Lab 7 - Examination of the body cavity fluids and the cerebrospinal fluid Flashcards
Body cavities:
abdominal cavity (peritoneal cavity)
thoracic cavity (pleural cavity), mediastinum is included
pericardial cavity
Causes of the accumulation of fluids is different cavities
Increased permeability of vessels due to the underlining non inflammatory causes
Increased permeability of vessels due to inflammatory causes
Causes of the accumulation of fluids is different cavities
Increased permeability of vessels due to the underlining non inflammatory causes
1 increase of hydrostatic pressure of the blood
2 decrease of plasma colloid oncotic pressure decrease of plasma albumin
3 impeded lymphatic flow (backward stasis)
4 hormonal effects
Causes of the accumulation of fluids is different cavities
Increased permeability of vessels due to the underlining non-inflammatory causes
1 increase of hydrostatic pressure of the blood
- right-sided heart failure
- liver hypertension, failure, cirrhosis
- blockage of a blood vessel
- renal fibrosis
Causes of the accumulation of fluids is different cavities
Increased permeability of vessels due to the underlining non-inflammatory causes
2 decrease of plasma colloid oncotic pressure decrease of plasma albumin
- Type and quantity of protein intake
- Gastric, pancreatic (EPI), intestinal digestion (specific intestinal diseases), absorption ((specific intestinal diseases)),
- Synthesis (liver failure),
- Utilization (growth, pregnancy, work, exercise, tumour)
- Loss (renal - glomerulonephropathy, intestinal - protein losing enteropathy)
Causes of the accumulation of fluids is different cavities
Increased permeability of vessels due to the underlining non-inflammatory causes
4 hormonal effects
Aldosterone, AHD - primary or secondary case increased circulatory volume
Causes of the accumulation of fluids is different cavities
Increased permeability of vessels due to inflammatory causes
- Bacterial toxins (endotoxins, exotoxins)
- Viral effects (immune complexes)
- Parasitic toxins
- Inflammatory mediators (histamine etc., immune complexes)
Types of fluids
transudate (hydro-) exudate (pyo-) modified transudate blood chylus (lymph)
Sampling
Samples must be taken in sterile environments,
- using syringe, iv. catheters, or vacuum bottles, into glass tube (in order to evaluate coagulation ability) and
- Na(K)2EDTA containing tubes.
- If necessary tubes must be taken one for:
biochemical and
cytological analysis and one for
microbiology examination
(in this case special tubes are provided) .
Course of sample analysis and preparation
organoleptic examination
Rivalta-test
analysis of total and nucleated cell count
(by using automatic cell counters or haemocytometer)
centrifuging (2000 rounds/min. for 5-10 minutes) by centrifuge or by cytospin
separating upper layer for further biochemical analysis
separation of sediment for cytological analysis
Parameters determined from body cavity fluids
outlook physical parameters (colour, odour, consistency) Rivalta-test coagulation ability specific gravity pH red blood cell count nucleated cell count total protein concentration albumin/globulin ratio creatinine, urea concentration alpha-amylase, lipase activity LDH activity triglycerol, cholesterol concentration cytological analysis
Rivalta test
Results If coagulation (smoky appearance) occurs the result is ?
Exudate
- due to the coagulation of labile proteins (fibrinogen, globulins), as weak acid can coagulate these proteins.
Rivalta test
Results
If coagulation is not observed but the sample is dissolved in the solution the result is?
Transudate
- due to the fact that stabile proteins, such as albumin do not show coagulation in weak acids
(note: in case of urinalysis 20% salicylic acid is used that coagulates all proteins included albumin)
Rivalta test
Results
What If the sample contains much of globulins
- Makes the sample to be honey-like in case of FIP after adding some drops of sample into the solution
- smoky appearance of coagulation is not visible, but the sample does not dissolve in the solution but remains forming one drop.
- In this case the globulins are coagulated on the surface of this highly consistent material that lets it to stay in one drop.
