routineexaminationofstool-170326170848.pptx

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1. STOOL EXAMINATION

2. DEFINITION S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 2 Human feces is called as stool. faeces / feces is plural of latin term faex meaning RESIDUE. It is the waste residue of indigestible materials of an animal’s digestive tract expelled through the anus during defecation. Meconium is newborn’s first feces. SCATOLGY or CAPROLOGY is the study of feces.

3. C OMPOSITI O N S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 3 ¾ water, ¼ solid Undigested and unabsorbed food Intestinal secretions, mucous Bile pigments and salts Decomposed products Bacteria and inorganic material Epithelial cells, leukocytes.

4. PRECAUTION BEFORE COLLECTION S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 4 Patient should avoid the following things for at least 48 hours before collection of stool: Mineral oils, bismuth, non absorbable anti diarrhoeal drugs, antimalarial drugs, antibiotics, etc Pt. Should not have barium swallow examination before stool R/E Avoid iron containing drugs, meat, fish etc for atleast 48 hours before stool for occult blood. In constipated patients use only non residual purgative

5. COLLECTION S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 5 Universal precautions Pt. is asked to pass stool in a clean container. Stool should be collected in a steralized, wide mouthed container. Loose/last/portion containing mucus, blood etc is to be collected in a wide mouthed bottle. Shoul d b e un c o n t a m i n at ed with urin e o r a n y othe r body secretions. >2gm is required. Properly named and always a fresh sample should be tested. Liquid stool to be examined within ½ hour Solid stool to be examined within 1 hour. If delayed store in a refrigerator.

6. COLLECTION CONTD... S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 6 3 samples of stool within 10 days to exclude false negatives. 2 samples to be examined on alternate days after normal defaecation and 1 sample after a purgative for certain worms. Formalin is the best preservative. It kills the bacteria but ptreserves the protozoa and helminthes. For culture no preservatives to be used

7. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 7

8. TYPES OF EXAMINATION S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 8 PHYSICAL EXAMINATION : colour, volume, consistency, odour, mucus, pus, concreations, helminths. CHEMICAL EXAMINATION : reactions, occult blood, fat, carbohydrate, protein, etc MICROSCOPIC EXAMINATION : pu s ce l ls, ma c r opha g es, R BCs, r em n a n ts of f ood, crystals, ba c t e r i a , yeasts, molds, protozoa, helminths. STOOL CULTURE:

9. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 9 Physical examination AMOUNT CONSISTENCY COLOUR ODOUR REACTION MUCUS CONCRETION BLOOD PUS FOOD REMNANT UNDIGESTED TABLETS

10. MACROSCOPIC EXAMINATION S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 10 AMOUNT Normal is 150 g to 200 g/day Increased in steatorrhoea, diarrhoea, indigestion of carbohydrate.

11. CONSISTENCY OR FORM S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 11 Normal is soft but formed Excessively hard/scybala- habitual constipation Flattened or ribbon like-intake of excess of mineral oil, carcinoma of rectum, stricture of rectum Soft, mushy, liquid and voluminous- diarrhoea, intake of purgatives Small numerous, largely mucus and blood with small amount of stool- dysenteries Rice watery without fecal matter- Cholera

12. 12 Stool examination by Dr. Priyanka Buragohain

13. Colour S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 13 Dark Grey - excessive cocoa or chocolate ingestion Reddish or blackish brown - large amount of fruits Green – ingestion of green leafy vegetables, administration of calomel due to biliverdin Red – Beat ingestion fresh blood Yellow – rhubarb or senna ingestion, normal stool

14. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 14 Clay – obstructive jaundice, barium meal x-ray Tarry black – haemorrhage in stomach/upper intestine Dark brown to bright red – bleeding in rectum or sigmoid colon Red streaks of blood on the surface of faeces- haemorrhoids, fissures, carcinoma ,ulcerative colitis

15. Odo u r S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 15 Normal odour is aromatic due to indole and skatole Increased - excessive protein ingestion Sour rancid- fatty acid in milk indigestion (in children and adults), normal in infants Putrid- severe diarrhoea of malignancy, gangrenous dysentry

