Body cavity fluids

Introduction:
There is normally a small amount of fluid in these
cavities, which keeps the visceral and parietal surfaces
moist and lubricated, to avoid any friction. If there is
an increase in the volume of fluid then it is called as
“effusion” and may interefere with normal body
function.
At such times, fluid needs to be aspirated and
examined to determine the cause and help in
appropriate therapy for that particular condition.
Collection of the sample fluid:

All these fluids are obtained by percutaneous

punctures( if necessary by radioimage guiding) By
entering into various cavities. Strict aseptic
precautions need to be taken to avoid iatrogenic
infection. Damage to blood vessels should be avoided.
The fluids thus collected should be sent to the
laboratory as soon as possible, to avoid any false
results because cells distegrate and biochemical
parameters may vary and bacteria will grow and
change its composition.
If fluid appears reddish, appropriate anticoagulant
should be added to the bottle containing the sample.
The following are the fluids examined
routinely:
Type of fluid
1. Pleural fluid cavity
Pleural cavity Descriptive
Pleural effusion
condition

2. Peritoneal fluid peritoneal ascites

or
Ascitic fluid Abdominal cavity Peritoneal effusion

3. Pericardial fluid Pericardial cavity Pericardial effusion

4. Synovial fluid Synovial cavity Synovial effusion

(joint)
 SYNOVIAL FLUID (JOINT FLUID)
Synovial fluid is formed by dialysis of fluid, which moves
across the synovial membrane.
Specific to this hyaluronic acid, which makes the fluid
viscous.
1. clot test:
1-2 ml of fluid is taken and is immediately placed on an
clean, dry tube. After one hour, the fluid is examined for
clotting.
Result: if the fluid clots- indicates fibrinogen and
inflammation. Clot formation is graded from 1+to 4+
Note:
Clot due to blood components should be ruled out.
Test for viscosity
It’s a simple test. Place a drop of sample between the tip os 2
fingers and check for stretching before it ‘breaks’.
If the fluid has decrease viscosity, then it will not ‘stretch or
form string’ between the thumb and index finger. It feels like
water.
This test can also be done by dropping fluid froma syringe and
check for ‘stringing’sing.
Result: normal string -is 4cm in length
 decreased string – less than 1cm.
Indicates inflammation. Decreased hyaluronic acid
 Mucin clot test or ropes test
Add 1ml of synovial fluid to 20 ml of 5% acetic acid in a small beaker and
examine for clot.
Results: large clot, clear fluid- good
 soft clot -fair
 friable clot, cloudy fluid - poor
No clot and flakes in cloudy suspension –very poor
Examination of crystals:
Fresh wet preparation and a stained smear should be examined for crystals-
uric acid – especially seen in gouty arthritis. These uric acid crystals are
seen with in the cytoplasm of phagocytes in acute gouty arthritis. (Gouty
arthritis: An attack that is usually extremely painful of joint inflammation due to
deposits of uric acid crystals in the joint fluid (synovial fluid) and joint lining
(synovial lining).
 Pleural fluid (Effusion)
 The pleural fluid lies between the lung and chest wall. The
 pleural space normally contains a very thin layer of fluid
which is about 200ml and acts a lubricant between the visceral
and parietal layers of the pleura. The fluid is clear, pale yellow.
Any increase in this fluid is called “pleural effusion”.
 Etiology: pleural fluid accumulates, when pleural fluid
formation is more than pleural fluid absorption.
 1. pleural fluid enters the pleural space, from the capillaries in
the parietal, pleura and is removed by the lymphatics, which
are situated in the parietal pleura.
 2. fluid also enters the pleural space from the interstitial
spaces of the lung via. The visceral pleura.
 3.Fluid can also come from the peritoneal cavity via, small
holes in the diaphragm.
Cont….
The lymphatics have the capacity to absorb 20 times more
fluid than what is normally formed. Therefore, pleural
effusion may develop, when there is excess pleural fluid
formation, as is described above, or when there is
decreased fluid removal by the lymphatics.
Pleural fluid can either be a transudate or exudate.
Cause of transudate are:
1.Congestive heart failure
2.Hepatic cirrhosis
3.Nephrotic syndrome.
Indication
Pleuritis
Pleural Effusion
Infectious diseases like pneumonia
Bleeding- Bleeding disorders, like pulmonary embolism, Trauma
Inflammatory conditions like chronic lung diseases
Malignancies like Lymphoma, leukemias, lung cancer and metastatic
cancer.
Other conditions like Idiopathic condition, cardiac bypass surgery,
heart or lung transplantation, pancreatitis, or intra-abdominal
abscesses.
Complications
1.Haemothorax due to laceration
2. Mediastinal shift if large amount of fluid.
ii. Causes of exudate are:
 Neoplasma
 Bromehogenic carcinoma
 Metastatic carcinoma
 Lymphoma
Infections:
Tuberculosis
Bacterial pneumonia
Mestatic carcinoma
Lymphoma
iii. Causes of chylous effusion
Damage or obstruction to thoracic duct.

