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Y3 MOD clinical pathology > Effusions and Fluid Analysis > Flashcards

Effusions and Fluid Analysis Flashcards

1
Q

Peritoneal, pleural and pericardial cavities are lined by ?

A

Mesothelium

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2
Q

How is movement of the mesothelium facilitated?

A

Contain serous fluid

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3
Q

Describe the serous fluid

A

This fluid is an ultrafiltrate of blood

  • Low cellularity
  • Low total protein
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4
Q

Describe the pathophysiology of fluids in the body

A

Volume of fluid present depends upon equilibrium between:

  • Hydrostatic pressure of blood
  • Oncotic pressure of blood (proteins)
  • Permeability of vessels
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5
Q

Define effusion

A

Effusion: any accumulation of fluid in a body cavity

  • Indicative of a pathological process
  • Rate of fluid formation&raquo_space; Rate of fluid removal
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6
Q

What are the two classifications of effusions based on protein, cell count and cytology?

A

Transudate

Exudate

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7
Q

Define transudate

A

Effusion usually caused by imbalances of hydrostatic and/or oncotic pressure

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8
Q

Define exudate

A

Effusion usually caused by increased vascular permeability due to inflammation – higher protein much more cellular fluid

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9
Q

How are effusions classified based on aetiology and composition?

A

Haemorrhagic
Chylous
Pseudochylous
Neoplastic

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10
Q

Analysis of effusions is based on what characteristics?

A
  • Colour
  • Turbidity: clear or opaque
  • Odour
  • Cell counts and total protein
  • Microscopic examination
  • Biochemistry depending on the case
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11
Q

Describe haemorrhagic effusions and their causes

A 
- Heavily blood-stained 
Caused by:
- True cavity haemorrhage: vessel disruption
- Iatrogenic blood contamination
- Splenic tap
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12
Q

How will a sample appear if it has been Iatrogenically contaminated?

A
  • Initially clear then bloody or vice-versa
  • Swirling of blood
  • Should form clot
  • Supernatant clear
  • Can seen platelets
  • No erythrophagocytosis
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13
Q

What are the causes of true body cavity haemorrhage?

A

Bleeding tumour
Coagulopathy
Trauma

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14
Q

Describe the features and cytological appearance of a true body haemorrhage

A
  • Fluid does not clot
  • Supernatant often haemolysed due to RBC degradation in cavity
  • Microscopy:
    Erythrophagocytosis (RBC removed by macrophages)
    No platelets
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15
Q

How can abdominal haemorrhage be investigated?

A
  • Coagulation profile / haematology
  • Ultrasound abdomen to detect masses
  • Look for neoplastic cells on the cytology slide
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16
Q

What is chyle?

A

Chylomicron-rich lymph

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17
Q

What are chylomicrons and their functions?

A
  • TG-rich lipoproteins absorbed from the intestine
  • Transport of dietary lipid
  • Enter lymphatics, then the blood via thoracic duct
  • BIG so make fluid opaque (milky)
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18
Q

Describe the features of a chylous effusion

A
  • Milky fluid (white, opaque)
  • Protein often >25g/l*
  • Cell count very variable
  • Cytology mainly lymphocytes, but can be mixed
  • Neutrophils increase with chronicity
  • High [triglyceride] (> serum): over 1.13 mmol/L -> chyle
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19
Q

How does a chylous effusion form?

A

Formed due to lymphatic drainage impairment or lymphatic leakage
- Lymphatic drainage impairment or lymphatic leakage

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20
Q

What are the causes of a chylothorax?

A

Heart disease
Trauma/surgery
Neoplasia
Idiopathic

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21
Q

How is pseudochyle different to chyle?

A
  • Looks similar grossly
  • BUT not high in triglycerides
  • White colour due to cell debris, protein and cholesterol
  • Uncommon
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22
Q

Describe the features of (Low protein) Transudate

A
  • Clear, colourless
  • Protein < 25 g/l
  • Cell count < 1.5 x109/l
  • Few cells
  • Mainly monocytes and macrophages
  • Lymphocytes
  • Mesothelial cells
  • Few neutrophils
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23
Q

What is the pathophysiology of (Low protein) Transudate formation?

A

Decreased oncotic pressure due to low serum protein

Low protein fluid leaks out of vessels

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24
Q

What are the causes of transudates?

A
  • Decreased oncotic pressure - Severe hypoalbuminaemia
  • Portal hypertension
  • Over hydration
  • Cardiac failure
  • Thrombi in major vessels (acute phase)
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25
Q

What are the 3 causes of hypoalbuminaemia

A
  • Protein losing enteropathy
  • Protein losing nephropathy
  • Reduced protein production in liver disease
26
Q

How can transudates be further investigated?

A
  • Biochemistry (plasma/serum): Albumin, Creatinine
  • Urinalysis (check for proteinuria) - Urine protein:creatinine ratio
  • Imaging
  • Look for GI or renal disease
27
Q

Describe the features of High protein (modified) transudates

A
  • ‘Modified’: more protein and cells than pure transudate but not as much exudate
  • Colourless to amber or pink
  • Clear (low cell count)
  • Protein > 25 g/l
  • Cell count < 5.0 x109/L
28
Q

What is the pathophysiology of High protein (modified) transudates

A

Increased hydrostatic pressure

(Higher protein) fluid pushed out

29
Q

How does a High protein (modified) transudates appear on cytology?

A
  • Low cellularity (usually higher than pure transudates)
  • Mixed population of cells
  • More neutrophils than transudate
30
Q

What are the causes of modified transudates?