16. R eaction S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 16 Normal is neutral Ph varies from 6.9 to 7.2 pH is dependent on bacterial fermentation and putrefaction in the bowel. Alkaline – excess protein ingestion Acidic – excess carbohydrate ingestion

17. Mucus S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 17 Small quantity of mucin is normal Small quantity – faeces from small gut Excessive quantity – infection of intestine Entirely mucus with little or no faeces and streaks of blood- dysentery, ileo colitis, intussusception

18. Concretion S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 18 In infants whitish curds may be found Gall bladder stones may be rarely found

19. Blood S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 19 Absent in normal faeces Formed stool with streaks of blood – lesion in sigmoid colon, rectum or anal canal Liquid stool with bright red blood, pus and mucus - bacillary dysentery, ulcerative colitis Semi formed stool with deep tarry black blood- melena Loose stool with deep cherry red blood- melena

20. Pus S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 20 Normally absent Pus with blooded mucus- ulcerative colitis, bacillary dysentery, ulcerative carcinoma

21. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 21 GROSS FOOD REMNANTS MAY IN NORMAL STOOL UNDIGESTED TABLETS MAY BE FOUND

22. CHEMICAL EXAMINATION S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 22

23. Chemical Examination Of Stool S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 23 Acidity/basicity Fats Nitrogen Stercobilinogen Coproporphyrin Occult blood Reducing substances N. B : most commonly used chemical examination of stool is pH, occult blood and reducing substances

24. S t e r c o b il i n o g en S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 24 Normal is 40 to 280 mg/day Average is 150 mg/day Dependent on amount of bilirubin passing to intestine(jaundice)

25. Occult blood S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 25 Detect blood which is present in amount or form not visible macroscopically Normally nil Abnormal presence in condition of occult haemorrhage in the GI tract BENZIDINE TEST GUAIAC TEST ORTHOTOLIDINE TEST Most commonly used test is benzidine test

26. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 26 BENZIDINE TEST 4 gm benzidine in 100 ml of glacial acetic acid Emulsify pea sized bit of faeces in 5 ml of water. Mix 1 ml emulsion and 1 ml of reagent in test tube Add several drops of 35 H2O2 Blue colour indicates positive reaction

27. Trace- faint blue colour after 1 min 1+ - definite blue green slowly 2+ - green blue rapidly 3+ - blue almost immediately 4+ - dark blue immediately S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 27

28. GUAIAC TEST Less sensitive With loss of 20 to 30 ml of blood all test will be positive Guaiac reagent consist of 1 gm Guaiac in 5 ml of 95% ethanol. Make a small smear of feces on a filter paper Add 2 to 3 drops of gum guaiac solution + 2 to 3 drops of glacial acetic acid + 2 to 3 drops of 3% H2O2 S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 28

29. Trace- faint blue green in 1 min 1+ light blue slowly 2+ clear blue rapidly 3 + deep blue almost immediately 4+ deep blue immediately S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 29

30. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 30 ORTHOTOLIDINE TEST Intermediate sinsitivity Smear the stool on a filter paper with an applicator Pipette a few drops of the reagent on to the filter paper(orthotolidine barium peroxide 200 mg+ glacial acetic acid 5 ml) After 30 sec examine for a blue colour Blue green colour within 30 sec means positive test

31. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 31 Interpretation Gastric disease eg chronic ulcer and malignancy Intestinal diseases eg dysentery, typhoid fever, carcinoma Haemorrhoids During instrumentation

32. Faecal reducing substance test S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 32 To diagnose lactose intolerance Sample of 5 gm stool is needed Sample needs to be delivered to the laboratory as soon as possible, preferably within 1 hr , cause lactose in the stool will normally be broken down by chemical processes within 2-4 hrs after the specimen is produced.

33. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 33 Interpretation Negative/ trace- < 0.25 g/dl Suspicious(grade 1) – 0.25-0.5 g/dl Abnormal(grade 2-4)->0.5 g/dl Found in Carbohydrate malabsorption Tropical sprue

34. MICROSCOPIC EXAMIN A TION S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 34

35. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 35 NEED FOR MICROSCOPIC EXAMINATION For the diagnosis of microscopic elements. Trophozoites and its movements are better seen in unstained preparation of a fresh material. Cystic forms &Nuclear character are better seen in stained preparation(iodine) Gycogen mass- stained with iodine Chromatoid bars- unstained preparation N.B – Both stained and unstained materials are to be prepared

36. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 36

37. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 37 Need of concentration technique To see whether treatment of parasite is successful To find ova of S. Mansoni or Taenia if few or other ova and cyst are not seen in routine examination To examine stool specimens from patients who do not come from an area where a particular parasite is found

38. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 38

39. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 39 FLOATATION TECHNIQUE Use solutions which have highier specific gravity(zinc sulphate or Sheather’s sugar) than the organisms to be floated so that the organisms rise to the top and the debries sink to the bottom. Advantage – produce a cleaner material than the sedimentation technique Disadvantage – walls of eggs and cyst will often collapse, hindering identification. Some parasite eggs do not float.

40. SEDIMETATION TECHNIQUE Use solutions of lower specific gravity than the parasitic organisms(formalin ethyl acetate technique) Recommended for general diagnostic laboratories due to easy to perform and less prone to technical error. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 40

41. Sedimentation techniques S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 41 Mix a small piece of stool with 10 ml of water or saline in a tube/ bottle Sieve the suspension into a beaker through a strainer with small holes. Pour the contents into a centrifuge tube Centrifuge at 2000-3000/rpm for 1 min Pour off the supernatant part Resuspend the deposit in clean water and add enough water to fill the tube. Mix well and recentrifuge Pour off the supernatant part Resuspend in zinc sulphate solution, fill the tube with the solution Centrifuge at high speed for 1 min Transfer the contents from the surface of the tube to a slide, using a bacteriological wire loop Add small drops of saline and mix Cover with a cover slip Examine under 10x and 40x objectives

42. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 42

43. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 43 Stainning methods Wet mount normal saline Iodine solution Buffered methylene blue solution Eosin solution Stainning for permanent preparation Schaudinn’s fluid Heidenhain’s Haematoxilin method Trichome stain

44. Microscopic examination of wet mount S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 44

45. Saline wet mount S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 45

46. Iodine wet mount S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 46 Iodine kills the organisms, therefore motility is lost. Used mainly to stain nuclei and glycogen mass if present. Flagella becomes recognisable. Cyst can usually be specifically identified in this method. Lugol’s iodine solution is used.

47. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 47 Lugol’s iodine Its very strong Must be diluted about 5 times with distilled water Stain deteriorates quickly hence to be prepared every 2 weeks Contains: Iodine crystals(powdered): 5 g Potassium iodide Distilled water :10 g : 10 Potassium iodide is dissolved in distilled water and iodine crystals are slowly added. Solution is filtered and kept in a stoppered bottle of amber colour

48. Buffered methylene blue wet mount Stains only trophozoites of amoeba It does not stain amoebic cyst or trophozoites and cyst of flagellates. Nucleus and the inclusions such as RBC or yeast cells stain dark blue Cytoplasm stains light blue S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 48

49. Eosin wet mount Detection of trophozoites and cyst They can be much more easily detected against the pink- red background of eosin preparation S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 49

50. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 50

51. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 51

52. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 52

53. Cover with a cover slip S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 53

54. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 54

55. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 55

56. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 56 microscopic examination findings REMNANTS OF FOOD vegetable cells Muscle fibres Starch granules Fat globules Connective tissue/ elastic fibres Mineral oil or castor oil globules CELLS Epithelial cells Pus cells Macrophages Ghost cells Pyknotic bodies Eosinophills RBC Crystals Yeasts and molds Protozoa Helminthic parasites

57. Vegetable cell Sometimes causes confusion with ova, eggs, cyst or cell bodies IRREGULAR OUTER MARGIN Excess quantity is seen in excess intake of vegetables or indigestion S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 57

58. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 58 Muscle fibres May confuse with Tinea segments Excess protein intake or indigestion Its excess excretion is called Creatorrhoea (flesh-flow)

59. Starch granules Variable in size, round to polygonal in shape, colourless, circular or Y shaped dot in the centre Confused with ova of helminths Found in carbohydrate dyspepsia Better seen in iodine preparation S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 59