Eg: trauma lymphoma, carcinoma or TB.

Transudate and exudative pleural effusion can be distinguished by measuring LDH

(lactate dehydrogenase) and protein levels in the pleural fluid.

Transudate

Total protein < 3.0 g/dl

Exudate:

Total protein>3.0 g/dl

Other test done on pleural fluid:

1. physical examination: describe the colour, quantity, consistency, any clot formation.

2. Chemical examination: tests for glucose, amylase, measurement of pH.

3. Microscopic examination:
Total leucocyte count, erythrocyte count and differential count
are considered as routine examination percentage of
mesothelial cell has clinical significance&should be reported
4. microbiologic examination:
Acid- fast gram stain and culture should be done in an
appropriate clinical background.
Clinical significance:
The leading causes of transudative pleural effusion are left
ventricular failure, pulmonary embolism and cirrhosis, where as
exudative pleural effusion are usually due to bacterial
pneumonia, malignancy viral infection & pulmonary embolism.
We should differentiate transudate from an exudate, so that for
exudative effusions need further analyses as mentioned above.
Clinically patients present with breathlessness and at times with
chest pain.
Diagnostic procedure
Radia imaging by x-ray and CT scan, followed by

thoraco centesis.
Management:

The underlying cause should be treated. Often in our

indian set up, first and foremost, tuberculosis should

be ruled out and treated with anti tuberculosis drugs.
 PERICARDIAL FLUID (EFFUSION)
Causes:
Infections
Bacterial pericarditis
Tuberculosis
Fungal pericarditis
viral or mycoplasmal pericarditis
NEOPLASMS:
Metastatic carcinoma
Trauma
Myocardial infaraction
Hemorrhagic effusion
Normal pericardial fluid is clear, pale, yellow and varies from
about 10-50ml in volume. Most pericardial effusions are caused
by damage to mesothelial linings rather than mechanical factors.
Microscopic examination
Tuberculous pericarditis- there is increase in

lymphocytes.
Bacterial pericarditis – increased in leucocytes

Amoebic pericarditis- is also possible.

Routine study of pericardial effusion includes gross

appearance, total protein, erythrocyte count, leucocyte

count, differential count and microscopic study of
gram’s stain, culture and cytologic study.
Chemical examination
Glucose in pericardial fluid may be decreased in bacterial

pericarditis, in non- septic inflammation due to rheumatoid

disease malignancy.

Indications of pericardial fluid:

Acute or chronic tamponade of unknown etiology.

Complications of aspiration:

1. Cardiac arrhythmias

2. Infections

3. laceration of atrium or a caronary artery

GASTRIC FLUID ANALYSIS
Analysis of gastric contents plays a useful role in clinical
diagnosis and treatment of that condition.
Other measures like gastroscopy, barium studies and gastric
cytology are helpful.
Indications:
1.to know whether the patient can secrete any gastric acid or
not. i,e it is called anacidity- conditions like pernicious
anemia can be detected.
2. to measure amount of acid secreted peptic ulcer patients
on treatment or post operative cases.
3.To know hypersecretory state
4.Post vagotomy cases – to know the completeness.
 COMPOSITION OF GASTRIC SECRETION

