LECTURE | 3-ya-8 | 1st Semester |

And olfu valenzuela

Body fluids Myen carol r. Sarmiento
Week 15: serous fluid
• Also known as Serosal Fluid
• Originated from Latin word “Serosus” = serum
• A body fluid that resembles a serum, pale yellow,
transparent, and benign in nature
• Fills the inside of body cavities (example in abdominal
cavity, thoracic cavity)
• Main purpose: To reduce friction from the muscle
movement, removal of waste, and exchange of nutrients

SEROUS FLUID
❖ Formed as an ultrafiltrate of plasma
- Because there is presence of membrane which serves as
sealed that filters the blood and forming ultrafiltrate of
plasma
- Usually seen in spaces between organs, and the - Pericardiac cavity is between the parietal and visceral
membrane encloses them. layer. It provides lubrication between the two membranes
- Example: Heart and Pericardium, Abdomen and as they move
Peritoneum - Peritoneal cavity is found in the peritoneum (abdomen).
- Increased serous fluid is an indicative of pathological - Pleural fluid is found in lungs
conditions. Example liver cirrhosis – also causes increased
production of serous fluid in peritoneum. Heart diseases SPECIMEN COLLECTION
causes increased production of serous fluid in pericardium ❖ ANTICOAGULATED TUBE (EDTA): CELL COUNT and differential
- Sometimes, not pathological but could be caused by count
surgical complications (disruption of membrane) ❖ STERILE TUBE: CULTURE
❖ Production & reabsorption is due to hydrostatic
- Use of SPS tube for bacteriological studies
- Hydrostatic – force in blood vessels that pushes the fluid - Microbiology and cytology
- Oncotic – prevents the fluid in leaking out to the inters ❖ HEPARINIZED TUBE: CHEMISTRY
tertium - If we do not have heparinized, we can use plain or red top
- Also controlled by the presence of the membrane tube
- Two classes of membrane: PARIETAL and VISCERAL
❖ NON-ANTICOAGULATED: CLOTTING
Membrane
• If checking for pH, it should be maintained anaerobically in
- Visceral membrane – lines the organ itself.
ice (no presence of oxygen)
- Parietal Membrane – attached to the body wall
- We use anaerobe heparinized syringe, no need to transfer
- The location of the serous fluid is between the parietal and
in a tube
visceral membrane
• Fluid should be retained for 7-10 days in case of further
- The permeability of the membrane causes the
testing
ultrafiltration
- Should not be discarded right away
❖ Colloidal (oncotic) pressure
❖ Collected by needle aspiration procedure
- Invasive procedure: Inserting a needle directly on the body • Effusion is classified into TRANSUDATES and EXTRUDATES
wall to aspirate the fluid TRANSUDATES
❖ Accumulation of fluid: EFFUSION (Caused by imbalance of ❖ Effusion that forms due to systemic disorder disrupting the
fluid production and reabsorption) balance in the regulation of fluid filtration and reabsorption
- Systemic means there is imbalance in regulation of the
❖ PLEURAL FLUID – THORACENTESIS fluid due to systemic problem in the body (no problem in
- Fluid seen in lungs the membrane)
- Normal Volume: <30 mL ❖ CONGESTIVE HEART FAILURE
❖ PERICARDIAL FLUID – PERICARDIOCENTESIS - Increased of HYDROSTATIC PRESSURE, increasing the
- From pericardium pressure, filtrate, and amount of serous fluid
- Normal Volume: <50 mL ❖ NEPHROTIC SYNDROME
❖ PERITONEAL FLUID – PARACENTESIS - Whole body is affected, especially in the presence of
- Seen in peritoneum ALBUMIN = serves as an oncotic pressure
- Sometimes called as Peritoneocentesis - Shield of negativity is disrupted the reason why albumin
- Other term for peritoneal fluid: Ascitic Fluid (which is negatively charge) can pass through the
- Normal volume: <100 mL
 membrane and come out in urine = Increased protein in Serum-ascites >1.1 <1.1
urine making protein in blood HYPOPROTEINEMIA albumin gradient – ascites = peritoneal
- HYPOPROTEINEMIA – increased amount of fluid in cavity SAAG. The only fluid
parameter where
due to increased oncotic pressure
transudate is higher
❖ LIVER CIRRHOSIS
- we can also check GLUCOSE: Decreased in Transudate and
- Diminished production of protein = low protein production
Increased in Exudate
decreasing oncotic pressure
• RIVALTA’S TEST or SEROSAMUCIN CLOT TEST –
• Malnutrition – decreased macromolecules (protein),
