in
adults
> The fecal fat for children up to the age of 15 years is as follows
> Fecal fat in grams per 24 hours = [0.1939 X (acid steatocrit in percent as a whole number)] –
l0.2174

> Acid steatocrit is higher in infants and lowers with age

> An acid steatocrit of <10% indicates steatocrit in children

MICROSCOPIC EXAMINATION

> WBCS
> INCREASED FECAL FAT
> MEAT OR MUSCLE FIBERS

MICROSCOPIC SCREENING:
− Fecal WBCS are seen in bacterial dysentery and ulcerative colitis.
− Invasive organisms are positive for fecal WBC.
− Toxin producing organisms are negative for fecal WBC.
− Wet preparation with methylene blue, gram’s stain or wright’s stain
− 3 WBC/ HPF is significant
− Lactoferrin latex agglutination test
− Detects fecal WBC even on frozen specimen
 − WBCS
o Neutrophils:
▪ Infection or inflammatory intestinal mucosal wall
▪ Bacteria (salmonella, shigella, campylobacter, yersinia, and e. Coli)
o CLINICAL SIGNIFICANCE:
▪ Ulcerative colitis
▪ Dysentery (bacterial)
▪ Ulcerative diverticulitis
▪ Intestinal tb
▪ Abscess

MICROSCOPIC SCREENING: MUSCLE FIBER

− Signifies pancreatic insufficiency (acute and chronic pancreatitis, cystic fibrosis)
o Usually associated with bulky frothy stool with lots of fecal fat
− Gastrocolic fistula (abnormal connection of the stomach and intestine)

− PROCEDURE:
o Stool with 10% eosin
o Examine slides for 5 minutes
o Count the striated muscle fibers
− Digested meat fibers has no striations
− Partially digested fibers has 1 striation
− Undigested fibers has 2 striations (more than ten per slide is significant)

MICROSCOPIC SCREENING: QUALITAIVE FECAL FAT

− Done in cases of steatorrhea and malabsorption syndromes
− TYPES OF FATS:
o Neutral fat (tag)
o Fatty acid salts or soaps
o Fatty acid
o Cholesterol
− Stain used are Sudan 3(most commonly used), 4 or ORO
− Neutral fat stain
o Mix stool with Sudan 3
o Count the large orange-red droplets
o >60 droplets/HPF is significant
− Split fat stain measures “total fecal fat”
o Mix stool with acetic acid and heat. It measures soap and fatty acid
o Count and take note of size of fat droplets
o Normal is 100 small droplets <4 um in diameter (6 to 75 um is significant)
− Cholesterol Fecal Fat
o Stool is mixed with Sudan 3 then heated.
o Allow to cool and then look for cholesterol crystals (notched-end rhombic plates)