Hydrochloric acid, digestive enzymes like pepsin gastrin,

lyases, mucus, serum proteins like albumin, electrolyte,

intrinsic factor- which is mucoprotein. HCL is secreted by
parietal cells of neck, fundus and body of stomach. This
provides acidity for activation of proenzymes. Chief cells
gastric glands at body and fundus.
SECRETE PEPSIN: intrinsic factor is a mucoprotein
secreted by gastric mucosa which helps in B12 vitamin
absorption in the ileum. This is controlled by gene
expression.
Parameters measured:
1. gastric fluid volume- in millilitres
2. titratable acidity (after titrating with Naoh)
(The acid content of the must is determined
by titrating a sample (a given volume) with a base such as
sodium hydroxide solution to a phenolphthalein end
point or alternatively, to a pH of 8.2. The titratable
acidity is expressed as grams of tartaric acid per 100 ml.)
3. pH meq/litre.
4 . Basal output – meq/hour –four individual samples at 15
minutes interval
 5. maximal acid output- after stimulation with
pentagastrin or histamine injection.
Anacidity:
 absence of free acid – pH of the secretion will not fall
bellow 6.0 & 7.0 or pH persistently above 3.5
(achlorhydria).
Gasric intubation is done to get this fluid ( ryles type)
Physical features:
gastric fluid is pale grey and viscous nature, bile,
blood and mucus contamination can present.
Microscopic examination:-

leukocytes,squamous epithelial cells, parasites like

gonidia lamblia trophozoites can be found.

 Duodenal contents examination
Collection of duodenal contents is by refuses tube with a metal
tip introduced into the stomach, clear the stomach contents is
much as possible. As the diameter of this tube is lesser than
ryle’s tube it can pax thro pylorus and drain the duodenal
contents freely.
Collect the contents in a clean test tube.
Physical characters:
Water clear or pale yellow in colour presence of bile or blood
contamination always noted as they indicate in a clean test
tube.
Chemical tests:
tests for enzymes like trypsin and amylase can be done.
Benzidine test – done to none the presence of blood.
Microscopic examination:
Duodenal contents are centrifugal and sediment is
taken for examination. Look for epithelial, puss cells,
gram stain preparation for bacteria.
SPUTUM EXAMINATION
Material that is coughed up from the bronchi and trachea
is sputum.
Collection of sputum:
Sputum is collected as – an early morning specimen or an
entire 24 hour specimen.
Necessary instructions to the patient is given as they
should cough out from the lungs and collect in a sterile
container.
Note: only from the mouth/ oral cavity gives and saliva &
not sputum.
Examination of sputum:
Sputum is examined under the following headings as
follows:
Physical characteristics:
Like amount, odour, color and consistency can help in
identifying certain diseases.
Quantity:
> 100cc / 24 hour- indicates pulmonary edema,
bronchiectasis and lung abscess. Less amounts- diffuse
bronchitis.
Consistency:
May be serous., frothy, mucoid, purulent,
haemorrhagic
 ODOR-
putrid odor- lung abscess and bronchiectasis.
Sweetish odor- pulmonary tuberculosis and fungal
infections
Cheesy or necrotic- long standing samples and
malignancies.
 COLOR:
gray colour- purulent sputum
green colour- bronchiectasis due to bile pigment
presence
Black – inhalation of coal dust, dirt
Bloody sputum- pulmonary tuberculosis
Prune juice appearance- pneumonia
EXAMINATION OF UNSTAINED SPUTUM:
Look under microscope for elastic fibres- wavy refractile
fibres in bundles.
Curschmann’s spirals- are wirey, spiral structures eg: seen
in asthmatics.
Charcot leyden crystals- are fine needle shaped colourless
crystals seen in asthmatics.
Pigment cells – are large mononuclear cells with
darkbrown, blood or black carbon pigment.
Sulhur granules- are yellow granulear structures found in
actinomycosis. They are colonies of fungus.
Bronchial casts- fibrinous casts from inside the bronchial
tree are coughed out.
EXAMINATION OF STAINED SPUTUM
The sputum smears are made on clean slides, allowed to dry
and are fixed over a flame. Various stains may be used like
methylene blue, gram’s stain, zeihl nelson’s acid fast stain,
etc… the stained smear is examined under oil immersion.
Look for organism, polymorphs, lymphocytes, eosinohils,
large mononuclear cells, epithelial cells, RBCs, parasites are
very rartely found in sputum, should also be kept in our
mind while examination. Parasites eg: entamoeba histolytica
can be found in sputum, if hepatic abscess reptures in to the
lungs.
Chemical examination of sputum:
Normally no chemical examination is done on sputum.
Occassinally occult blood need to be tested and the
procedure in same as is done for urine occult blood.