Differentiation using Acetic Acid + H2O
decreasing oncotic pressure
- Heavy Precipitate = EXUDATE
- No heavy precipitation = TRANSUDATE
EXUDATES • Specific Gravity – lower in TRANSUDATE (<1.015), higher in
❖ Produced by conditions that directly involve the membrane of EXUDATE (>1.015)
the particular cavity • Total protein – Transudate = <3g/dL, Exudate = 3g/dL
- Damage directly associated with the organ or with the • LDH – Transudate = <200 IU, Exudate = >200 IU
membrane
❖ INFECTION PLEURAL fluid
- Disrupts the membrane causing accumulation of fluid ❖ Abnormal accumulation occurs due to conditions that affect:
❖ MALIGNANCY • Capillary Hydrostatic Pressure
❖ SLE • Colloidal Pressure
- The membrane of the cavities is being attacked by the - Hydrostatic and Colloidal pressure causes by Transudative
autoantibodies Effusion
• Example: tuberculosis, endocarditis, lymphoma, pneumonia • Permeability
- Increased capillary permeability
- Permeability causes Exudative effusion
• Lymphatic Drainage
Conditions that can cause accumulation of pleural fluid
▪ Congestive Heart Failure
- Increased hydrostatic pressure
▪ Hypoalbuminemia
- Decreased colloidal/oncotic pressure
▪ Pneumonia
- Increased permeability
▪ Carcinoma
- Direct damage to the membrane
- Transudative – decreased protein and oncotic
pressure. No one will push the hydrostatic pressure
APPEARANCE
causing its increase. INCREASED HYDROSTATIC
PRESSURE AND DECREASED ONCOTIC PRESSURE ❖ NORMAL: clear and pale yellow
- WHITE: Most of the time = Tuberculosis or SLE
- Exudative – increased capillary permeability due to
- BROWN: disruption of amoebic liver abscess
inflammation or infection. High in protein - BLACK: fungal infection = Aspergillosis
LABORATORY DIFFERENTIATION OF TRANSUDATES AND - Highly viscous because of the presence of Hyaluronic Acid,
EXUDATES
not normal. Possible for Malignant Mesothelioma
Transudate Exudate
❖ TURBID: WBC And Bacterial infection; Immunologic Disorder
Appearance Clear Cloudy
❖ BLOOD: Hemothorax (Traumatic Injury),
Fluid:serum <0.5 >0.5
Malignancy, Traumatic Aspiration
protein ratio – most
reliable - Differentiate Hemothorax to Hemorrhagic Effusion by
Fluid:serum LD <0.6 >0.6 Observation, Hematocrit,
ratio – most reliable • Hemothorax – bleeding in the lungs causing accumulation
WBC count <1000/uL >1000/uL - Uneven distribution of blood
(Pericarditis if seen in - Check pleural fluid hematocrit if >/= to ½ of whole blood
pericardium) hematocrit
Spontaneous No Possible – fibrinogen - Higher because the effusion is occurring from the
clotting can pass through
inpouring of blood because of injury
Pleural fluid <45-60 mg/dL >45-60 mg/dL
• Hemorrhagic Effusion – there is damage or bleeding by
cholesterol
other causes
Pleural fluid:serum <0.3 >0.3
cholesterol ratio - Even distribution of blood
Pleural <0.6 >0.6 - < ½ of whole blood hematocrit
fluid:bilirubin ratio - Lower because effusion contains blood and increased
serous fluid, already diluted
❖ MILKY: Chylous (Thoracic Duct Leakage) or Pseudochylous • Most frequently performed especially for autoimmune
(Chronic Inflammatory) material disorders.
- Chylous due to increased lipid content. Lymph duct - Antinuclear Antibody (ANA) for SLE
leakage, increasing lymph fluid (high in chylomicrons and - Rheumatoid factor (RF) for Rheumatoid arthritis
TAG) ❖ Increased immunoglobulin or decreased complement
• inflammatory reaction
DIFFERENTIATION BETWEEN CHYLOUS AND PSEUDOCHYLOUS ❖ Increased Carcinoembryonic antigen (CEA)
PLEURAL EFFUSION • Tumor marker associated with malignancy
Chylous Effusion Pseudochylous - Not that specific for pleural fluid. CYFRA 21-1 or
Effusion Cytokeratin Fragment is more specific which is used
Cause Thoracic leakage Chronic for lung cancer, breast cancer, urinary bladder
inflammation cancer
Appearance Milky/white Milky/green tinge
- CA 125 for ovarian
Leukocytes Predominant Mixed cells
lymphocytes
Cholesterol crystals Absent – there is no Present PERICARDIAL fluid
cholesterol in lymph - The increased in pericardial fluid is same as pleural
fluid which are changes in permeability of the
Triglycerides >110mg/dL <50mg/dL membrane.
Sudan III staining Strongly positive – Negative/weakly ❖ Abnormal effusion due to infections, malignancy, or
due to presence of positive metabolic change
TAG
❖ Volume: 10-50mL

