Serousal Fluids

 The closed cavities of body are lined by serosal

membranes (pleura – pericardium and pertoneum)
 The fluid is a plasma filtrate from capillaries of the
parietal membrane
 The fluid is reabsorbed through the lymphatics and
venules of the visceral membrane
 The small amounts of fluid facilitates movement of
two membranes
 The serosal fluids are plasma ultra filtration and
mesothelial lining does not add any substance
 For laboratory assessment needle aspiration is
done (Thoracocentesis – Pericardiocentesis –
Paracentesis)
 Serousal Fluids
Transudate and Exudate
 Evaluation of serous fluids directed first toward
differentiating transudate from exudate
 Transudative effusions (usually bilateral in pleura)
have mechanical process owning to systemic
conditions, leading to increase capillary hydrostatic
pressure or decreased plasma oncotic pressure
 Exudative effusions (usually unilateral in pleura)
have inflammatory process, associated with
disorders of vascular permeability or interfere with
lymphatic resorption
 Serousal Fluids
Transudate Exudate
Appearance Clear Cloudy
Specific gravity < 1.015 > 1.015
Total protein < 3.0 gr/dl > 3.0 gr/dl
F/S protein ratio < 0.5 > 0.5
LD < 200 IU > 200 IU
F/S LD ratio < 0.6 > 0.6
Cell count < 1000/ul > 1000/ul
Spontaneous clotting No Yes
•Total leukocyte and red cells counts are of limited use in the evaluation
of serousal Fluids
 Serousal Fluids
Pleural Fluid
 Transudates generally require no further work-up additional
testing for cholestrol and albumin gradient may discriminate
effusions with equivocal Light’s criteria (the first three
criteria)

PF/S protein ratio > 0.5

PF/S LD ratio > 0.6
Pleural Fluid LD > 2/3 upper limit of serum
Pleural Fluid cholestrol > 45 mg/dl
PF/S cholestrol ratio >0.3
Serum-pleural fluid albumin gradient < 1.2 g/dl
PF/S bilirubin ratio > 0.6

