FECAL
ANALYSIS
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ANN FATIMA G. QUINDAO, RMT, LPT, MPH
Prepared by: ABBLM
Table of Contents
■ Physiology
■ Diarrhea and Steatorrhea
■ Specimen Collection
■ Macroscopic Screening
■ Microscopic Examination of Feces
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■ Chemical Testing of Feces
Physiology
● Normal fecal specimen
○ Bacteria, cellulose, undigested
foodstuffs, GI secretions, bile pigments,
cells from intestinal walls, electrolytes,
and water.
● 100 – 200 g of feces (24-hour period)
● Flatus – bacterial metabolism produces
strong odor associated with feces and
intestinal gas.
● Excessive gas production also occurs in
lactose-intolerant people.
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Physiology
● Digestion of ingested proteins, carbohydrates, and fats takes place
throughout the alimentary tract
● Small intestine - is the primary site for final breakdown and reabsorption.
● Digestive enzymes secreted into the small intestine by the pancreas
include;
○ TRYPSIN, CHYMOTRYPSIN, AMINO PEPTIDASE, AND LIPASE
● Bile salts provided by the liver aid in the digestion of fats.
● A deficiency in any of these substances creates an inability to digest and,
therefore, to reabsorb certain foods.
● Excess undigested or unreabsorbed materials then appear in the feces,
and the patient exhibits symptoms of maldigestion and malabsorption.
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Physiology
● Under normal conditions;
○ Only between 500 to 1500 mL of this fluid reaches the large
intestine
○ Only about 150 mL is excreted in the feces
○ Large intestine is capable of absorbing approximately 3000
mL of water
● Diarrhea- produce when the amount of water reaching the
large intestine exceeds this amount, it is excreted with the solid
fecal material.
● Constipation - provides time for additional water to be
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reabsorbed from the fecal material, producing small, hard
stools.
Diarrhea and Steatorrhea
● DIARRHEA - defined as an increase
in daily stool weight above 200 g,
increased liquidity of stools, and
frequency of more than three times
per day.
● Classified in 4 factors;
○ Illness duration, Mechanism
○ Severity, and Stool
characteristics
● Acute diarrhea - less than 4 weeks
● Chronic diarrhea - more than 4
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weeks
Diarrhea and Steatorrhea
● Major mechanisms; ● Laboratory test used
✓ Secretory ✓ Fecal electrolytes (fecal
sodium, fecal
✓ Osmotic
potassium)
✓ Intestinal hypermotility
✓ Fecal osmolality
✓ Stool pH
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Diarrhea and Steatorrhea
● Normal total fecal osmolarity ● The osmotic gap in all forms of
(290 mOsm/kg) osmotic diarrhea is greater than
● Normal fecal sodium (30 50 mOsm/kg and less than 50
mmol/L) mOsm/kg in secretory diarrhea.
● Fecal potassium (75 mmol/L) ● Electrolytes - increased in
● Fecal osmotic gap secretory diarrhea and negligible
✓ Osmotic gap = 290 - in osmotic diarrhea.
[2 (fecal sodium + ● Fecal fluid pH (less than 5.6) -
fecal potassium)] malabsorption of sugars (osmotic
diarrhea)
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Diarrhea and Steatorrhea
● SECRETORY DIARRHEA - caused by increased secretion of
water.
● Bacterial, viral, and protozoan infections produce
increased secretion of water and electrolytes
● Enterotoxin-producing organisms
○ Escherichia coli, Clostridium, Vibrio cholerae,
Salmonella, Shigella, Staphylococcus, Campylobacter,
protozoa, and parasites such as Cryptosporidium
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Diarrhea and Steatorrhea
● Other causes:
○ Drugs ○ Endocrine disorders
○ Stimulant laxatives (hyperthyroidism,
○ Hormones Zollinger-Ellison
○ Inflammatory bowel syndrome, VIPoma)
disease (Crohn disease, ○ Neoplasms
ulcerative colitis, ○ Collagen vascular
lymphocytic colitis, disease
diverticulitis)
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Diarrhea and Steatorrhea
● OSMOTIC DIARRHEA - caused by poor absorption that
exerts osmotic pressure across the intestinal mucosa.
● Incomplete breakdown or reabsorption of food
presents increased fecal material to the large
intestine, resulting in water and electrolyte
retention in the large intestine.
● Maldigestion and malabsorption - contribute to
osmotic diarrhea
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Diarrhea and Steatorrhea
● The presence of ● Causes of osmotic diarrhea
unabsorbable solute ○ disaccharidase deficiency,
increases the stool osmolality malabsorption, poorly
and the concentration of absorbed sugars, laxatives,
electrolytes is lower, resulting magnesium-containing
in an increased osmotic antacids, amebiasis, and
gap. antibiotic administration
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Fecal Tests for Diarrhea
● Laboratory
testing of feces is
frequently
performed to aid
in determining
the cause of
diarrhea.
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Fecal Tests for Diarrhea
● Differentiates
the features of
osmotic
diarrhea and
secretory
diarrhea.
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Altered Motility
● Describes conditions of enhanced motility or slow motility.