CELL COUNT APPEARANCE:

- Test the amount of significant cells seen in pleural fluid ❖ Pale Yellow and Clear: Transudates and Normal
❖ Diagnosis of Tuberculosis and bacterial infections ❖ Turbid: infection & Malignancy
❖ Increase lymphocytes & Plasma cells ❖ Milky: chylous & Pseudochylous Effusion
• Tubercular effusion ❖ Blood-streaked: Frequently in Malignant Effusions
• Autoimmune disorders such as rheumatoid arthritis and SLE ❖ Grossly Bloody: Accidental Cardiac Puncture, Misuse of
❖ Increase neutrophils Anticoagulant
• Bacterial infection - Error during collection
- Neutrophils associated to pneumonia, pulmonary
impaction, pancreatitis
LAB CORRELATIONS
- Increased Eosinophils – allergic and parasitic infection,
sometimes in pneumothorax/hemothorax and trauma ❖ CELL COUNT:
- Mesothelial cells – normally seen and lines the serous • Increased Neutrophils: bacterial endocarditis
membrane. Indicative of tuberculosis if too low or lacks - Usually, endocarditis is caused by previous
mesothelial cell respiratory infection like Hemophilus infection,
- Malignant cell - carcinoma Streptococcus, staphylococcus, pyogenesis
• Malignant cells – metastasized of carcinoma = Metastatic
carcinoma
CHEMISTRY TEST ❖ CHEMISTRY TEST:
• Most commonly checked is the glucose level. Can also • Decreased glucose level: bacterial infection, malignancies
check for lactate, TAG, pH, Adenosine deaminase, Amylase • Gram Staining and culture – for confirming bacterial
(pancreatitis) infection
❖ Decrease glucose level: Tubercular & Rheumatoid • Tubercular effusion – umaabot sa pericardial, increased
inflammation Adenosine deaminase
- If glucose is decreased, Lactate is increased
- TAG for chylous effusion
PERITONEAL fluid (ASITIC FLUID)
❖ Decreased pH 7.2: Need for chest tube drainage
❖ Lavage for detection of abdominal injuries: Normal saline
- Possible esophageal fracture, especially if 6
- Injury without fluid accumulation: perform
- Empyema – pus filled pleural cavity causing decreased pH
peritoneal lavage. It is a procedure where you have
- In pneumonia is unresponsive to antibiotic
to irrigate the peritoneum with normal saline then
❖ Increased pH 7.4: Malignancies
aspirate.
❖ As low pH 6.0: Esophageal rupture
- Check for the presence of Psammoma bodies
❖ > 40 U/L Adenosine Deaminase: Tuberculosis
❖ Psammoma bodies
• Containing concentric striations of collagen-like material
SEROLOGY TEST • Seen in benign conditions, ovarian and thyroid
• For checking tumor markers malignancies
- sensitive in intra-abdominal bleeding
 - >100,000 RBC/uL - slightly increased. Bicarbonate ions gives the specific
alkalinity of duodenal fluid
❖ 145 mEq/L of bicarbonate ion

