serous fluid Dr shweta [Autosaved].pptx

Nutema hospital

1. SEROUS FLUID EXAMINATION Dr Shweta Garg MD Pathology KGMU Lucknow CONSULTANT PATHOLOGIST NUTEMA HOSPITAL, MEERUT.

2. LEARNING OBJECTIVE NORMAL FORMATION OF SEROUS FLUID DIFFERENTIATE BETWEEN TRANSUDATE AND EXUDATE VARIOUS OTHER ROUTINE & SPECIAL TEST & THEIR CLINICAL & DIAGNOSTIC SIGNIFICANCE

3. GENERAL CONSIDERATION Serous fluids – secreted by serous membrane (Parietal and visceral), lining the close cavity of body These are named as per location Pleural Pericardial Peritoneal Their function is to provide lubrication between two membranes

4. FLUID FORMATION These are extravascular fluid collected in intercellular spaces (body cavity) and come from vascular space. It is produced by exertion of hydrostatic pressure and oncotic pressure and small amount is absorbed by lypmphatics

5. HOW DOES EFFUSION OCCUR ? Increase venous pressure i.e Hydrostatic pressure Greater exit of fluid from the vascular system than it is absorbed Capillary permeability does not change Fluid resembles like normal tissue fluid – few cells & very low protein Congestive heart failure, salt & fluid retention Increase capillary permeability Due to inflammation or toxic damage to capillaries – microbial infection Contain high concentration of protein

6. HOW DOES EFFUSION OCCUR ? Decrease in plasma colloidal pressure In cases of Hypoproteinaemia – like nephrotic Syndrome Hepatic cirrhosis Malnutrition, Protein losing enteropathy Interference with lymphatic flow Due to obstruction of lymphatic flow – Filaria, Cancer, Scar tissue, thoracic duct injury Contain high concentration of protein & lipids

7. TRANSUDATE & EXUDATE Transudate is fluid buildup caused by systemic conditions that alter the pressure in blood vessels causing fluid to leave the vascular system. Exudate is fluid build up caused by tissue leakage due to inflammation or local cellular damage.

8. LIGHT’S CRITERIA The fluid is exudate if one of the following Light’s criteria is present: Effusion protein/ serum protein ratio > 0.5 Effusion lactate dehydrogenase( LDH) / serum LDH ratio >0.6 Effusion LDH level greater than two thirds the upper limit of reference range of LDH

9. GENERAL LAB TESTING Specimen collection and handling Examination of Fluid Physical examination Microscopic examination Chemical examination Microbiological and serological test Ancillary test

10. SPECIMEN COLLECTION AND HANDLING Pleural fluid : Thoracocentesis is indicated for therapeutic purposes in patients with massive symptomatic effusion. Peritoneal fluid : Diagnostic Paracentesis is performed in most pts of ascites. Min of 30 ml is required. Pericardial fluid : Sample is obtained by Pericardiocentesis in a wide mouth universal container. Post test the samples are stored at 4-8֯ C for 48 hours.

11. COLLECTION OF SAMPLE To be collected in three tubes EDTA for Haematolgy Plain for Biochemistry Sterile heparinised / Plain for microbiology & Cytology It should be examined as early as possible to avoid chemical change, bacterial growth & cellular disintegration Remaining sample can be stored at 2 – 4 C for further ancillary testing

12. PROCEDURAL STEPS Physical examination: Volume Color Appearance Presence/absence of coagulum Coagulum formation occurs due to substantial inflammatory reaction and presence of fibrinogen due to capillary wall damage

13. MICROSCOPIC EXAMINATION Done for routine TLC & DLC and cytological purpose For TLC , mix the specimen carefully, if clear, use undiluted. If blood- tinged prepare 1:2 dilutions with diluting fluid If cloudy, prepare 1:20 dilution with diluting fluid or normal saline ( composition of Turk solution : Glacial acetic acid 4 ml, methylene blue solution 10 drops, & distilled water to make 200 ml). Count the cells in the corner 4 squares of neubauer chamber.