60. Fat globules Appear similar to parasitic cyst or cell bodies Emulsifying agents are used to eliminate confusion Confused with ova of helminths Found in fat dyspepsia S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 60

61. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 61 Connective tissue/elastic fibres Confused with tinea segments Signify indigestion

62. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 62 Mineral oil/ castor oil globules When taken as purgative May be confused with ova of helminthes

63. Epithelial cells Excess presence due to inflammatory conditions of colon, rectum, anal canal S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 63

64. Pus cells Commonly found in normal stool, help to ease the passage of stool Normally not visible to human eye. If visible indicates disease Bacillary dysentery, UC, acute Amoebic dysentery, malignancy of rectum, drug induced enterocilitis S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 64

65. Macrophages Large mononuclear cells with vesicular nucleus and ingested materials including RBC Confused with E. Histolytica cyst or E. Coli cyst Excess in Amoebic or bacillary dysentery S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 65

66. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 66 Ghost cells Degerative form of macrophages, epithelial cells Its an enlarged/swollen eosinophilic epithelial cell with only eosinophilic cytoplasmic outline but without a nucleus Characteristic of bacillary dysentery

67. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 67 Pyknotic bodies Nuclear remains of tissue cells and leucocytes Characteristic of acute amoebic dysentery

68. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 68 Eosinophils In intestinal allergy Diluting fluid used- Randolph’s diluting fluid,Pilot’s stain Carbol chromotrope technique A measured quantity of the deposit is taken and diluted with the diluting fluid 1:10 or 1: 20 according to the concentration of the residue and counted in haemocytometer. Increased in allergic conditions, parasitic infestation and drug allergy, ulcerative colitis

69. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 69 RBCs seen in cases of ulcrative lesions of gut in bacillary dysentery – yellowish discrete Amoebic dysentery – greenish and in clumps

70. Crystals Fatty acid crystals Calcium oxalate crystals Triple phosphate crystals Charcot Leyden crystals Haemotoidin crystals Crystals of drugs S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 70

71. Charcot Leyden crystal: Slender and pointed at both ends, Hexagonal bipyramidal structures localised in the primary granues of cytoplasm of eosinophils and basophils Evidence of parasitic infiltrate eg amoeba, ascaris, hookworm, fasciola diamond shaped or whetstone shaped crystals Normally colourless, stained purplish- red by trichome Vary in size and may be as large as 50 µm in length Found in UC, dysentery, malignant ulcers, schistosomiasis etc S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 71

72. Haematoidin crystals: Ironless pigment derived from haemoglobin and formed within tissues(reticuloendothelial cells) but found extracellularly after 5-7 days in foci of previous haemorrhage. Occurs as refractile, yellow- brown and orange-red granules Characteristically as rhomboid plates arranged in a radial pattern, so called hematoidin burrs. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 72

73. Yeast and molds Yeast are normally present Excess in cases of AIDS Molds are rare but may be seen in immunodeficiency conditions S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 73

74. Parasites Stool examination by Dr. Priyanka Buragohain 80

75. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 75

76. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 76

77. S t o o l 83 protozoa e x ami n a tion by D r . Pri y a n k a Buragohain

78. Entamoeba histolytica TROPHOZOITE STAGE Identified by motility and presence of ingested RBC Shape : constantly changing position Size :ranges from 18 to 40 µm ,average being 20 to 20 µm Cytoplasm :divisible in two portion Nucleus :spherical in shape S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 84

79. S t o o l e x ami n a tion by D r . Pri y a n k a B u r a g o h ain 85 RBC appear yellowish green inside the endoplasm Nucleus is not visible but a faint outline may be detected Endoplasm shows bluish or ground glass appearance Eccentric nucleus with karyosome (a small dot at the centre surrounded by a clear halo), nuclear membrane, Linen network having a spoke like radial arrangement

80. PRE CYSTIC STAGE Size :small in size,10 to 20 µm Shape :round or slightly ovoid with blunt pseudopodium Free from ingested RBC and other materials Nucleus : large nucleus Retains the characteristics of trophozoite. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 80