Physiology
• Acidic gastric contents enter the duodenum
• Acidic pH stimulates the mucosal cells to produce SECRETIN
- Secretin will provoke pancreas to secrete bicarbonates,
making duodenal fluid alkaline

SECRETIN AND PANCREOZYMIN

❖ Secretin
- PSAMMOMA BODIES in Gram Stain • Provokes the pancreas to secrete bicarbonate
- This is seen in peritoneal exudates • Stimulates watery pancreatic secretion with high
SIGNIFICANCE OF PERITONEAL FLUID TESTING bicarbonate content
Test Significance • Most sensitive test for impaired pancreatic function
Appearance • Administered intravenously, then DF bicarbonate is tested
Clear, pale yellow Normal - Produced by the pancreas
Turbid – increased cell Microbial infection ❖ Pancreozymin
Green – possible rupture of cell Gallbladder, pancreatic • Provokes enzyme production by the pancreas
disorders
Blood-streaked Trauma, infection, or
malignancy PANCREATIC CANCER VS CHRONIC
Milky – because of the presence Lymphatic trauma and PANCREATITIS
of lipids blockage Pancreatic Cancer Chronic Pancreatitis
Peritoneal lavage >100,000 RBCs/uL indicates Decreased volume Decreased volume
blunt trauma injury Normal bicarbonate Decreased bicarbonate
WBC Count Normal Amylase Decreased amylase
<500 cells/uL Normal
>500 cells/uL Bacterial peritonitis, cirrhosis
Differential Bacterial peritonitis WEEK 15.3 GASTRIC fluid
Malignancy • Mixture of different substances like water, hydrochloric
Carcinoembryonic antigen Malignancy of gastrointestinal acid (for digestion of food), electrolytes, organic substances
- Tumor markers origin (mucus, pepsins, proteins)
CA 125 Malignancy of ovarian origin • pH is highly acidic because of hydrochloric acid and very
Glucose Decreased in tubercular rich in enzyme because it is the first part of digestive system
peritonitis, malignancy where food will be digested
Amylase Increased in pancreatitis,
gastrointestinal perforation
Alkaline phosphatase Increased in gastrointestinal GASTRIC ACID SECRETION
perforation
Blood urea Ruptured or punctured bladder
nitrogen/creatinine
Gram stain and culture Bacterial peritonitis
Acid-fast stain Tubercular peritonitis
Adenosine deaminase Tubercular peritonitis