● Can be seen in irritable bowel syndrome (IBS)
○ extra sensitive, causing cramping, bloating, flatus,
diarrhea, and constipation
● IBS can be triggered by food, chemicals, emotional
stress, and exercise.
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Altered Motility
● Intestinal hypermotility is the excessive movement of
intestinal contents through the GI tract.
● Rapid gastric emptying (RGE) - describes hypermotility of
the stomach and the shortened gastric emptying half-
time, which causes the small intestine to fill too quickly
with undigested food from the stomach.
● It is the hallmark of early dumping syndrome (EDS).
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Altered Motility
● Gastric emptying half-time range of 35 to 100 minutes
(varies age and gender)
● Normal gastric emptying is controlled by fundic tone,
duodenal feedback, and GI hormones.
● RGE divided into early dumping and late dumping
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Altered Motility
● Early Dumping Syndrome ● Late Dumping Syndrome
○ symptoms begin 10 to 30 ○ Occurs 2 to 3 hours
minutes following meal after a meal
ingestion ○ Characterized by
○ Nausea, vomiting, weakness,
bloating, cramping, sweating, and dizziness
diarrhea, dizziness, and
fatigue
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Diarrhea and Steatorrhea
● STEATORRHEA (fecal fat) - useful in diagnosing
pancreatic insufficiency and small-bowel disorders that
cause malabsorption.
● Absence of bile salts that assist pancreatic lipase in the
breakdown and subsequent reabsorption of dietary fat
(primarily triglycerides) produces an increase in stool fat
(steatorrhea) that exceeds 6 g per day.
● Steatorrhea may be present in both maldigestion and
malabsorption conditions and can be distinguished by the D-
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xylose test.
Diarrhea and Steatorrhea
● D-Xylose is a sugar that does not need to be digested but
does need to be absorbed to be present in the urine.
● If urine D-xylose is low, the resulting steatorrhea indicates a
malabsorption condition.
● Malabsorption causes include bacterial overgrowth, intestinal
resection, celiac disease, tropical sprue, lymphoma, Whipple
disease, Giardia lamblia infestation, Crohn disease, and
intestinal ischemia.
● Normal D-xylose test indicates pancreatitis
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Specimen Collection
● Stool specimen - a collection of a fecal specimen
● Patients should be instructed to collect the specimen in a
clean container. (bedpan or disposable container)
● Patients should understand that the specimen must not be
contaminated with urine or toilet water
● Containers that contain preservatives for ova and parasites
must not be used to collect specimens for other tests.
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Specimen Collection
● Random specimens suitable for qualitative testing for blood and
microscopic examination for leukocytes, muscle fibers, and fecal
fats are usually collected in plastic or glass containers with screw-
tops.
● For quantitative testing, such as for fecal fats, timed specimens are
required.
● Care must be taken when opening any fecal specimen to slowly
release gas that has accumulated within the container.
● Patients must be cautioned not to contaminate the outside of the
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container.
Macroscopic Screening
● The first indication of GI disturbances
can often be changes in the brown
color and formed consistency of the
normal stool.
● The appearance of abnormal fecal
color may also be caused by
ingestion of highly pigmented foods
and medications, so a differentiation
must be made between this and a
possible pathologic cause.
○ Color
○ Appearance
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Microscopic Examination of Feces
● It is performed to detect the presence of leukocytes
associated with microbial diarrhea and undigested muscle
fibers and fats associated with steatorrhea.
● FECAL LEUKOCYTES - seen in the feces in conditions that
affect the intestinal mucosa, such as ulcerative colitis and
bacterial dysentery.
○ Microscopic screening is performed as a preliminary test
○ Presence or absence of fecal neutrophils can
provide the physician with diagnostic information before
receiving the culture report.
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Microscopic Examination of Feces
● Specimens can be examined: as wet preparations stained with
methylene blue or as dried smears stained with Wright’s or Gram stain.
● A lactoferrin latex agglutination test is available for detecting fecal
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leukocytes and remains sensitive in refrigerated and frozen specimens.
Microscopic Examination of Feces
● MUSCLE FIBERS - Microscopic examination of the feces
for undigested striated muscle fibers can be helpful in
diagnosing and monitoring patients with pancreatic
insufficiency.
● Increased amounts of striated fibers may also be seen
in biliary obstruction and gastrocolic fistulas.
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Microscopic Examination of Feces
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Microscopic Examination of Feces
● Undigested fibers have visible ● Patients should be
striations running both instructed to include red
vertically and horizontally. meat in their diet before
Partially digested fibers collecting the specimen
exhibit striations in only one ● Specimens should be
direction, and digested fibers examined within 24
have no visible striations. Only hours of collection.
undigested fibers are
counted, and the presence
of more than 10 is reported as
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increased
Microscopic Examination of Feces
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Microscopic Examination of Feces
● QUALITATIVE FECAL FATS - Specimens from suspected cases
of steatorrhea can be screened microscopically for the
presence of excess fecal fat (steatorrhea).
● The procedure can also be used to monitor patients
undergoing treatment for malabsorption disorders.