14. Calculation: TLC/ cumm = n ×D/V where “n”= no. of cells in four corner squares “D”= dilution factor “V”= volume (vol. of 4 wbc chamber)

15. NEUBAUER CHAMBER

16. Now the fluid is centrifuged at 1500 rpm for 5 minutes & sediment is used to prepare smears for DLC, malignant cell & cytology. Smears are stained with Leishman, Giemsa & PAP stain. Limitations : Counts should be performed as soon as possible. Specimen should be stored at 2-8 ֯C for 48 hrs

17. FLUID CYTOLOGY

18. Chemical Examination Following chemical test are preformed Protein & Albumin in some Glucose LDH Others – Triglyceride to rule out chylous effusion Amylase – to rule out pancreatitis or esophageal rupture ADA – helps in making diagnosis of tuberculosis ( Usually > 40 IU/L in tubercular effusion & ascites)

19. APPROACH TO PLEURAL FLUID EXAMINATION

20. HAEMATOLOGY TEST Increase Neutrophil Bacterial infection, Pancreatitis, Pulmonary infarction Increase Lymphocytes Tuberculosis, Viral infection, Autoimmune disorders, Malignancy Increase Eosinophils > 10 % Trauma introducing air and blood, allergic reaction, parasite / fungal infection, pulmonary infarction, Drugs

21. Eosinophilic effusion

22. PERICADIAL FLUID EXAMINATION

23. PERICADIAL FLUID EXAMINATION Normally 10 -50 ml of pericardial fluid Straw coloured Transudate (Pale yellow, clear) – Hypothyroidism, Uraemia , Autoimmune disorder Exuduative (Turbid ) – Infection , Malignancy Haemorrhagic – Trauma, Uraemia , Tubercular Milky – Chylous and Pseudochylous

24. PERICADIAL FLUID EXAMINATION CHEMICAL EXAMINATION Protein – little use Glucose < 40 mg/dl in Tuberculosis, bacterial and Rheumatic diseases and malignancy ADA – increase in Tuberculosis MICROSCOPY WBC > 1000 cells/cu mm in Bacterial infection and TB Malignant cell – Metastatic from lung and breast

25. PERICADIAL FLUID MICROBIOLOGICAL EXAMINATION Gram Stain – positive in 50% bacterial infections Culture – Positive in 80% of bacterial infections AFB – Positive in 50% of Tubercular cases

26. ASCITIC FLUID EXAMINATION

27. PERITONEAL FLUID Peritoneal cavity normally contain upto 50ml of clear straw colored fluid Patient with peritoneal effusion is said to have ascitis and it is called ascitic fluid The procedure of collecting the ascitic fluid is called abdominal paracentesis Indications: ascites of unknown etiology , acute abdominal pain, post operative hypotension, intra abdominal hemorrhage etc Specimen collected into tubes same as for other fluid

28. CAUSES OF ASCITES

29. PHYSICAL EXAMINATION Colour and appearance: normally clear and pale yellow Turbid: appendicitis, pancreatitis etc. Green: intestinal perforation, cholecystitis Milky: nephrotic syndrome, carcinoma, parasitic infection Bloody: hemorrhagic pacreatitis , reptured spleen or liver Examine for clot formation

30. MICROSCPIC EXAMINATION Total leukocyte useful in spontaneous bacterial peritonitis (SBP) Approximately 90% of (SBP) have leukocyte count >500/ cumm and over 50% neutrophiles Increase lymphocyte – Favours TB Eosinophilia >10% most commonly associates with CHF, vasculitis, lymphoma and ruptured hydatid cyst

31. CHEMICAL EXAMINATION Estimation of glucose has little value Decreased in peritonitis ,malignancy Estimation of amylase - Increased in acute pancreatitis, (more than 3 times of serum values) , Gi perforation Estimation of ALP - Elevated in intestinal perforation Estimation of LDH – Increase in Malignancy

32. CHEMICAL EXAMINATION Estimation Urea and Creatinine – Traumatic rupture of urinary tract or in renal transplant surgery (ureteric dehiscence) ADA – increase more than 40 unit/ liter in TB peritonitis Tumour marker Presence of CA 125 antigen with a negative CEA suggests the source is from ovaries, fallopian tube, or endometrium Presence of CEA suggests source is gastrointestinal

33. MICROBIOLOGY TESTS Gram stains and aerobic and anaerobic cultures Aerobic cultures : inoculate blood culture in blood culture bottles , sensitivity increases from 50 % to 80% if done with BACTEC vis a vis conventional Acid fast smear , adenosine deaminase and culture for TB

34. THANK YOU

35. Examination of pleural fluid

36. Ascites • Diagnosis: • established with a combination of a physical examination & an imaging test (USG). • Approx 1500 mL of fluid had to be present for flank dullness to be detected • lesser degrees of ascites can be missed. • Ultrasonography can be helpful when the physical examination is not definitive