* Bilirubin measurement has not help as a strong discreminator

Serousal Fluids
Pleural Fluid
 Indications of thoracocentesis:
1. Any undiagnoesd pleural effusion
2. Therapeutic purposes in massive effusions
 Collection:
1. Heparinized tubes to avoid clotting
2. Except for an EDTA tube for all counts and
differentials
 Inoculation into the blood culture medium at the
bed side
* If necessary fresh specimen for cytology may be
stored up to 48 hours in the refrigerator with
satisfactory results.
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Pleural Fluid
 Amylase: measurement of this enzyme is recommended for
all pleural effusions with unknown ethiology Increased levels
found in esophageal rupture
 PH value > 7.3 is related to uncomplicated cases
 PH < 7.2 is related to complicated cases such as bacterial
pneumonia, Tb or malignancy
 PH < 6.0 is characteristic of esophageal rupture
 Pleural fluid TG > 110 mg/dl indicate a chylous effusion
 Values between 60-110 mg/dl are less certain and require
lipoprotein electrophoresis for chylomicrons
 Pleural fluid TG < 50 mg/dl indicate a pseudochylous
effusion, seen in chronic inflammatory process
 Adenosine deaminase (ADA) is a rapid chemical evidence
of Tb. ADA-2 from lymphocytes
 Serousal Fluids
Pleural Fluid
 Formal cell counts have little practical value
 Pleural fluid Hct > 50% of blood is a good evidence
for hemothorax
 A bloody pleural effusion (Hct >1% or
RBC> 100,000/ul) suggest trauma, malignancy and
pulmonary infarction
 Differential cell count on an air-dried Romanowski’s
stain
 Filtration or automated concentration methods with
Papanicolaou stain for cytologic evaluation
 Preparation of cell block is unnecessary except for
effusions in which malignancy is a consideration
 Serousal Fluids
Pleural Fluid
 Neutrophils: Predaminate in pleural fluid with inflammation.
Over 10% of transudates also have a predominance of
neutrophils but has no clinical significance
 Lymphosytes: Associated with transudate and no clinical
significance
* Most are small but medium, large and reactive variants
may be seen
* Nuceloi and nuclear cleaving are more prominent in
effusions than in prepheral blood
* Low grade NHL or CLL may be difficult to distinguish from
benign lymphocyte-rich serous effusions. In conjunction with
cellular morphology, immunophenotyping by flowcytometry
or immunocytochemistry is usually helpful
 Serousal Fluids
Pleural Fluid
 Eosinophils: an eosinophilic effusion is defined as
having > 10% eosinophils
* The most common causes are related to the
presence of air or blood in the pleural cavity
* Most are exudates
* in about 35% of patients the ethiology is unknown
* though not of much assistance in diagnosing an
effusion, eosinophilia does appear to independently
associated with longer survival
 Serousal Fluids
Pleural Fluid
 Mesothelial cells: Are common in pleural fluid from
inflammatory process.
* Rare in patients with Tb pleurisy, empyema, RA
and patients who have pleurodesis
* Fibrin deposition and fibrosis occurring in these
conditions prevent exfoliation of mesothelial cells
* Carcinoma cells may form easily recognized
tumor clusters or closely mimic mesothelial cells a
panel of immunocytochemistry stains may be
necessary for conformation
Serousal Fluids
Pleural Fluid
Serousal Fluids
Pleural Fluid
 Serousal Fluids
Peritoneal Fluid
 Up to 50 ml Fluid normally present in peritoneal cavity
 Peritoneal effusion is called Ascites
 Laboratory criteria for dividing ascitic fluid into transudate
and exudate is not well defined as it is for pleural fluid
 Diagnostic peritoneal lavage (DPL) have limited use:
1. Rapid screening for significant abdominal hemorrhage
2. Evaluation of hollow viscus injuries
 Peritoneal dialysis: submitted to check for infection
 Peritoneal washing: performed intra operatively to document
early intra abdominal spread of gynecologic and gastric Ca.
 Serousal Fluids
Peritoneal Fluid
 Total leukocyte useful in spontaneous bacterial
peritonitis (SBP)
 Approximately 90% of (SBP) have leukocyte count
> 500/ul and over 50% neutrophiles
 Eosinophilia > 10% most commonly associates with
chronic peritoneal dialysis. Also in CHF, vasculitis,
lymphoma and ruptured hydatid cyst
 Overall sensitivity of cytology for malignant ascitis
is 40-65%
 Peritoneal carcinomatosis accounts for two thirds of
malignant effusions
 Immunocytochemical stains are useful in
characterizing atypical cells
 Serousal Fluids
Peritoneal Fluid
 Amylase activity in normal peritoneal fluid is similar to blood
levels
 A fluid amylase level greater than three times of serum
value is good evidence of pancreas-related ascitis and also
in GI perforation
 Increased peritoneal BUN and Cr + increased serum BUN +
normal serum Cr (due to back diffusion of urea) suggests
bladder rupture
 CEA sensitivity 40-50% specificity 90% using cut off point of
3 ng/ml
 Increase CEA in peritoneal washing suggest a poor
prognosis of gastric Ca
 CA-125 extremely high in epithelial Ca of ovary, follopian
tube or endometrium
Serousal Fluids
Peritoneal Fluid
Serousal Fluids
Peritoneal Fluid
Serousal Fluids
Peritoneal Fluid
 Serousal Fluids
Pericardial Fluid
 10-15 ml fluid normally present in pericardial space
 Causes of pericardial effusion: 1)infection 2)neoplasm 3)MI
4)hemorrhage 5)methabolic 6)RA
 HIV infected patients commonly have asymptomatic
pericardial effusion
 In HIV associated cardiac temponade 45% are idiopathic,
Tb and bacterial infections each accounts for 20% of cases
 Large effusions (>350 ml) most often caused by malignancy
or uremia
 Blood-like fluid represent hemorrhagic effusion or aspiration
of blood from the heart
 Hct comparable to peripheral and blood gas analysis help
to differentiate
 Serousal Fluids
Pericardial Fluid
 Postpericardiotomy syndrome common but
nonspecific complication of cardiac surgery, days to
weeks following the injury
Exudative pericardial effusion developed in over
80% of cases
Presence of antimyocardial Abs suggests an
immune mediated process
 Hct and RBC count have limited value in differential
diagnosis of pericardial effusions. Total WBC >
10,000/ul suggests bacterial, Tb or malignant
pericarditis
 Metastatic Ca of lung and breast are most frequent
cause of malignant pericardial effusion