Stool Analysis

What is the stool or feces?

1. Waste residue of indigestible material (cellulose

during the previous 4 days)
2. Bile pigments and salts
3. Intestinal secretions, including mucus
4. Leukocytes that migrate from the bloodstream
5. Epithelial cells that have been shade
6. Bacteria and Inorganic material(10-20%) chiefly
calcium and phosphates. Undigested and unabsorbed
food.
 Random Collection
1. Universal precaution
2. Collect stool in a dry,clean container
3. uncontaminated with urine or other
body secretions, such as menstrual
blood
4. Collect the stool with a clean tongue
blade or similar object.
5. Deliver immediately after collection
 Ova and parasites
collection
1. Warm stools are best for detecting ova or parasites.
Do not refrigerate specimen for ova or parasites.
2. If the stool should be collect in 10 % formalin or PVA
fixative, storage temperature is not critical.
3. Because of the cyclic life cycle of parasites, three
separate random stool specimens are recommended.
 Enteric pathogen collection
1. Some coliform bacilli produce antibiotic substances
that
destroy enteric pathogen.Refrigerate specimen
immediately.
2. A diarrheal stool will usually give accurate results.
3. A freshly passed stool is the specimen of choice.
4. Stool specimen should be collected before antibiotic
therapy, or as early in the course of the disease.
5. If blood or mucous is present, it should be included in
the specimen
 Interfering factors
1. Patients receiving tetracyclines, anti-diarrheal drugs,
barium, bismuth, oil, iron , or magnesium may not yield
accurate results.
2. Bismuth found in toilet tissue interferes with the
results.
3. Do not collect stool from the toilet bowl. A clean, dry
bedpan is the best.
4. Lifestyle, personal habbits, environments may interfere
with proper sample procurement.
 Normal values in stool Analysis
Macroscopic examination Normal value
Amount 100-200 g / day
Colour Brown
Odour Varies with pH of stool and
depend on bacterial
fermentation
Consistency Plastic, not unusual to
see fiber, vegetable skins.
Size and shape Formed
Gross blood,Mucous,
Pus, Parasites None
 Normal values in stool analysis

Microscopic examination Normal

values
Fat (Colorless, neutral fat (18%) and fatty acid crystals
and soaps)
Undigested food None to small
amount
Meat fibers, Starch, Trypsin None
Eggs and segments of parasites None
Yeasts None
Leukocytes None
 Normal values in stool analysis
Chemical examination Normal
values
Water Up to 75 %
pH 6.5-7.5
Occult blood Negative
Urobilinogen 50-300 g/24hr
Porphyrins Coporphyrins:400-1200g/24hr
Uroporphyrins:10-40 mg/24hr
Nitrogen <2.5 g/24hr
 Normal values in stool analysis
Chemical examination Normal
values
Bile negative in adults
positive in children
Trypsin 20-950 units/g
positive in small amounts
in adults; present in greater
amounts in normal children.
Osmolarity used 200-250 mOsm with
serum osmolarity to calculate
osmotic gap
Sodium 5.8-9.8 mEq / 24hr
 Normal values in stool analysis
Chemical examination Normal values

Chloride 2.5-3.9 mEq / 24 hr

Potassium 15.7-20.7 mEq /24 hr
Lipids ( fatty acid) 0-6 g / 24 hr
 Clinical Implications
1. Fecal consistency may be altered in various disease
states

a. Diarrhea mixed with mucous and red blood cells is

associated with

1. Typhus 2. Typhoid 3. Cholera

4. Amebiasis 5. Large bowel cancer
 Clinical Implications
b. Diarrhea mixed with mucus and white
blood cells is associated with

1. Ulcerative colitis 2. Regional enteritis

3. Shigellosis 4. Salmonellosis
5. Intestinal tuberculosis
 Clinical Implications
C. ”Pasty” stool is associated with a high fat
content in the stool:

1. A significant increase of fat is usually detected

on gross examination
2. With common bile duct obstruction, the fat gives
the stool a putty- like appearance.
3. In cystic fibrosis, the increase of neutral fat
gives a greasy, “butter stool” appearance.
 Stool Odor
Normal value
Varies with pH of stool and diet.
Indole and sketole are the substances that produce
normal odor formed by intestinal bacteria
putrefaction and fermentation.
Clinical implication.
1. A foul odor is caused by degradation of
undigested protein.
2. A foul odor is produced by excessive carbohydrate
ingestion.
3. A sickly sweet odor is produced by volatile fatty
acids and undigested lactose
 Stool pH
Normal value : Neutral to acid or alkaline
Clinical implication
1. Increased pH ( alkaline)
a. protein break down b. Villous adenoma
c. Colitis d. Antibiotic use
2. Decreased pH ( acid)
a. Carbohydrate malabsorption
b. Fat malabsorption
c. Disaccharidase deficiency
 Stool color
Normal value : Brown
Clinical implication:
1. Yellow to yellow-green : severe diarrhea
2. Green : severe diarrhea
Black: resulting from bleeding into the upper
gastrointestinal tract (>100 ml blood)
3. Tan or Clay colored : blockage of the common bile
duct.
4. Pale greasy acholic (no bile secretion) stool found in
pancreatic insufficiency.
 Stool color(con)
4. Maroon-to-red-to-pink : possible result of
bleeding from the lower gastrointestinal tract (eg.
Tumors, hemorrhoids, fissures,inflammatory
process)
5. Blood streak on the outer surface of usually
indicates hemorrhoids or anal abnormalities.
6. Blood in stool can arise from abnormalities
higher in the colon. In some case the transit time
is rapid blood from stomach or duodenum can
appear as bright or dark red or maroon in stool.
 Blood in Stool
Normal value : Negative
Clinical Implication :
1. Dark red to tarry black indicates a loss of 0.50 to 0.75 ml
of blood from the upper GI tract.
2. Positive for occult blood may be caused by
a. Carcinoma of colon b. Ulcerative colitis
c. Adenoma d. Diaphramatic hernia
e. Gastric carcinoma f. Diverticulitis
g. Ulcers
 Mucous in Stool
Normal value : Negative for mucous
Clinical Implication:
1. Translucent gelatinous mucous clinging to the surface of
formed stool occurs in
a. Spastic constipation b. Mucous colitis
c. Emotionally disturbed patients
d. Excessive straining at stool
2. Bloody mucous clinging to the surface suggests
a. Neoplasm
b. Inflammation of the rectal canal
 Mucous in Stool (con)
3. Mucous with pus and blood is associated with
a. Ulcerative colitis
b. Bacilliary dysentery
c. Ulcerating cancer of colon
d. Acute diverticulitis
e. Intestinal tuberculosis
 Fat in Stool
Normal value : fat in stool will account for up to 20 % of
total solids. Lipids are measured as fatty acids (0-6.0
g/24hr)
Clinical Implication :
1. Increased fat or fatty acids is associated with the
malabsorption syndromes
a. Nontropical sprue b. Crohn’s disease
c. Whipple’s disease d. Cystic fibrosis
e. Enteritis and pancreatic diseases
f. Surgical removal of a section of the intestine
 Urobilinogen in Stool
Normal value : 125-400 Ehrlich units / 24 hr
75-350 Ehrlich units/100 g
Clinical Implication:
1. Increased values are associated with Hemolytic anemias
2. Decreased values are associated with
a. Complete biliary obstruction
b. Severe liver disease, infectious hepatitis
c. Oral antibiotic therapy that alters intestinal bacteria
flora
d. Infants are negative up to 6 months of age
 Bile in Stool
Normal value :
Adults –negative
Children may be positive
Clinical Implication:
1. Bile may be present in diarrheal stools.
2. Increased bile levels occur in Hemolytic
anemia
 Trypsin in Stool
Normal value : Positive in small amounts in 95 %
of normal persons.
Clinical Implication : Decreased amounts occur in
a. Pancreatic deficiency
b. Malabsorption syndromes
c. Screen for cystic fibrosis
 Leukocytes in Stool
Normal value : Negative Clinical Implication
1. Large amounts of leukocytes
a. Chronic ulcerative colitis
b. Chronic bacilliary dysentery
c. Localized abscess
d. Fistulas of sigmoid rectum or anus

2. Mononuclear leukocytes appear in Typhoid

 Leukocytes in Stool (con)
3. Polymorphonuclear leukocytes appear in
a. Shigellosis b. Salmonellosis
c. Yersinia d. Invasive Escherichia coli diarrhea
e. Ulcerative colitis
4. Absence of leukocytes is associated with
a. Cholera b. Non specific diarrhea
c. Viral diarrhea d. Amebic colitis
e. Noninvasive E.coli diarrhea
f. Toxigenic bacteria Staphylococci spp., Clostidium
Cholera
g. Parasites-Giardia,
 Porphyrins in Stool
Normal value : Coproporphyrin 400-1200 g / 24hr
Urophorphyrin 10-40 g / 24 hr.
These values vary from Lab to Lab.
Clinical Implication:
1. Increased fecal coproporphyrin is associated with
a. Coproporphyria (hereditary) b. Porphyria variegata
c. Protoporphyria d. Hemolytic anemia
2. Increased fecal protoporphyrin is associated with
a. Porphyria veriegata b. Protoporphyria

c. Acquired liver disease

 Stool Electrolytes
Normal values :
Sodium 5.8-9.8 mEq / 24
hr
Chloride 2.5-3.9 mEq / 24 hr
Potassium 15.7-20.7 mEq /24 hr
Clinical Implication :
1. Idiopathic proctocolitis Sodium and Chloride
Normal Potassium
2. Cholera Sodium and Chloride