● In general, correlation between the qualitative and
quantitative fecal fat procedures is good; however,
additional unstained phospholipids and cholesterol esters
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are measured by the quantitative procedure.
Microscopic Examination of Feces
● Lipids included in the microscopic examination of feces are
neutral fats (triglycerides), fatty acid salts (soaps), fatty acids, and
cholesterol.
● Their presence can be observed microscopically by staining
with the dyes Sudan III, Sudan IV, or oil red O; Sudan III is the
most routinely used.
● The staining procedure consists of two parts: the neutral fat stain
and the split fat stain.
● Neutral fats are readily stained by Sudan III and appear as large
orange-red droplets.
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● Split fat stain representing total fat content can provide a better
indication
Microscopic Examination of Feces
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Microscopic Examination of Feces
● Soaps and fatty acids do not
stain directly with Sudan III, so a
second slide must be examined
after the specimen has
been mixed with acetic acid and
heated.
● Examining this slide
reveals stained droplets that
represent not only the free fatty
acids but also the fatty acids
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produced by hydrolysis of the
soaps and the neutral fats.
Microscopic Examination of Feces
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Chemical Testing of Feces
● Occult Blood
○ Guaiac-Based Fecal Occult Blood Tests
○ Immunochemical Fecal Occult Blood Test
○ Porphyrin-Based Fecal Occult Blood Test
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Chemical Testing of Feces
● Occult Blood/fecal occult blood testing (FOBT)
○ most frequently performed fecal analysis
○ Methods for detecting fecal occult blood include
the guaiac immunochemical, and fluorometric
porphyrin quantification tests. Immunochemical
tests and fecal porphyrin quantification tests are
more sensitive and specific methods than the
guaiac-based fecal occult blood tests
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Chemical Testing of Feces
● Guaiac-Based Fecal Occult Blood Tests (gFOBT)
○ most frequently used screening test for fecal blood
○ the least sensitive reagent, guaiac, is preferred for routine
testing.
○ commercial testing kits contain guaiac-impregnated filter
paper enclosed in a cardboard slide
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Chemical Testing of Feces
● Immunochemical Fecal Occult Blood Test (iFOBT)
○ specific for the globin portion of human hemoglobin
○ uses polyclonal anti-human hemoglobin antibodies.
○ more sensitive to lower GI bleeding
○ it doesn't require any dietary restrictions before sample
collection and testing can often be performed on a
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random stool sample.
Chemical Testing of Feces
● Porphyrin-Based Fecal Occult Blood Test
○ The HemoQuant test includes the measurement of total
fecal hemoglobin or porphyrin derived from heme,
intestinal converted fraction (ICF)
○ more sensitive to upper GI bleeding
○ not affected by the presence of reducing or oxidizing
substances or the water content of the fecal specimen.
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Chemical Testing of Feces
● Quantitative Fecal Fat Testing
○ used as a confirmatory test
for steatorrhea
○ requires the collection of at
least a 3-day specimen
○ The specimen is collected in a
large, pre-weighed container
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Chemical Testing of Feces
• Fat Measurement
o Van de Kamer titration - routinely used, time consuming
o Gravimetric - measures all fecal fat
o Near-infrared reflectance spectroscopy – rapid procedure
for fecal fat that requires less stool handling by laboratory
personnel
o Hydrogen Nuclear magnetic resonance
spectroscopy method-homogenized specimen is
microwaved-dried and analyzed. The results correlate
well with the gravimetric method.
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Chemical Testing of Feces
● APT Test (Fetal Hemoglobin) APT Test Procedure
1. Emulsify specimen in water.
○ differentiate fetal blood 2. Centrifuge.
from swallowed 3. Divide pink supernatant into two
tubes.
maternal blood in the
4. Add 1% sodium hydroxide to one
evaluation of bloody tube.
stools. 5. Wait 2 minutes.
6. Compare color with that in the
control tube.
7. Prepare controls using cord blood
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and adult blood.
Chemical Testing of Feces
● Fecal Enzymes
○ Enzymes supplied to the gastrointestinal tract by the
pancreas are essential for digesting dietary proteins,
carbohydrates, and fats.
○ Pancreatic insufficiency
■ disorders such as chronic pancreatitis and cystic fibrosis.
Steatorrhea occurs, and undigested food appears in
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the feces
Chemical Testing of Feces
○ Proteolytic enzymes
■ Trypsin
■ Chymotrypsin
● more resistant to intestinal degradation, capable of
gelatin hydrolysis
■ Elastase I
● an isoenzyme of the enzyme elastase and is
the enzyme form produced by the pancreas.
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Chemical Testing of Feces
● Carbohydrates
○ The presence of increased carbohydrates in the stool produces
osmotic diarrhea
○ May be present as a result of intestinal inability to
reabsorb carbohydrates, as seen in celiac disease or;
○ Lack of digestive enzymes such as lactase (lactose intolerance),
and Idiopathic lactase deficiency
○ Most valuable in assessing cases of infant diarrhea and may be
accompanied by a pH determination
○ Normal stool pH is between 7 and 8
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○ Copper reduction test is performed using a Clinitest table
Chemical Testing of Feces
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