Transudate
Outlook
colour = Bloody (heart failure, stasis of vessels) Watery or Yellowish (liver failure) odour = No smell consistency = Watery
Transudate
- Rivalta-test
- Coagulation ability
- Specific gravity (g/ml)
- PH
- Nucleated cell count (x109/l)
- Total protein (TP) (g/l)
- Rivalta-test = negative
- Coagulation ability = negative
- Specific gravity (g/ml) = <1,017
- PH = slightly alkaline or 7
- Nucleated cell count (x109/l)= <1-10
- Total protein (TP) (g/l) = <25
Modified Transudate
- Rivalta-test
- Coagulation ability
- Specific gravity (g/ml)
- PH
- Nucleated cell count (x109/l)
- Total protein (TP) (g/l)
- Rivalta-test = +/-
- Coagulation ability = +/-
- Specific gravity (g/ml) = 1,017-1,025
- PH = slightly alkaline, acidic or 7
- Nucleated cell count (x109/l)= 10-50
- Total protein (TP) (g/l) = 25-35
Modified Transudate
Outlook
Colour= Bloody, opaque, grey-white, reddish, yellowish, sometimes transparent Odor= Sometimes Consistency= Watery sometime slightly viscous
Exudate
Outlook
Color= generally opaque, bloody, grey- white, yellow-white, light brown Odor= often penetrating Consistency = often viscous
Exudate
- Rivalta-test
- Coagulation ability
- Specific gravity (g/ml)
- PH
- Nucleated cell count (x109/l)
- Total protein (TP) (g/l)
- Rivalta-test = +/++/+++
- Coagulation ability= +
- Specific gravity (g/ml) = >1,025
- PH= Acidic
- Nucleated cell count (x109/l) = >50
- Total protein (TP) (g/l) = >35
Biochemical analysis
Albumin/globulin ratio Creatinine, urea concentration Alpha-amylase, lipase activity LDH activity Triglycerol (TG)/cholesterol (Chol) ratio
Biochemical analysis
Albumin/globulin ratio
Generally TP and albumin concentration is measured, the difference gives globulin concentration
- DIAGNOSTIC IMPORTANCE= CAT, FIP
> 50% of TP are globulins = highly suggestive for FIP infection.
Biochemical analysis
Creatinine, urea concentration
Generally, it is enough to measure 1 of these parameters, - Better to take the creatinine value.
- If the values = peritoneal fluid > in plasma = highly suggestive for urine bladder rupture, or the rupture of kidney pelvis, or one of the ureters.
Biochemical analysis
Alpha-amylase, lipase activity
Generally, it is enough to measure 1 of these parameters.
- If the values = Peritoneal fluid > plasma, = Highly suggestive for duodenal perforation or gall bladder rupture, or the rupture of an abscess developed by pancreatitis.
- The determination of these parameters is required if there is marked peritonitis, otherwise, the elevation of these values can be expected in case of urine bladder rupture, too.
- If the sample is derived from the pleural cavity and it is highly inflammatory, and there is a high alpha-amylase activity in it, it is suggestive for esophageal rupture.
Biochemical analysis
LDH activity
If there is a diagnostic problem to evaluate modified transudates, whether there is tumor in the background or other process, it is advisable to determine LDH activity.
- If there is a marked increase in this value in body cavity fluid, or the value is higher in fluid than in plasma, it is suggestive for fluid of neoplastic origin.
- In case of peritonitis, or pleuritis as neutrophils also contain LDH, so the activity can be high in the fluid.
Biochemical analysis
Triglycerol (TG)/cholesterol (Chol) ratio
If there is a diagnostic problem to evaluate whether the origin of fluid is lymphatic or not, it is advisable to determine TG/Chol ratio.
- As if the fluid is chylus or of lymphatic origin.
- The fluid will contain more TG, than Chol.
Cytological analysis
- After smearing the samples we have to
- airdry them on room temperature (non heating ventilator can be used) and after
- using fixative we can stain them by using the normal stains (Giemsa, Papanucolau, Romanowsky, Pappenheim, Doiff-quick etc.).
- After the preparation the smears can be analysed by microscope.
- First the analysis must be doen on low power (100-400 x), then high power (1000x) by using immersion lens.
Cytological analysis
Basis of the differentiation:
Samples can be inflammatory and non-inflammatory.
Inflammatory samples can be septic or non-septic.
Non inflammatory samples can be reactive or neoplastic.
Cytological analysis
These answers can be given by analysing:
Major cell types, The environment of cells, Extracellular matrix, Connection of cells, Clumps, Aggregates, and Soliter cells, Individual cells, Typical and atypical cell types, Appearance of individual cells normal (reactive, apoptotic) and Pathological (inflammatory, neoplastic and necrotic) changes of them, Criteria of malignancy of the cells, Pathologic microorganisms (bacteria, viral inclusion bodies, parasites, fungi)
Transudates
Causes of the development
- Increased vessel permeability due to the underlining causes
- Increase of hydrostatic pressure of the blood
- decrease of plasma colloid oncotic pressure
- impeded lymphatic flow
- Hormonal effects
TRANSUDATES
Cytology
- In case of low cellularity (especially in liver failure), the basic cell types are small lymphocytes.
- In case of heart disease more blood cells (red and white) are entering into the cavities.
- More macrophages and quite a few reactive mesothelial cells are seen.
