CLINICAL PARASITOLOGY LAB

MACROSCOPIC AND CHEMICAL EXAMINATION OF FECES

The examination of fecal material starts not only on the microscopic examination of the sample for
parasitic disease but the first step for a proper correlation and disease diagnosis is the macroscopic and
chemical evaluation. Evaluating both Macroscopic and Chemical parameter of the stool specimen would give a
great enlighten and correlation to the current status of the patient. These parameters are sometimes
neglected but each variation of each parameter would indicate one condition to another. A simple macroscopic
examination would tell the physician either an underlying or significant disease. Chemical test would serve also
screening test for certain diseases. Thus both testing of these areas must be done to complete the proper
stool examination.
IMPORTANCE OF MACROSCOPIC EXAMINATION
 Gross examination must be done before proceeding to microscopic analysis
 It helps in correlating microscopic findings to gross physical characteristics
PARAMETERS IN MACROSCOPIC EXAMINATION
 It is not purely microscopic examination, it includes gross examination of the physical characteristics of
stool sample.
a. Amount
b. Color
c. Odor
d. Form
e. Consistency
f. Presence of adult worms (proglottids of tapeworm)
g. Presence of blood streaks and mucus
AMOUNT
 Normal Output is 100 to 200 grams stool passed per day
 Diarrhea is evident when an increase in daily stool weight is above 200 g with increased liquidity and
frequency of more than three (3) times a day
 Steatorrhea happens when there is increase in stool fat exceeding 6 grams per day
ODOR
 Normal odor of feces is offensive but not excessively foul cue to intestinal putrefaction forming indole
and skatole
 When stool specimen is Excessively foul it means sample’s pH is alkaline due to ulcers in malignancy,
syphilis and gangrenous dysentery
 Sour and Rancid feces odor indicates gas formation, carbohydrate fermentation or hyperacidity
COLOR
 Normal fecal specimen is brown to dark brown due to oxidation of stercobilinogen to urobilin
(stercobilin)
COLOR/ APPEARANCE POSSIBLE CAUSE
Black Upper gastrointestinal bleeding
Iron therapy
Charcoal
Bismuth (antacids)
Red Lower gastrointestinal bleeding
Beets and food coloring
Rifampin
Pale yellow, White, gray Bile duct obstruction
Barium sulfate
Green Biliverdin/ oral antibiotics
Green vegetables
 Bulky/ Frothy
Ribbon- like
Mucus/ blood-streaked mucus
BRISTOL STOOL CHART
Bile duct obstruction
Pancreatic disorders
Intestinal obstruction
Colitis
Dysentery
Malignancy
Constipation
BRISTOL STOOL CHART
Type 1 Separate hard lumps, like nuts (hard to pass)

Type 2 Sausage-shaped, but lumpy

Type 3 Sausage- shaped, but with cracks on surface

Type 4 Sausage or snake like, smooth and soft

Type 5 Soft blobs with clear- cut edges (easy to pass)

Type 6 Fluffy pieces with ragged edges, mushy

Type 7 Watery, no solid pieces (entirely liquid)

STOOL COLOR AND CONSISTENCY REPORTING CODES

COLOR CODE CONSISTENCY CODE
Brown B HARD/ SCYBALOUS (resists puncture) H
Light brown LB WELL-FORMED (light resistance to puncture) WF
Dark brown DB FORMED (can be punctured) F
Yellowish brown YB SOFT (can be cut with applicator) S
Greenish brown GB MUSHY (can be reshaped) MUSHY
Grayish brown GyB LOOSE (too soft) L
Blackish Blkish MUCOID (thick and sticky) MUC
Yellowish Yish DIARRHEIC (flows) D
Greenish Gish WATERY (pours W
Presence of Mucus
 Microscopic quantity is normal for lubrication
 Excessive quantity indicates infection
 Pure mucus indicate dysentery or ileocolitis
Presence of Concretions
 Enteroliths include gallstone, pancreatic calculi and intestinal sands
 Corpoliths are larger than entroliths which appear aas large masses of
feces built around vegetable matter
 All stones are made up of cholesterol
Presence of Parasites
 Whole adult worms or segments of tapeworms can be macroscopically
seen in the fecal material
 Use of hand lens can also be useful
Procedures in Macroscopic Exam
1. Prepare the working area.
2. Carefully open the specimen container. (cover is placed upside down on the working table)
3. Observe the color, odor, form & consistency of the stool sample.
4. Estimate the amount of specimen
5. Note the presence of parasites, undigested food, mucus, pus, blood and fats. (Emulsify the specimen in
NSS and strained through a wire mesh sieve to recover smaller worms.
6. Record your observations.
7. Disinfect the stool sample with Lysol and discard in the biohazard container.
8. Disinfect all used materials with Lysol before washing
CHEMICAL EXAMINATION OF FECES
a. pH ( 6.5 to 7.70
b. Occult blood
c. Gmelin’s test (bile pigments) / Clinitest
d. Qualitative Fecal fat
e. Enzymes
f. APT test
OCCULT BLOOD
 Most frequently performed fecal analysis
 Bleeding excess of 2.5 mL oer 150 grams of stool is pathologically significant, with no visible signs of
bleeding
 Test for suspected cases of GIT disease
 High positive predictive value for detection of Colorectal carcinoma particularly for persons older than
50 years old.
 It is detected based on the detection of the Pseudoperoxidase activity of Hemoglobin and Myoglobin
 The chromogens used in detection are in the following order of decreasing sensitivity
 Benzidine < Ortho-tolidine < Gum Guaiac
BENZIDINE TEST
PRINCIPLE: The heme portion of blood contains peroxidase that reacts with H202 with the liberation of O2.
The liberated O2 oxidizes benzidine to form a blue colored compound.
Procedure:
1. Smear a small amount of feces on a clean filter paper.
2. Add 2 drops of 6% hydrogen peroxide on the smear and 2 drops of Benzidine solution.
3. Observe the color development
immediately.