81. CYSTIC STAGE Size : 6 to 9 µm / 12 to 15 µm Shape : round, surrounded by a highly refractile membrane called cyst wall Nucleus :quadrinucleate Clear and hyaline cytoplasm Nuclear structure retainning the character of trophozoite S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 81

82. S t o o l e x ami n a tion Burago by D r . Pri y a n k a hain 88 Saline mounting Chromatid bodies are seen as round refracile bars Cyst wall smooth and thin Glycogen bar not visible Outlines of nuclei may be visible Iodine mounting Body of the parasite stains yellow to light brown Nucleus is clearly seen with a karyosome Cytoplasm is smooth and hyaline appearance Glycogen mass stains brown Iron haematoxillin stain Chromatid body and nucleus stain jet black Cytoplasm stains bluish or greyish Glycogen mass gets dissolved in the process of stainning and remains as a vacuole

83. Entamoeba coli S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 83 TROPHOZOITE STAGE Largest amoeba 20-40 µm in diameter Sluggishly motile Cytoplasm not clearly defined Opaque endoplasm packed with food vacuoles with bacteria and others but no RBC Nucleus visible in unstainned preparation In stainned prep nucleus shows large eccentric karyosome surrounded by broader halo and coarse chromatin ranules linning nuclear membrane

84. CYST 15- 20 µm in diameter Rounded body Octanucleate Largen glycogen mass in binucleate stage Chromatoid body if present are in slender filaments or pointed threads Glycogen mass and chromatoid bodies are absent in mature cyst S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 84

85. Endolimax nana Commensal in large intestine of man Trophozoites are smaller in size(8-9 µm in diameter) Sluggish in motility Cytoplasmic inclusions contain bacteria and food particles but no RBC Nucleus has irregular karyosome, eccentric and in contact with nuclear membrane S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 85

86. CYST Cyst are oval Same size as the trophozoites Number nuclei are 1-4 Mature cyst are quadrinucleate Chromatoid bodies and glycpgen mass are not seen S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 86

87. Difference between different trophozoites S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 87

88. Difference between different cyst S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 88

89. S t o o l e x ami n a tion by D r . Pri y a n k a B u r a g o h ain 95 OTHER NON PATHOGENIC AMOEBIDA SPECIES Trophozoite of E. hartmani Trophozoite of Iodamoeba butschlii Cyst of blastocystis hominis

90. S t o o l e x ami n a tion by D r . Pri y an k a 96 Balantidium coli Largest protozoal parasite Pig is the common reservoir Two stages Trophozoite and encysted stage TROPHOZOITE Oval body 60-70 µm in length and 40-50 µm breadth Body is covered with a delicate pellicle showing longitudinal striations Cilia are short and delicate, of uniform length, on mouth are longer called adoral cilia Thin layer of ectoplasm and granular endoplasm Groove at the anterior end(peristome) leading to a mouth(cytostome) terminating in a short funnel shaped gullet(cytopharynx) extending upto 1/3 rd of the body At the posterior part permanent anus called cytophage is situated 2 nuclei: kidney shaped macronucleus, round micronucleus in the concavity of micronucleus 2 contractile vacuole, many food vacuole B u r a g o h ain

91. CYST Smaller than trophic, 50-60 µm in diameter Cytoplasm is granular contains the macronucleus, micronucleus, refractile body Contractile vacuole Thick transparent double layered wall S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 91

92. Giardia lambia TROPHOZOITE Flat view: a tennis or badminton racket Side view: longitudinally split pear Dorsal surface is convex and the ventral surface in concave with a sucking disc Size is 14 × 7 µm Anterior end is broad and rounded, posterior end tapers to a sharp point Bilaterally symmetrical and all organs are paired. 2 axostyles, 2 nuclei, 4 pairs of flagella Exist in 2 phase: trophozoite and cyst S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 92

93. CYST Oval in shape Size is 12 × 7 µm Axostyle lie diagonally like dividing wall within the cyst wall 4 nuclei lie clustered at one end, lie in pairs at opposite poles Remains of flagella and sucking disc may be seen in cytoplasm Acid causes the parasite to encyst S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 93

94. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 94

95. What we can see in microscopic examination of stool ? ADULT WORM LARVA OVA C Y S T S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 95

