Stool Examination for Routine Practice

This is the brief Notes on Stool Examination which may be useful in Routine clinical practice for practitioners.

1. STOOL EXAMINATION PRESENTED BY:- DR.RAJESH UIKEY Assist. Prof DEPT. OF ROG NIDAN EVAM VIKRITI VIGYAN

2. GENERAL INTRODUCTION Average healthy adults defecate from three times a day to three time a week. Common pattern is once a day . The stool tends to be soft and bulky on a diet high in vegetables and small and dry on a diet high in meat. Two thirds of the stool weight is attributable to its water content ,The normal brown color is of still undetermined origin. The odour results from indole and skatole produced by bacteria from tryptophan.

3. FECES ARE COMPOSED OF:- Waste residue of indigestible material in food Bile (pigments and salts). Intestinal secretion ,including mucous. Leucocytes that migrate from the blood stream Shed epithelial cells Large numbers of bacteria that make up to one third of total solids Inorganic material (10-20%) that is chiefly calcium and phosphate Digested food (present in very small quantities)

4. TYPE OF FECES Bristol Stool Scale is a medical aid designed to classify the form of human feces into seven categories.

5. STOOL COLLECTION Universal precaution :- Collect stool in a dry ,clean container Faces should be urine free when collected. Collect the entire stool and transfer to another container by a tongue blade. Delivered to the laboratory immediatetly after collection. Worm stool are best for detecting ova and parasites . Do not refrigerate for ova and parasites.

6. Continue:- Some coliform bacilli produce antibiotics substances that destroy enteric pathogens. A diarrhoeal stool will usually give good results A freshly passed stool is the specimen of choice Preferably stool specimens should be collect before antibiotics therapy is initiated and as early in the course of disease as possible

7. Continue:- Only a small amount of stool is a needed the size of walnut . If mucous and blood are present ,they should be indicated in part of the specimen to be examined. Do not use a stool that has been passed into the toilet bowl or that has been contaminated with barium or other x-ray Label all stool specimen with patients name, date and reason for examination testing.

8. INTERFERING FACTORS Meat interferes with some tests and should usually be omitted from the diet for 3 day before a test for blood Stool specimen from patients receiving barium, bismuth, oil, or antibiotics are not satisfactory Bismuth from paper towels and toilet tissues interferes with tests.

9. NORMAL VALUES IN STOOL ANALYSIS PHYSICAL EXAMINATION NORMAL Colour brown odour Varies with pH stool and depend upon bacterial fermentation and putrefaction Consistency Plastic ,not unusual to see seeds and veg. skin ,soft and bulky in a high veg. diet , small and dry in a high meat diet PHYSICAL EXAMINATION

10. PHYSICAL EXAMINATION NORMAL Size and shape Formed Gross blood Absent Mucous, Pus and Parasites Absent Fat Colourless ,neutral fat and fatty acid crystals and soaps Undigested None to small amount food, meat fibers, strach,trypsin Eggs and Sags Absent Yeasts and Leucocytes Absent

11. CHEMICAL EXAMINATION CHEMICAL EXAMINATION NORMAL pH Neutral to weakly alkaline Adult= 7.0-7.5 New born= 5.0-7.0 Bottle fed infant= neutral to slightly alkaline pH of=7.0-8.0 Breast fed infant=Slightly acidic

12. CHEMICAL EXAMINATION NORMAL Occult blood Negative Urobilinogen 50-300mg/24hrs Porphyrins Coproporphyrins <200µg/24hrs Protoporphyrins,1500µg/24hrs Uroporphyrin <100µg/24hrs Nitrogen 1-2 gm/24 hrs Bile Negative in adult,positive in childeren Trypsin Positive in small amount in adult, in greater amount in normal children

13. EXAMINATION BY INSPECTION A simple inspection of feces may lead to a diagnosis of parasitic infection, obstructive jaundice, diarrhoea , malabsorption , rectosigmoidal obstruction , dysentry or ulccerative colitis or gastrointestinal tract bleeding TYPE OF STOOL LIKELY REASON Watery stool Diarrhoea Large amount of mushy, foul smelling, gray stool that float in water Steatorrhoea

14. TYPE OF STOOL LIKELY REASON Little firm ,spherical masses Constipation (irritable colon syndrome, overuse of laxative) Narrow ribbon like stool Spastic bowel or narrowing or stricture Clay Coloured Obstructive jaundice, or present of barium sulfate Reddish stool Blood from lower GIT, beets consumption or BSP use Black ,tarry stool Bleeding for upper GIT , iron, bismuth or charcoal, consumption