37. Causes of Ascites • Ascites can be classified based on the underlying pathophysiology: • Portal hypertension – Cirrhosis – Alcoholic hepatitis – Acute liver – Hepatic veno -occlusive disease ( eg , Budd-Chiari syndrome) – Heart failure – Constrictive pericarditis – Hemodialysis -associated ascites (nephrogenic ascites)

38. Causes of Ascites • Hypoalbuminemia – Nephrotic syndrome – Protein-losing enteropathy – Severe malnutrition • Peritoneal disease – Malignant ascites ( eg , ovarian cancer, mesothelioma) – Infectious peritonitis ( eg , tuberculosis or fungal infection) – Eosinophilic gastroenteritis – Starch granulomatous peritonitis – Peritoneal dialysis

39. Causes of Ascites • Other etiologies – Chylous ascites – Pancreatic ascites (disrupted pancreatic duct) – Myxedema – Hemoperitoneum

40. International Ascites Club Grading system • Grade 1 – Mild ascites detectable only by ultrasound examination • Grade 2 – Moderate ascites manifested by moderate symmetrical distension of the abdomen • Grade 3 – Large or gross ascites with marked abdominal distension

41. Abdominal Paracentesis • Most efficient way to confirm the presence of ascites, diagnose its cause, and determine if the fluid is infected. • Safe procedure, with an extremely low incidence of serious complications despite the coagulopathy that is usually present in patients with cirrhosis. • Coagulation parameters beyond which paracentesis should be avoided. • There are no data-supported however, patients with clinically evident fibrinolysis or disseminated intravascular coagulation should not undergo paracentesis.

42. TESTS PERFORMED ON ASCITIC FLUID Routine tests Cell count and differential Albumin concentration Total protein concentration Culture in blood culture bottles Optional tests Glucose concentration LDH concentration Gram stain Amylase concentration Other tests • Tuberculosis smear and culture • Cytology • Triglyceride concentration • Bilirubin concentration

43. Cell count and differential • The cell count with differential is the single most helpful test performed on ascitic fluid to evaluate for infection. • Polymorphonuclear count ≥ 250/mm3 – spontaneous bacterial peritonitis. • In bloody ascites: – one neutrophil should be subtracted from the absolute neutrophil count for every 250 red cells to yield the "corrected neutrophil count“

44. SERUM-TO-ASCITES ALBUMIN GRADIENT • The serum-to-ascites albumin gradient (SAAG) accurately identifies the presence of portal hypertension and is more useful than the proteinbased exudate/transudate concept. • SAAG – serum albumin value - ascitic fluid albumin – (obtained on the same day). • SAAG ≥ 1.1 g/dL (11 g/L) – Indicates portal hypertension – (Budd-Chiari syndrome, heart failure, or liver cirrhosis) • SAAG

45. Sending Cultures • Bacterial cultures of ascitic fluid should be sent from patients with – new onset ascites • admitted with ascites • Who deteriorate with – Fever, – Abdominal pain – Azotemia, – Acidosis – confusion

46. Protein, Glucose, LDH • Protein — Ascitic fluid had been classified as an exudate if the total protein concentration is ≥2.5 or 3 g/dL and a transudate if it is below this cut-off. However, the exudate/transudate system of ascitic fluid classification has been replaced by the SAAG. • Measurement of total protein, glucose, and lactate dehydrogenase (LDH) in ascites may also be of value in distinguishing SBP from gut perforation into ascites • Patients with ascitic fluid that has a neutrophil count ≥250 cells/mm3 and meets two out of the following three criteria are unlikely to have SBP and warrant immediate evaluation to determine if gut perforation into ascites has occurred. – Total protein >1 g/dL – Glucose

47. TESTS FOR TUBERCULOUS PERITONITIS Direct smear - 0 to 2% sensitivity in detecting Mycobacteria Culture - When one litre of fluid is cultured, sensitivity for Mycobacteria 62 to 83% Fluid for PCR for tuberculosis Cell count - Tuberculous peritonitis can mimic the culture-negative variant of SBP, but lymphocyte cells usually predominate in tuberculosis Adenosine deaminase Adenosine deaminase activity of ascitic fluid has been proposed as a useful non-culture method of detecting tuberculous peritonitis; however, patients with cirrhosis and tuberculous peritonitis usually have falsely low values .