96. HELMINTHES PLATYHELMINTHES NEMATHELMINTHES CESTODE TREMATODE NEMATODE TAPEWORM Taenia solium Taenia saginata ECHINOCOCCUS S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 96 G. Hominis F . B u ski F . Hep a t i c a C. Sinensis P . w e s t ermani A. Lumbricoids T . T r i c hiu r a A. Duodenale E. Vermicularis S. Stercoralis

97. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 97 ADULT WORM TAENIA SAGINATA/SOLIUM DIPHYLLOBOTHRIUM HYMENOLEPIS DYPILIDIUM LARVAL STAGE ECHINOCOCCUS: Hydatid cyst SPIROMETRA HYMENOLEPIS TAENIA SOLIUM MULTICEPS:

98. Taenia solium Segments of Tape worm or single segment may be found White in colour, semi transparent. May be 3 – 10 m long/ 1-3 cm segments maybe upto 24 m Variable length(1000-2000 proglottids) When stool is allowed to dry up the pieces of segments will roll upand appear as round worm, moistening the segments will restore the shape Head is quadrate in outline, has 4 circular suckers Head is absent of r o s t e l lu m / hookl e ts S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 98

99. E g gs o f T . sagin a t a Spherical and brown in colour 31-43µm in diameter Thin outer transparent shell(remnants of yolk mass), causes egg to clump together Inner embryophore is brown, thick walled, radially striated Contains an oncosphere(14- 20µm), with 3 pairs of hooklets Doesnot float in saturated solution of common salt S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 99

100. Taenia solium 2-3 metres long(800-900 proglottides) Scolex is 1mm in diameter, globular in outline, 4 circular suckers, Head with rostellum armed with a double row of alternating large and small hooklets, shaped like daggers or Arabian poniards Segments are shed in chains of 5-6 at a time, not single. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 100

101. EGGS Same as T. Solium 30x40 µm sized egg Pale yellow Thick radially striated embryophore with 6 hooklets inside S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 101

102. Echinococcus granulosus Commonly called dog tapeworm/ hydatid worm Man harbours the larval form, not the adult Larva found wiyhin the hydatid cyst, scolex of the future adult worm remains invaginated within a vesicular body. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 102

103. S t o o l Hymenolepis diminuta e x ami n a tion by D r . Pri y a n k a Buragohain 103

104. Gastrodiscoides hominis Prevalent in Assam and Bengal Pyriform in shape Measures 5-10 mm × 4-6 mm Body has 2 parts: anterior conical and posterior hemispherical portion which is hollowed out ventrally to form a concave disc Acetabulum is postero terminal, situated ventrally Notch at posterior end Eggs are ovoid, operculated, 130×60 µm, immature when oviposited S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 104

105. Fasciola hepatica Eggs Large, operculated, ovoid , brownish yellow(bile stained) Size is 140× 80 µm Contains a large unsegmentad ovum in a mass of yolk cells Excreted with bile into duodenum and then passed out along with the faeces Does not float in saturated common salt sol. Can develop only in water S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 105

106. Fasciola buski Reported in Assam , bengal, china, thailand and other oriental regions Largest trematode(2-7.5 length, 8-20 mm bredth, 0.5-3 mm thickness) Elongated and oval in shape Resembles F. Hepatica but does not possess any cephalic cone Each worm lay 25,000 eggs per day Eggs are indistinguishable from F . hep a ti c a S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 106

107. Clonorchis sinensis EGGS Yellowish brown Flask shaped Operculated Possess a terminal hook like spine(resembling an electric bulb) Small in size(35×20µm) Ciliated embryo (oviposited stage) Do not float in saturated solution of common salt S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 107

108. Paragonimus westermani Golden brown in colour Oval in shape with flattened opercula 80- 55 µm Each egg contains an unsegmented ovum surrounded by yolk cells Prevalent in Assam Found in sputum and faeces S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 108

109. Ascaris lumbricoids Large round worms may be males and females or both Pinkish in colour 0.3-0.4 cm in thickness 15-25 cm long Males are shorter than females Have curved tapering tail S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 109

