Peritonial fluid

It is fluid which is present in
the abdominal cavity.
The peritoneal cavity is a potential
space lined by mesothelium of the
visceral n parietal peritoneum.

1. Ms Ankita R Bhatiya Assistant Professor Shree P.M.Patel COLLEGE OF PARAMEDICAL SCIENCE N TECHNOLOGY PERITONEAL FLUID EXAMINATION

2. It include: 1.What is Peritoneal fluid? 2.Function of Peritoneal fluid. 3.Collection of Peritoneal fluid. 4. Examination of Peritoneal fluid. PERITONEAL FLUID EXAMINATION

3. Introduction: It is fluid which is present in the abdominal cavity. The peritoneal cavity is a potential space lined by mesothelium of the visceral n parietal peritoneum. PERITONEAL FLUID EXAMINATION

4. Peritoneal fluid Formation: Peritoneal fluid is a selective ultra filtrate of plasma. Small amount of the Peritoneal fluid is also formed from the cells lining the peritoneum and other by capillaries. There is about 50-60 ml of peritoneal fluid at any one time and about 125 ml is generated every day. PERITONEAL FLUID EXAMINATION

5. Composition of Peritoneal fluid: Volume: 50-60 ml Protein: up to 3 gm/dl Glucose: Same as plasma Amylase; Same as blood amylase BUN: similar to blood BUN WBC: <500/µL pH of 7.5 to 8 LDH:70-140 U/L Alkaline phosphates: 20-90IU(For adult) 93-221 IU(For children) PERITONEAL FLUID EXAMINATION

6. Function of Peritoneal fluid: Protection: It helps to protect the abdominal organ from the sudden injury n damaged. Also acts as a medium for the transfer of substances from the abdominal organ tissue to blood . Nutrition : Removal of waste : Lubrication : PERITONEAL FLUID EXAMINATION

7. Collection of Peritoneal fluid: Paracentesis is a process by which peritoneal fluid is collected. A needle is placed through the skin and muscles of the abdominal wall into the peritoneum space. PERITONEAL FLUID EXAMINATION

8. Procedure: 1.Take consent of a patient. 2.Position of patient: The patient is lied in supine position over bed table. 3.Proper aseptic precautions are taken with the help of spirit –iodine-spirit. 4.Before puncture give injection of atrophin to prevent vasovagal shock. 5.Give xylocane injection as local anesthesia before puncture. PERITONEAL FLUID EXAMINATION

9. 6. Along with sonography the needle is inserted in to abdominal space & allow the fluid to flow in container. 7. Pleural fluid is collected in 3 tubes: 1. EDTA Bulb: Cell count n differential count. 2. Flouride Bulb: For glucose examination. 3. Plain Bulb: Chemical n immunology study PERITONEAL FLUID EXAMINATION

10. Indication of Pleural fluid: A) Transudate: Increase hydrostatic pressure Decreased plasma oncotic pressure Congestive heart failure Hepatic cirrhosis Hypo proteinemia B) Exudate: Increased capillary permeability Decrease lymphatic resumption Primary bacterial peritonitis, Secondary bacterial peritonitis, TB Neoplasm Hematoma, Lymphoma Metastatic carcinoma Trauma, Pancreatitis , Bile peritonitis PERITONEAL FLUID EXAMINATION

11. Examination of Peritoneal fluid: Physical examination: Chemical examination: Microscopic examination: PERITONEAL FLUID EXAMINATION

12. Physical examination of Peritoneal fluid: 1.Volume: Normally: 50 to 60 ml Transudates – 100 to 150 ml Condition : Increase hydrostatic pressure Decrease plasma oncotic pressure Congestive heart failure Hepatic cirrhosis, Hypoproteinemia Exudates – More than 150 ml Condition: Increased capillary permeability Decrease lymphatic resumption Primary bacterial peritonitis,Secondary bacterial peritonitis TB, Neoplasm, Hematoma Lymphoma, Metastatic carcinoma Trauma, Pancreatitis ,Bile peritonitis PERITONEAL FLUID EXAMINATION

13. 2. color : Normally: colorless Transudates : Pale yellow or straw clr Exudates: Reddish : Hemorrhagic pancreatitis, Rupture spleen, Liver, Trauma, Malignancy, TB. Green ; Perforated intestine and gall bladder, Duodenal ulcer, Cholecystitis , Acute pancreatitis, Appendicitis Amber 0r yellow : Hepatic vein obstruction ,cirrhosis Nephritic syndrome ,Congenital cardiac failure PERITONEAL FLUID EXAMINATION

14. 3.Appreance: Normally: Clear or transparent Transudate : Clear or transparent Exudate : Turbid : Appendicitis, Pancreatitis, Infected intestine Tuberculosis, Cloudy : Bacterial Perotonititis, Primary bacterial infection, Perforated bowel, Appendicitis, Pancreatitis. Milky : Chylous effusion, Malignancy, Lymphoma, TB, Parasitic infection, Hepatic cirrhosis PERITONEAL FLUID EXAMINATION

15. 4. Clot: Normally: absent Transudate : absent Exudate : Present Tuberculous Peritonititis 5.Specific gravity: Transudate : below 1.010 Exudate : above 1.010 Peritonititis ( Bacterial, Viral, Fungal) Cancer Pancreatitis PERITONEAL FLUID EXAMINATION