A

Increased intravascular hydrostatic pressure in liver or lung (venous congestion):
- Congestive heart failure
- Thrombi or neoplasia
Also:
- Non-exfoliating neoplasia
- Lung lobe/ splenic torsion
- Occasionally feline infectious peritonitis

31
Q

Describe the appearance and features of exudates

A
  • Turbid (due to lots of cells)
  • Yellow/brown/bloody
  • High nucleated cell count
  • High protein
  • Mostly neutrophils: Inflammation (e.g. pleuritis, peritonitis, pericarditis)
32
Q

Describe the pathophysiology of exudates

A

Increased vessel permeability

High protein, cellular fluid leaks out

33
Q

Describe septic exudates and its cause

A
  • Intracellular organisms
  • But not always visible
  • Absence of organisms does not rule out sepsis
  • Often degenerate neutrophils (karyolysis & karyorrhexis)
34
Q

Describe non-septic exudates and its cause

A
  • Non-degenerate neutrophils

- Lower numbers of hypersegmented neutrophils and pyknotic cells

35
Q

What are the causes of septic exudates?

A
  • Penetrating wound
  • Foreign body
  • GI perforation or ischaemia
  • Haematogenous route
36
Q

Describe the effect of gut contamination on a sample

A

Smelly
Brown
Bits of plant material
Free bacteria

37
Q

What are the causes of non-septic exudates?

A
  • Ruptured gall bladder
  • Ruptured urinary bladder
  • Necrotic tumour
  • Pancreatitis
  • FIP*
38
Q

Describe the fluid sample that would be taken in the case of feline infectious peritonitis

A
  • Yellow sticky fluid
  • High protein -> froths
  • Moderate cellularity
  • Globulin:albumin ratio
    A:G low in FIP
    A:G< 0.4 then FIP likely
    A:G> 0.8 NOT FIP
39
Q

Describe how the cytology of an FIP case would look

A
  • Abundant proteinaceous background
  • Cells mainly neutrophils
  • Fewer macrophages
40
Q

What are some further tests used for FIP diagnosis?

A
  • Immunohistochemistry of fluid pellet for coronavirus and/or PCR
  • Serology
  • Can measure alpha 1-acid glycoprotein = Acute phase protein
  • No single test definitively diagnostic (except for histology)
41
Q

Describe bile peritonitis and how it occurs

A
  • Ruptured gall bladder / bile duct
  • Trauma
  • Following obstruction
  • Chemical peritonitis
    +/- secondary infection
42
Q

What colour is the fluid from bile peritonitis?

A

Green

43
Q

Describe how the cytology from bile peritonitis would look

A
  • Neutrophils
  • Macrophages with green pigment
  • [Bilirubin] fluid higher than [bilirubin] plasma
44
Q

The concentration of which substance changes if there’s a ruptured bladder?

A

[Creatinine] fluid > [Creatinine] plasma

Usually at least twice

45
Q

How would fluid from a ruptured bladder case appear? How does it change?

A
  • Urea equalises between fluid and plasma so may be similar (or higher)
  • Fluid starts as transudate (very low protein because diluted by urine)
  • Urine -> irritant -> changes to exudate
46
Q

What are the effects of neoplastic effusions

A
  • Compression of blood vessels and lymphatics -> increased hydrostatic pressure and/or abnormal vasculature
  • Increased vessel permeability
  • Inflammation
  • Necrosis
  • Haemorrhage
  • Cell exfoliation
47
Q

Name 3 tumours that can cause neoplastic effusions

A

Lymphoma
Adenocarcinoma
Mesothelioma

48
Q

What are some pitfalls in diagnosing neoplasias?

A
  • Mesothelial cells found in all effusions
  • Shed off pleura / peritoneum
  • Can become reactive and look like tumour cells!
49
Q

Describe the appearance of reactive mesothelial cells

A
  • Eosinophilic fringe or brush-boarder
  • May be multinucleated
  • May contain prominent multiple nucleoli or variable shapes and sizes
  • May phagocytose cells and particulate matter
50
Q

What are the indications for using arthrocentesis?

A
  • Joint disease of unknown aetiology
  • Diseases in multiple joints
  • Suspected infective arthritis
  • Pyrexia of Unknown Origin
  • Monitoring therapeutic response
51
Q

Describe the normal appearance of synovial fluid

A

Clear, pale yellow

52
Q

Describe the appearance of synovial fluid during inflammation

A

Yellow turbid

53
Q

What does uniformly bloody synovial fluid suggest?

A

Haemarthrosis

54
Q

What does clear then bloody synovial fluid suggest?

A

Contamination

55
Q

What are the main principles when handling a sample

A
  • Make smear immediately
  • Note viscosity
  • Collect into EDTA and sterile plain tube
  • Always send fresh smear with sample
56
Q

Describe all of the normal features of synovial fluid

A

Clear pale yellow
Very viscous
Hypocellular
Protein background

57
Q

How does synovial fluid appear grossly and on cytology when there has been trauma

A

Grossly red
Low viscosity due to effusion
Red cells
Some neutrophils

58
Q

How would the cytology of synovial fluid in the case of osteoarthritis appear?

A
  • Cellularity normal or mildly increased
  • Predominantly mononuclear
  • Can see osteoclasts (rarely)
59
Q

How would the cytology of synovial fluid in the case of inflammatory arthropathy appear?

A
  • Viscosity reduced
  • Cellularity increased
  • Increased cell count
  • Mainly neutrophils
  • Degenerative change rarely evident if infective
60
Q

How would the cytology of synovial fluid in the case of septic arthritis

A
  • Usually monoarticular
  • Penetrating wound
  • Haematogenous spread (rare)
  • Often we do not see bacteria and culture is negative

Y3 MOD clinical pathology (10 decks)

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