- Due to long term stasis secondary inflammatory process develops that leads to the increase of neutrophils and macrophages.
Exudates
Causes of the development
Increased permeability of vessels due to inflammatory causes
- bacterial
- viral
- parasitic
- iInflammatory mediators
Increased migration of phagocytes
Increased proliferation of mesothelial cells
Increased production of inflammatory proteins
EXUDATES
Major causes of septic exudates
- Trauma of pleural, peritoneal, pericardial wall
- Proliferation and overgrow of bacteria through walls of organs
pneumonia,
constipation,
ileus,
Pancreatitis,
pyometra,
prostatitis
- Internal perforation of organs esophageal, gastric, small intestinal, rectal perforation, gall bladder, urine bladder rupture, prostatic, uteral perforation
- Haematogenous or lymphatic spreading of bacteria mycobacteriosis, actinobacillosis, nocardiosis, actinomycosis
EXUDATES
Cytology
Many neutrophils, macrophages, and reactive mesothelial cells are seen.
- Cells (mainly neutrophils) might show nuclear degeneration (mainly karyolysis, karyorhexis - these are necrotic degenerations, sometimes karyopicnosis is also seen - this is apoptotic degeneration).
- Bacteria (rods and cocci) often visible generally intracellular phagocytosed form.
- If bacteria appear out of the cells it is an indicator of the worsening (end-stage) process.
- If there are bacteria out of the cells only, it is suggestive of bacterial contamination.
Major causes of non septic exudates
viruses - FIP
urine bladder rupture
Major causes of non septic exudates
viruses - FIP
Parasites
- Dioctophyma renale,
- Toxocara spp. (visceral larva migrans),
- Fluke (Dicrocoelium dendriticum, Fasciola hepatica),
- Taenia caused cysticercosis,
- Echynococcus granulosus caused blisters,
- Dirofilaria immitis and repens larvae,
- Opistorrhis felineus etc.
Fungi
- systemic mycosis on pleural wall (Aspergyllosis, Cryptococcosis, Candidiasis, Blastomycosis etc.,)
- Rupture of gall bladder
- in this case, bile pigments are often seen in cells
Major causes of non septic exudates
urine bladder rupture
- Secondary inflammatory processes due to neoplasms or tissue necrosis i.e. pancreatitis
Lymph - appearance is due to i.e. blockage of lymphatic vessels, congenital dilation of lymphatic vessels, trauma caused lymphatic vessel damage, enlarged lymph nodes caused lymphatic vessel obstruction
Cytology - Non septic exudates
In case of non septic exudates the major cell types are = NEUTROPHILS that might show karyopicnotic degeneration, reactive macrophages and mesothelial cells.
- Phagocytic cells might contain inclusion bodies i.e. bile pigment, haemosiderin granules, viral inclusion bodies, tissue necrotic products. Some pathologic micoorganisms are also seen i.e. parasites (Dirofilaria, Toxocara larvae), parasitic ova (Opistorrhis felineus), fungal hyphae or sporulated fungi.
- Sometimes in the case of severe inflammatory immunological processes cell types are not diagnostic, but the extracellular matrix is highly azurophilic, showing the high protein content of the fluid.
If the fluid is of chylus origin, typical celltypes are small and medium sized lymphoid cells, lymphblasts, sometimes plasma cells, and macrophages. In this case lipid droplets are also visible in the extracellular matrix that has high protein content and therefore the background is azurophilic. If chylus appears in the baody cavity due to the obstruction of lymphatic vessels by enlarged lymphnodes in lymphoma, malignant lymphoblast cells are also visible.
Modified transudates
Causes of the development and the major causes of modified transudates
- Long-term stasis of fluid in the body cavities causes tissue necrosis on the neighboring tissues and therefore secondary inflammatory process.
- In the beginning of the development of highly exudative process there can be severe plasma fluid accumulation first.
- If blood appears in the body cavities - trauma caused lung, splenic, liver rupture, coagulopathy, thrombocytopathy, bleeding neoplasms (i.e. haemangiosarcoma, heart base tumours i.e. chemodectoma),
- Idiopathic (idiopathic haemopericardium)
Neoplastic processes typically cause modified transudates - carcinoma, adenocarcinoma, lymphoma, mesothelioma, systemic mastocytosis etc.)
Modified transudates
Cytology
In case of modified transudates the greatest challenge is to differentiate neoplastic processes from inflammatory processes.
Generally the major cell types are neutrophils, macrophages and highly reactive mesothelial cells.
If the process is neoplastic, tumour cells appear in the smear.
The problem is to make difference between reactive mesothelial cells and carcinoma cells.
