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
membrane encloses them.
- Example: Heart and Pericardium, Abdomen and
Peritoneum
- Increased serous fluid is an indicative of pathological
conditions. Example liver cirrhosis – also causes increased
production of serous fluid in peritoneum. Heart diseases
causes increased production of serous fluid in pericardium
- Sometimes, not pathological but could be caused by
surgical complications (disruption of membrane)
❖ Production & reabsorption is due to hydrostatic
- Hydrostatic – force in blood vessels that pushes the fluid
- Oncotic – prevents the fluid in leaking out to the inters
tertium
- Also controlled by the presence of the membrane
- Two classes of membrane: PARIETAL and VISCERAL
Membrane
- Visceral membrane – lines the organ itself.
- Parietal Membrane – attached to the body wall
- The location of the serous fluid is between the parietal and
visceral membrane
- The permeability of the membrane causes the
ultrafiltration
❖ Colloidal (oncotic) pressure
❖ Collected by needle aspiration procedure
- Invasive procedure: Inserting a needle directly on the body
wall to aspirate the fluid
❖ Accumulation of fluid: EFFUSION (Caused by imbalance of
fluid production and reabsorption)
❖ PLEURAL FLUID – THORACENTESIS
- Fluid seen in lungs
- Normal Volume: <30 mL
❖ PERICARDIAL FLUID – PERICARDIOCENTESIS
- From pericardium
- Normal Volume: <50 mL
❖ PERITONEAL FLUID – PARACENTESIS
- Seen in peritoneum
- Sometimes called as Peritoneocentesis
- Other term for peritoneal fluid: Ascitic Fluid
- Normal volume: <100 mL
- Pericardiac cavity is between the parietal and visceral
layer. It provides lubrication between the two membranes
as they move
- Peritoneal cavity is found in the peritoneum (abdomen).
- Pleural fluid is found in lungs
SPECIMEN COLLECTION
❖ ANTICOAGULATED TUBE (EDTA): CELL COUNT and differential
count
❖ STERILE TUBE: CULTURE
- Use of SPS tube for bacteriological studies
- Microbiology and cytology
❖ HEPARINIZED TUBE: CHEMISTRY
- If we do not have heparinized, we can use plain or red top
tube
❖ NON-ANTICOAGULATED: CLOTTING
• If checking for pH, it should be maintained anaerobically in
ice (no presence of oxygen)
- We use anaerobe heparinized syringe, no need to transfer
in a tube
• Fluid should be retained for 7-10 days in case of further
testing
- Should not be discarded right away
• Effusion is classified into TRANSUDATES and EXTRUDATES
TRANSUDATES
❖ Effusion that forms due to systemic disorder disrupting the
balance in the regulation of fluid filtration and reabsorption
- Systemic means there is imbalance in regulation of the
fluid due to systemic problem in the body (no problem in
the membrane)
❖ CONGESTIVE HEART FAILURE
- Increased of HYDROSTATIC PRESSURE, increasing the
pressure, filtrate, and amount of serous fluid
❖ NEPHROTIC SYNDROME
- Whole body is affected, especially in the presence of
ALBUMIN = serves as an oncotic pressure
- Shield of negativity is disrupted the reason why albumin
(which is negatively charge) can pass through the
 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
❖ Diagnosis of Tuberculosis and bacterial infections
❖ Increase lymphocytes & Plasma cells
• Tubercular effusion
• Autoimmune disorders such as rheumatoid arthritis and SLE
❖ Increase neutrophils
• Bacterial infection
- Neutrophils associated to pneumonia, pulmonary
impaction, pancreatitis
- Increased Eosinophils – allergic and parasitic infection,
sometimes in pneumothorax/hemothorax and trauma
- Mesothelial cells – normally seen and lines the serous
membrane. Indicative of tuberculosis if too low or lacks
mesothelial cell
- Malignant cell - carcinoma
CHEMISTRY TEST
• Most commonly checked is the glucose level. Can also
check for lactate, TAG, pH, Adenosine deaminase, Amylase
(pancreatitis)
❖ Decrease glucose level: Tubercular & Rheumatoid
inflammation
- If glucose is decreased, Lactate is increased
- TAG for chylous effusion
❖ Decreased pH 7.2: Need for chest tube drainage
- Possible esophageal fracture, especially if 6
- Empyema – pus filled pleural cavity causing decreased pH
- In pneumonia is unresponsive to antibiotic
❖ Increased pH 7.4: Malignancies
❖ As low pH 6.0: Esophageal rupture
❖ > 40 U/L Adenosine Deaminase: Tuberculosis
SEROLOGY TEST
• For checking tumor markers
❖ Pale Yellow and Clear: Transudates and Normal
❖ Turbid: infection & Malignancy
❖ Milky: chylous & Pseudochylous Effusion
❖ Blood-streaked: Frequently in Malignant Effusions
❖ Grossly Bloody: Accidental Cardiac Puncture, Misuse of
Anticoagulant
- Error during collection
LAB CORRELATIONS
❖ CELL COUNT:
• Increased Neutrophils: bacterial endocarditis
- Usually, endocarditis is caused by previous
respiratory infection like Hemophilus infection,
Streptococcus, staphylococcus, pyogenesis
• Malignant cells – metastasized of carcinoma = Metastatic
carcinoma
❖ CHEMISTRY TEST:
• Decreased glucose level: bacterial infection, malignancies
• Gram Staining and culture – for confirming bacterial
infection
• Tubercular effusion – umaabot sa pericardial, increased
Adenosine deaminase
PERITONEAL fluid (ASITIC FLUID)
❖ Lavage for detection of abdominal injuries: Normal saline
- Injury without fluid accumulation: perform
peritoneal lavage. It is a procedure where you have
to irrigate the peritoneum with normal saline then
aspirate.
- Check for the presence of Psammoma bodies
❖ Psammoma bodies
• Containing concentric striations of collagen-like material
• Seen in benign conditions, ovarian and thyroid
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

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

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