WEEK 15.2 DUODENAL fluid

• Fluid from the first part of small intestine. Different from
gastric fluid
• Gastric fluid is the fluid inside the stomach
• Aspirating fluid from the duodenum to check for signs of • G Cells present in the stomach are the one that produces
infection GASTRIN. Gastrin stimulates parietal cell to produce
• Rarely check for pediatric patients, especially for newborns hydrochloric acid
if there is Biliary Atresia • Parietal cells produce Hydrochloric acid and Intrinsic Factor.
❖ 1,200 to 1,500 mL/day Intrinsic factor is for vitamin B12 absorption.
❖ Clear, enzyme rich - If you have anti-parietal cell or anti-intrinsic factor =
- Enzymes are necessary of digestion. It is from pancreas Pernicious Anemia. No production of HCl
and liver • Hydrochloric acid will activate pepsinogen to become
❖ pH 8.0-8.5 pepsin
 - Pepsinogens are from Chief cells. GASTRIC STIMULANTS
- Zollinger Ellison syndrome – gland-like tumor caused by an TEST MEALS 1. Ewald’s – bread, tea or
adenoma on the islets of Langerhans of pancreas. This water
tumor also produces Gastrin. In this syndrome, expect that 2. Boa’s – oatmeal
the amount of HCl in the stomach will be increased 3. Riegel’s – beef steak and
• Pepsin is used to digest protein mashed potato
- Digestion of proteins starts in the stomach because of the CHEMICAL STIMULANTS 1. Pentagastrin – most
preferred (1hr)
presence of pepsin
2. Histamine (1hr)
3. Histalog (Betazole) (2hr)
CELLS OF THE STOMACH 4. Insulin – assess vagotomy
procedure (hindi ka na
❖ Parietal Cells
makararamdam magugutom)
• Produce HCl and intrinsic factor
SHAM FEEDING Fictitious Feeding (Sandwich)
• Intrinsic Factor – needed for Vitamin B12 absorption (taste but will not swallow)
❖ Chief Cells
• Produce pepsinogen
BAO MAO BAO/MAO
❖ Specialized G cells
(mEq/hr) (mEq/hr)
• Produce gastrin
NORMAL 2.5 25 10%
PERNICIOUS 0 0 0
SPECIMEN COLLECTION ANEMIA – zero
because there is
❖ Method of Collection= Aspiration no production of
❖ Gastric Tubes: HCl
• Levin tube: inserted through the nose GASTRIC 1.0 4.0 25%
- A.k.a Ventrol Levin CARCINOMA
- More painful DUODENAL 5 30 17%
CANCER
• Rehfuss: inserted through the mouth
ZOLLINGER- 18 25 72% - increased
ELLISON due to gastric
MACROSCOPIC EXAMINATION stimulation and
SYNDROME increased gastrin
COLOR SIGNIFICANCE
Pale Gray with mucus Normal
Yellow-green Large amount of bile TERMINOLOGIES
VOLUME SIGNIFICANCE TERM DEFINITION SIGNIFICANCE
Few mL to 50mL Normal (fasting specimen) EUCHLORHYDRIA Normal free HCl
> 50 mL Abnormal Fasting Specimen HYPERCHLORHYDRIA Increased free HCl Peptic Ulcer
20-16 mL up to 120 mL After Ewald’s test meat HYPOCHLORHYDRIA Decreased free HCl Carcinoma of the
45-150 mL After alcohol test meal or after stomach
histamine accumulation ACHLORHYDRIA No free HCl Pernicious anemia
- Hypochlorhydria is different from Acidity but both signifies
pernicious anemia
❖ Basal Acid Output (BAO)
- Achlorhydria, the gastric fluid pH is >3.5 and it does not fall
• Total gastric secretion during unstimulated fasting state
even in gastric stimulation. Absence of HCl
1-hour collection
- Acidity, failure to produce a pH of <6.0 following gastric
- Routinely used
stimulation
- Consisting of four 15 minutes specimen
2-hour collection
QUALITATIVE TEST FOR FREE HCL
- Not common DIMETHYLAMINOAZOBENZOL (+) CHERRY RED
- Used for insulin hypoglycemia test GUNZBERG (+) PURPLISH RED
❖ Maximal Acid Output (MAO) BOAS (+) ROSE RED
• Total gastric secretion after gastric stimulation
1-hour collection QUANTITATIVE TEST FOR GASTRIC ACIDITY
- Consisting of four 15 minutes specimen → used of FREE HCL – TOTAL ACIDITY COMBINED
Pentagastrin and Histamine what we HCL (BOUND
2-hour collection check most TO