Interpretation
COLOR GRADING
NO COLOR CHANGE NEGATIVE
GREENISH TINGLE TRACE
LIGHT GREEN 1+
 DARK GREEN 2+
BLUE GREEN 3+
DEEP BLUE 4+

HEMATEST
PRINCIPLE: The test is based on the peroxidase-like reaction. Tartaric Acid and Calcium acetate reacts with
strontium peroxide to form H2O2 with the liberation of O2. The liberated O2 oxidizes orthotoluidine to a blue
color concentration of blood is roughly proportional to the intensity of blue color and space within which it
develops.
Procedure
1. Make a thin smear of feces on a filter paper square.
(DO NOT use emulsion)
2. Place hematest tablet over the fecal smear.
3. Add one drop of water on top of the tablet.
4. Wait for 5-10 seconds and add the second drop of
water onto the filter paper.
5. Observe the color of the filter paper around the tablet
exactly after 2 minutes
Interpretation
 Filter paper around the tablet unchanged for 2 minutes – negative.
 Filter Paper around the tablet turns blue within 2 minutes – positive.
 Ignore any color on tablet & smear & color appearing on the filter
paper after 2 minutes.
Interferences
 MYOGLOBIN is a heme containing compound commonly found on
muscles having a pseudoperoxidase activity like hemoglobin in red
blood cells
 Chemical reactions in Occult blood is based on Oxidation reaction
wherein reducing substances interfere
FALSE POSITIVE FALSE NEGATIVE
Aspirin and Anti-inflammatory medications Vitamin C> 250 mg/d
Red meat Iron supplements containing Vitamin C
Horseradish
Raw broccoli, cauliflower, radishes, turnips
and melons
Menstrual and Hemorrhoid contamination
Resolution
 Fasting of red meat at least 3 days before collection and test
 Do not collect during menstrual period
 Avoid intake of aspirin and anti-inflammatory medicine ( 7 days)
 Limit consumption of broccoli, horseradish and vegetables having high pseudoperoxidase activity for 3
days
 Reducing substances such as Ascorbic acid must be avoided 3 days prior the exam
FOB RAPID TEST DEVICE
PRINCIPLE: is an immunochromatographic in vitro assay for qualitative determination of human hemoglobin
in feces.
Procedure
1. Trying not the spill the buffer, unscrew and remove the cap with the attached applicator stick from the
collection tube.
2. Using the stick, insert into the feces a few times.
 3. Remove excess of feces from the stick by gently
wiping it with an absorbent tissue.
4. Reinsert the stick into the tube and tighten the cap.
5. Shake the tube to ensure proper mixing of sample
with the buffer.
6. Open the sealed pouch containing the FOB rapid test
device.
7. Holding the tube vertically, carefully break the tip of
the purple cap.
8. Invert the collection tube carefully dispense 3-4
drops of the liquid into the sample well of the FOB
testing device
9. Read the results at 3-10 minutes and record.
Interpretation
 Negative - only one colored band appears on the control region.
 Positive - colored band in both control and test region.
 Invalid - total absence of color in both region (indicates procedure error or deteriorated reagent).
* NOTE: Two samples from three different stools should be tested before a negative result is reported
MATERIALS NEEDED:
a) Specimen Cups e) Green wax cellophane immersed in water
b) Clay or Loam Soil f.) Personal Protective Equipment
c) Newspaper or Manila Paper g.) Hypochlorite solution
d) Marker h) distilled water/ tap water
e) Applicator sticks i) Iodine or Tea colored solution
f) Microscope slides j) Wooden spatula/Tongue depressor
g) Coverslips k) Tissue paper
INSTRUCTION:
Based on the Bristol stool chart replicate all consistencies using clay and loam soil as the primary material.
Make sure to demonstrate like inside a laboratory setting with proper PPEs and set-up.
COLLECTION AND MACROSCOPIC EVALUATION
 Prepare different consistencies of stool based on the Bristol stool chart using primarily clay or loam soil
 Put adequate amount of stool in respect to different consistencies
 Show proper labelling of specimen containers and indicate the consistency of the sample
DIRECT FECAL SMEAR PREPARATION
 Demonstrate proper preparation of the following prepared consistencies for DFS
a. FORMED b. Watery
 Show good quality smears with appropriate labelling
 Explain accordingly the significance of each step and reagents used
PRESERVATION AND DISPOSAL
 Demonstrate proper preservation technique for different consistencies
 Present proper fecal material disposal and used materials
 Explain accordingly the significance of each step performed