16. Chemical examination of Peritoneal fluid: 1.Glucose: Normal range: 40-60 mg/dl Transudate : same as blood glucose Exudate : slightly reduce Method: 1.Visualised method Benedict test 2.Colorimetric method GOD-POD Condition for decrease glucose: Bacterial ,Viral, Fungal Perotonititis Pancreatitis Tuberculosis Perotonititis Cancer PERITONEAL FLUID EXAMINATION

17. 2. Protein: Normal range: 6-8gm/dl Transudate : below 3 gm/dl Exudate : Above 3 gm/dl Method: 1.Turbidometric method method SSA Heat n acetic acid 2.Colorimetric method Biuret Condition for Increase protein: Peritonititis (Bacterial, fungal,viral ) Tuberculosis PERITONEAL FLUID EXAMINATION

18. Serum ascetic albumin gradient (SAAG) The serum ascetic albumin gradient (SAAG) indirectly measures portal pressure and can be used to determine if ascites is due to portal hypertension. SAAG calculation SAAG = (serum albumin) – ( ascitic fluid albumin) Interpretation A high SAAG (>1.1g/ dL ) suggests the ascetic fluid is a  transudate . A low SAAG  (<1.1g/ dL ) suggests the ascetic fluid is an  exudate . PERITONEAL FLUID EXAMINATION

19. Causes of a high SAAG A  high   SAAG  (i.e. transudate ) suggests the presence of  portal   hypertension , which may be caused by: Cirrhosis Hepatic failure Venous occlusion (e.g. Budd Chiari syndrome) Fulminant hepatic failure Alcoholic hepatitis Kwashiorkor malnutrition Causes of a low SAAG Causes of a  low   SAAG  (i.e. exudate ) include: Malignancy Infection Pancreatitis Nephrotic syndrome PERITONEAL FLUID EXAMINATION

20. 3. Amylase: Normal range: 30-110 IU Transudate : Normal Exudate : Above 110U IU Condition: Acute Pancreatitis Pancreatitis pseudo cyst Trauma Gastrointestinal duodenal perforation Necrosis Acute vein thrombosis Non pancreatic malignancy PERITONEAL FLUID EXAMINATION

21. 4. Lactate dehydrogenate: Normal range: 140-280 U/L Transudate : NORMAL Exudate : Above 255 U/L Method: 1.Colorimetric method 2. U.V.Kinetic method Condition for Increase protein: Peritonititis (Bacterial, fungal,viral ) Tuberculosis Malignancy PERITONEAL FLUID EXAMINATION

22. 5.Alkaline Phosphatase : Normal range: 20-90 IU (Adult) 93-221 IU (Children) Method: 1.Colorimetric method P- nitrophenyl method(PNP Method) Transudate : NORMAL Exudate : Above 90 IU Condition: Bone cancer Hyperparathyroid Spontaneous bacterial peritonititis PERITONEAL FLUID EXAMINATION

23. 6.Creatinine & Urea : May differentiate between peritoneal fluid n urine. Elevated serum urea level but normal creatinine suggest bladder rupture. 7.Billirubin : Normally:0.7 to 0.8 mg/dl Billirubin level more then 6 mg/dl & ascitic fluid/serum billirubin ratio over 1 suggests choleperitoneum from a rupture gall bladder. PERITONEAL FLUID EXAMINATION

24. 8.Ph: Normally: 7.4 Acidic: Hemorrhagic, Malignancy, Pancreatic ascities , Tb peritonitis's 9.Lipid: Cholesterol Transudate : Below 46 gm/dl Exudate : Above 46 gm/dl Condition: Malignancy ,Hepatic cirrhosis PERITONEAL FLUID EXAMINATION

25. 10.Tumor marker: CEA: Increase in gastric carcinoma PERITONEAL FLUID EXAMINATION

26. Microscopic examination of peritoneal fluid: 1.TLC (Total leukocyte count): Normally: 0-50 cell/ cumm Transudate : 0-50 cell/ cumm Exudate : 50-500 cell Method: Same as Blood Condition in increase TLC count: Bacterial, Viral Fungal ( Peritonititis ) Primary bacterial peritonitis Secondary bacterial peritonitis TB Neoplasm Hematoma, Lymphoma Metastatic carcinoma Trauma, Pancreatitis, Bile peritonitis PERITONEAL FLUID EXAMINATION

27. 2. DC: Method: Same as Blood Neutrophilia : Bacterial Peritonitis , Tuberculosis Peritonitis, Pancreatitis Metastatic Tumor Lymphocytosis : Viral Peritonitis , Tuberculosis Malignancy Rheumatoid peritonitis , SLE,Leukemia Eosinophilia : Parasitic Infection Chronic inflammatory process Leukemia , Hypersensitivity reaction, Congestive heart failure PERITONEAL FLUID EXAMINATION

28. 3.Gram’s Stain: Normally: Bacteria absent Transudate : Bacteria absent Exudates: Bacteria present Clinical Condition: Bacterial Peritonititis , pancreatitis Bacteria: Diplococci Streptococcus Pseudomonas Neisseria Homophiles influenza 4.AFB Stain: Normally: Bacteria absent Transudate : Bacteria present Exudates: Bacteria present Clinical Condition: Tuberculosis Peritonititis Bacteria: Mycobacterium Tuberculosis PERITONEAL FLUID EXAMINATION