If blood appears in the body cavities, cytologically acute bleeding can be diagnosed by the appearance of thrombocytes, and chronic bleeding can be diagnosed by the appearance of phagocytosed red blood cells, which is called erythrophagocytosis.
Examination of cerebrospinal fluid
In case of the appearance of central nervous signs, we take CSF samples.
Two spaces can be used to get samples:
- ocipital zona,
- lumbosacral, or
- lumbal zone.
Samples were taken from the lumbosacral or lumbal zone contain more proteins and cells.
Before sampling, it is advisable to perform retina observation, whether there is increased intracranial pressure.
If yes, it is necessary to reduce it first.
During sampling, it is necessary to check the speed of dripping of CSF samples to evaluate intracranial pressure.
Samples must be taken to Na(K)2EDTA containing tubes.
Examination of cerebrospinal fluid
Physical examination
1- Colour
(red - fresh bleeding, yellow - bleeding in the past, opaque - in highly inflammatory or neoplastic conditions)
2- turbidity
- slightly - if cell count is 100-300/μl,
- severely - if cell count is 2000- 3000/μl
3- coagulation
(coagulative in highly inflammatory processes)
Examination of cerebrospinal fluid
Cell count
Total cell count: native (non centrifuged) samples are obtained to Bürker chamber (1 μl), or Fuchs-Rosenthal chamber (3 μl).
Cells is counted above the whole network.
Nucleated cell count: 0,1 ml Türk solution into 0,9 ml liquor cerebrospinalis in haemocytometer: count the cells in 50 large squares, multiply the number with 5, result in
μl-s (normal 25 cell/μ)
Normal cell count: 5-10/μl
Cytology evaluation
Preparation of sample:
- Native sample can be centrifuged on 1500 rounds / min. for 10 minutes,
- then upper layer is aspirated by pipette.
- 100-200μl upper layer must remain and with this fluid, the sediment must be resuspended.
- The suspension must be pipetted onto a glass slide and must be incubated at room temperature for 30 min..
- Then the drop must be shacked off the slide, the remanents must airdry.
- The sample then can be fixed and stained by any common stains.
- Major cell types are small lymphocytes, macrophages and some epithelial (ependyma) cells.
- Number of neutrophils granulocytes must not be more than 10%.
Cytology evaluation
Causes of neutrophil pleocytosis:
bacterial meningitis,
parasitic meningitis,
granulomatous meningoencephalitis /GME/,
steroid-responsive meningitis-arteritis.
Cytology evaluation
Causes high eosinophil granulocyte count:
eosinophilic meningoencephalitis.
Cytology evaluation
Causes of the proliferation of mixed cell population:
viral encephalitis (distemper) lymphocytic count > 80%
granulomatous meningoencephalitis /GME/: mainly macrophages and neutrophils
fungal encephalitis: mainly mononuclear cells, neutrophils, mainly eosinophils
head or spinal cord trauma: higher neutrophil count
toxoplasmosis: higher lymphocytic count
In case of inflammatory processes - what is measured
HIGHER PROTEIN concentration is measured.
The appearance of neoplastic cells
Appearance of neoplastic cells Protein content examination Glucose concentration examination Lactate concentration Enzyme activity examinations:
In case of inflammatory processes higher protein concentration is measured.
Appearance of neoplastic cells
The appearance of neoplastic cells in the CSF is very rare.
Most neoplasms:
- astrocytoma,
- ependymoma,
- meningioma,
- oligodendroglioma,
- choroid plexus papilloma,
- metastatic carcinoma és lymphoma.
In these cases mainly mononuclear cells are visible. Generally, higher protein concentration is measured.
In case of inflammatory processes higher protein concentration is measured.
Protein content examination
Ultrasensitive protein concentration analysis.
Pándy method (carbolic acid):
+, ++, +++ in case of CNS inflammation, there is increased globulin concentration
-
smoky grey colour occurs, as a result of globulin coagulation after the administration
of some drops of Pándy-reagent.
In case of inflammatory processes higher protein concentration is measured.
Glucose concentration examination
The concentration of glucose in CSF is 80-60% of the plasma glucose concentration in case of inflammation glucose concentration decreases
In case of inflammatory processes higher protein concentration is measured.
Lactate concentration
- normal value in CSF: <2.2 mmol/l
- increased lactate concentration:
bacterial meningitis,
subarachnoidal bleeding,
ischemic attacks
In case of inflammatory processes higher protein concentration is measured.
Enzyme activity examinations:
AST, CK-B (creatinine kinase),
LDH (lactic acid dehydrogenase) the activity of these enzymes increase as a result of CNS injury