110. UNFERTILISED EGGS Do not float on floatation method Size- 40×70 µm Yellow in colour Elongated Mammilated thin shell, ovum containing refractile yolk globules occupying the whole inside space May be confused with veg cell FERTILISED EGGS Float on floatation method Size- 40×70 µm Yellow in colour Oval or round Thick mammillated coat and single celled ovum inside S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 110

111. Enterobius vermicularis Small round worm or thread like worm or pin worm(spindle shaped) White coloured 0.5-1 cm long Tail pointed Males smaller than females and posterior body is curved and sharply truncated(found only after purgation) S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 111

112. EGGS Colourless(not bile stained) 20×50 µm Assymetrical, Oval planoconvex, thin transparent shelled, contain coiled tadpole likelarva inside Floats in saturated salt solution S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 112

113. Ancylostoma duodenale Hook worm Small greyish white or pink coloured cylindrical 1-1.5 cm long One end is curved like a hook 6 teeth, 4 hook like on ventral surface and 2 knob like on the dorsal surface S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 113

114. EGGS Oval or elliptical in shape 40x60 µm sized egg Colourless(not bile stained) Surrounded by a transparent hyaline shelled membrane Contains 4 segmented ovum inside. Floats on saturated solution of salt S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 114

115. Trichuris trichiura Whip worm Looks like a tiny whip with a handle and a lash 3-5 cm in length White coloured S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 115

116. 25x50 µm sized egg Brown coloured Double shelled, outer one is bile stained Thick shelled, barrel shaped with mucus plug at both pole Single ovum floats in saturated solution of common salt S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 116

117. Strongyloids stercoralis Adult worm: Females are readily discovered than males 2.5mm ×40-50 µm (females) Posterior extrimity is pointed Males are shorter and broader than females S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 117

118. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 118 Eggs Eggs are conspicuous within the body in a single line 55-30µm Thin shelled Transparent, oval Contain larva ready to hatch. It is the larva not the eggs are found in stool.

119. Rhabditiform larvae Develop directly from gravid females Short mouth, double- bulb oesophagus Filariform larvae Longer and slender Short mouth and cylindrical oesophagus S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 119

120. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 120

121. Helminthes that float/do not float on saturated solution of saline S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 121 A. Duodenale N. Americanas E. Vermicularis H. Nana A. Lumbricoids T . T richuria H. Diminuta Eggs that float Eggs that do not float A. Lumbricoids T . s o lium T . Sagin at a Trematodes F . Buski F . Hep a ti c a C. Sinensis

122. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 122

123. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 123

124. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 124

125. Plant hairs can be confused for larvae oh hookworm or Strongyloides stercoralis Plant hair resembling S. strongiloids S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 125

126. Parasite of earth worm Pollen grain resemblening to fertile egg of A. lumbricoids S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 126 Bee pollen resembling t. Trichuria egg

127. S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 127

128. STOOL CULTURE Used to detect the presence of disease causing(pathogenic )bacteria Help to diagnose an infection of digestive system Used in conjunction with stool test Reference range for stool culture is negative S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 128

129. Most common bacteria for culture of stool Campylobacter species Salmonella species Shigella species Yersinia species Vibrio species(travel history) Some bacteria cause illness by producing toxins(PCR, Antigen test are to be done with stool test) Escherichia coli Clostridium difficile S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 129

130. Collection Specimen collected via rectal swab(in infants) Sterile collection container not required No detergent or preservative should be present in the container Specimen should be immediately transported to the laboratory If transport is delayed by longer than 2 hours, transport media(eg Cary- Blair) is recommended Samples must be sent in a sealed, leak-proof container marked with a biohazard sticker S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 130

131. Medias used commonly MacConkey agar- Salmonella species, shigella species Eosin methylene blue agar Triple sugar iron(TSI)- differentiate salmonella and shigella Sabouraud agar Hekteon enteric agar Selenite broth S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 131

132. Summary S t o o l e x ami n a tion by D r . Pri y a n k a Buragohain 132 Definition of stool Composition of stool Precaution and collection of sample Physical examination Chemical examination Microscopic examination Artifacts Stool culture

133. THANK YOU !!! S t o o l e x ami n a D r . i y an u r a g oh