15. TYPE OF STOOL LIKELY REASON Green stool Ingestion of spinach etc, calomel, presence of biliverdin , seen in patients taking antibiotic orally

16. MICROSCOPIC EXAMINATION COVERSLIP PREPARATION FOR MICROSCOPIC EXAMINATION:- Normal saline one drop Iodine solution one drop 1.On a clean and dry slide add one drop each of normal saline and iodine solution

17. 2. By using an applicator stick take a small portion From formed sample:-portion from well inside and surface From liquid stool containing mucus. Take blood stained mucus and other small portion

18. 3. Mix the sample with the drop of sodium chloride on the Slide .Mix the sample with iodine solution drop

19. 4.Place a coverslip over each drop (apply coverslips as Shown to avoid the formation of air bubbles)

20. 5. Label the slide with identification number

21. 6. Examine the preparation under the microscopic First under – low power objective and afterwards With high power objective

22. CONCENTRATION METHOD OF MICROSCOPIC EXAMINATION Method:- When stools are mixed with a saturated solution of sodium chloride the ova float to surface. This method is recommended for ova of round worm hookworm, whipworm, hymnolopis nana, Tenia etc The method is not suittable for ova of schistosomes and Flukes and protozoa cysts

23. Place small portion of stool in a penicillin bottle . Add saturated sodium chloride (half bottle) 2. Mix by using applicator stick and add a saturated sodium chloride and fill the bottle completely

24. 3. Place a coverslip on the bottle mouth 4. Remove the coverslip with care , a drop of liquid should On it. Place it on the glass slide

25. 5.Examine under microscope(first under low power objective And afterwards under high power objective)

26. MICROSCOPIC ANALYSIS NO. DETECTION OF NORMAL FINDING ABNORMAL FINDING PATHOLOG.CONDITION DIAGRAM 1 CELLS:- Pus cells Present , few Present , many Bacillary dysentry , ulcerative colitis Epithelial cells -do- -do- Inflammation of the bowel macrophages Occasional many Bacillary dysentry , ulcerative colitis Erythrocytes Absent Present Lesion is in the colon , rectum or anus, the clump in amoebiasis

27. NO. DETECTION OF NORMAL FINDING ABNORMAL FINDING PATHOLOG.CONDITION DIAGRAM 2 Crystals:- Triple phosphate and calcium oxalate Present due to indigestion of certain food I,e . spinach, berries, tomato etyc - - Charcot- leyden crystals Absent Present ulcerative colitis amoebiasis Haematoidin crystals Absent Present Intestinal haemorrhage 3 Vegetable matter:- Vegetable cells, spirals, fibers, hairs etc Present in residuel constituent - -

28. NO. DETECTION OF NORMAL FINDING ABNORMAL FINDING PATHOLOG.CONDITION DIAGRAM 4 Animal matter:- Connective tissue, musle fibers and elastic tissue Present in residuel constituent or undigested fibers - - - 5 Undigested ingredients:- starch Absent Present in high proportion Indigestion Fat Absent Present in high proportion Indigestion 6 Other Findings:- Yests Present especialy blastocystis hominis - - Bacteria Constitute about one third of the weight of dried faces - -

29. INTESTINAL PROTOZOA ORGANIUM TYPE DIAGRAM Entamoeba histolytica cyst Pathogenic Entamoeba coli cyst Non pathogenic Giardia lamblia cyst Pathogenic

30. ORGANIUM TYPE DIAGRAM Balantidium coli cyst Pathogenic Enterobius vermicularis (pin worm) pathogenic Trichiura ( wipworm ) Pathogenic

31. ORGANIUM TYPE DIAGRAM Ascaris lumbricoides (round worm) Pathogenic Ancylostoma duodenale (hook worm) pathogenic Necator americanus Pathogenic

32. ORGANIUM TYPE DIAGRAM Strongyloides stercoralis Pathogenic Taenia solium (tape worm) pathogenic Schistosoma haematobium Pathogenic

33. References 1. Godkar Praful B., Godar Darshan P, Text book of medical laboratory technology, Parasitology and faeces Examination 42, Second ed , Mumbai: Balwani publishing house, 2003.

34. THANK YOU