- Used for insulin hypoglycemia test → use of Histalog of the time PROTEINS)
TITRANT NaOH NaOH NaOH
pH DAAB Phenolphthalein Na alizarin
INDICATOR (Topfer’s rgt)
END POINT Canary Faint pink Violet
yellow
NORMAL 25-500 50-750 10-150
VALUE
 3. 2 ounces of half-cooked rice
❖ Lactic acid + 12 raisins
- Indicative of advanced gastric cancer Lavine/Alcohol 1. Utilize 70% alcohol
- Gastric stagnation Motor 1. Spinach or raisins + 400 ml
water
TESTS FOR LACTIC ACID
TEST REAGENTS ENDPOINT
Keilling’s FECL3 Yellow ❖ HISTAMINE-PHOSPHATASE
Modified FECL3 + phenol Yellow - Most common
Uffelmann’s ❖ INSULIN
Strauss FECL3 + ether Yellow ❖ CAFFEINE
- Increases gastric fluid
COLLECTION METHOD ❖ PILOCARPINE & ACETYLCHOLINE
Levin (Ventrol Levin) 1. Smallest evacuation tube ❖ PENTAGASTRIN
2. Most commonly used - Most common
3. Propelled through mouth Gastric juice Test
or nostrils Component
Boa’s / Ewald’s 1. Ideal for emptying or FREE HCl: 20-80 meq/L 1.Boa’s test: (+) result-red
washing the stomach
2. For cases of poisoning 2.Gunzenberg’s test: reagents-
3. Flask is present at the tip vanillin, 95% ethyl alcohol; (+)
Rehfuss 1. Metallic tip result-purple red
2. Propelled in mouth FREE ACIDITY + FREE Na alizanine test: (+) result-
Miller-Abbott 1. Mercurial tip is chilled HCl =TOTAL ACIDITY violet color with bluish tinge
2. People who are easy to LACTIC ACID 1.Uffelman’s test: (+) canary
vomit yellow
Sawyer 1. Longest evacuation tube 2.Kelling’s test: (+) deep yellow
Kaslow 1. Softest evacuation tube 3.Strauss test: 0.05% (+) light
Jutte 1. Stylet tip green; 0.01% (+) intense yellow
green
4.Reitman (Gradwohl) test: (+)
STIMULANTS (TEST MEAL) canary yellow
BILE Gmelin’s test: conc. HNO3; (+)
band of colors
Ewald’s 1.Routine test for gastric juice
RENIN 1.Reitman(Gradwohl):
exam
hydrogen peroxide + milk
2.“breakfast-test meal”
3.Content: 40 g of bread + 400
2.Reigel’s test: hydrogen
ml of water or tea
peroxide + milk +
Dock’s 1.Modification of Ewald’s
phenolphthalein; (+)
2.Content:40 g of shredded
coagulation of milk
whole wheat biscuit + 400 ml
PEPSIN 1.Bray’s / Bauer’s test
of water or tea
2.Hammerschlag test
Riegel’s a. Ideal for determining
BLOOD Guiac/ Benzidine test (+) green
hypoacidity and achylia
to blue
b. Content: 100-150 g broiled
beef steak + 150-200g DIANEX BLUE TEST
mashed potatoes + 400 ml
- Uses urine as specimen
bouillion soup
- Stimulate gastric first using caffeine
Fischer’s 1.Same value as Riegel’s but
❖ Uses azure dye combined with HCl
gives increased acidity values
❖ Stimulant: caffeine
❖ HCl is measured in the intensity of the color of urine
Heckman’s 1. 2% methylene blue, ❖ (+) intense blue= increased amount of HCl
albumin, distilled water
❖ Test for gastric intubation
Boa’s 1. Ideal for lactic acid ❖ Without evacuation tube (alternative method)
determination

2. 1 tbsp of oatmeal in 1 drop DIAGNEX TUBELESS TEST

of water + pinch of salt ❖ Specimen: Urine
Stasis 1.Supplemented by barium
❖ Principle
meals
• Azure Blue is given by mouth
2.Undergoes fluoroscopic
• The presence of azure blue in urine indicates the presence
determinations
of Free HCl in the stomach
 - Exchange between azure blue and hydrogen ions of
HCl so that azure blue will be absorbed from small
intestine and excreted in urine
- The more azure blue is excreted, the more HCl is
present in the stomach
- Azure blue in urine = (+) free HCl
- (-) Azure blue in urine = (-) free HCl
- Use of Azure Blue or Azure A

MICROSCOPIC ANALYSIS
❖ Pus cells/WBC:
• Stomach abscess, chronic gastritis, gastric cancer
❖ RBC
• Ulcer or trauma
❖ Yeast Cells
• Fermentation in the stomach because large amount of
food have been retained
❖ Bacteria
❖ Food residues
❖ Parasites