Serous Fluids

Origin, anatomic relationship and functions

1. The cavities of the body that hold abdominal organs, lungs, and the heart are lined by two
membranes consisting of mesothelial cells.

• The membrane that lines the cavity is referred to as the parietal membrane and the membrane
that forms a sac around the organs is the visceral membrane.

• The small amount of fluid between these two membranes is serous fluid. Serous fluid is an
ultrafiltrate of plasma and is produced and reabsorbed at a constant rate.

• This fluid functions as a lubricant between the membranes of the cavities and to allow free
movement of the organs.
 The peritoneum encloses abdominal organs.

 The fluid contained between the visceral and parietal membranes is peritoneal fluid.

 The pleural cavity encloses the lungs. The fluid contained between the visceral and parietal membranes
here is pleural fluid.

 The pericardium encloses the heart. The fluid contained between the visceral and parietal membranes in
this cavity is pericardial fluid.

 Any disruption of the production and reabsorption of serous fluid because of an alteration in the
hydrostatic and oncotic pressure in the capillaries of the cavities will cause an increase in fluid volume
between the two membranes.

 This abnormal fluid buildup is an effusion. Abnormal accumulation of fluid in any body cavity indicates an
abnormality.
Primary causes of effusions include

 increased hydrostatic pressure (congestive heart failure),

 decreased oncotic pressure (hypoproteinemia),

 increased capillary permeability (inflammation and infection), and lymphatic

obstruction (tumors).
Fluid Aspiration

 Fluids for laboratory examination are collected by needle aspiration from the
respective cavities.

 These aspiration procedures are referred to as thoracentesis (pleural),

 pericardiocentesis (pericardial),

 and paracentesis (peritoneal).

3. There are two kinds of effusions, transudates and exudates.

a. Transudates

• result from excess filtration of blood serum across a physically intact vascular wall due to
disruption of reabsorption.

• This occurs in systemic diseases that alter the hydrostatic pressure of the capillaries and

• include congestive heart failure, hepatic cirrhosis or nephrotic syndrome.

b. Exudates

are the active accumulation of fluid within body cavities associated with inflammation of the
membranes and vascular wall damage.

Exudates, which are closer to serum in chemical composition, are caused by the following
conditions: (1) Inflammatory disorders, (2) Malignancies, (3) Infections.
Analysis of serous body fluids

1)Appearance

• Transudates are typically clear while exudate fluid is cloudy.

• Bacteria produce white, turbid fluid and the presence of blood in the fluid can indicate malignancy.

• Blood in pleural fluid can signify the occurrence of hemothorax; in pericardial fluid it can indicate
cardiac puncture; in peritoneal fluid it also signifies trauma.

• Milky appearing fluid indicates the presence of chylous material (triglycerides) from the thoracic duct
or pseudochylous material (cholesterol) from chronic inflammation
2) Cells

are differentiated using cytospin preparations. Typically, a 50- or 100-cell differential is performed.

Cells found in normal serous fluid include the following :

(1) Lymphocytes (2) Monocytes and macrophages (3) Mesothelial cells from the parietal and visceral
membranes

Nonmalignant cells :

(1) Neutrophils can be found in an exudate during the early stage of inflammatory diseases .

(2) Eosinophils found in serous fluids are associated with infections, malignancy, myocardial infarction, and
hypersensitivity reactions.

(3) RBCs can occur in association with hemorrhage, malignancy, or traumatic puncture.
 Malignant cells can be found in serous fluids in individuals who have leukemia, lymphoma, or
metastatic tumors.

 A lack of mesothelial cells in a pleural fluid sample indicates tuberculosis and is caused by the
exudate fluid coating the pleural membranes
3) Chemical examination of serous fluid differentiates between an exudate and a transudate
These include:

a. A total protein evaluation and fluid-to-serum protein ratio can help distinguish between the
physiologic basis of different fluids.

• A serous fluid with a protein value >50% of the serum value is considered an exudate,

• whereas a fluid protein <50% of the serum value is a transudate.

• Serum albumin-to-fluid albumin ratios are recommended for assessment of hepatic

transudates.

b. A lactate dehydrogenase (LD) For transudates, the ratio of fluid LD to serum LD is <0.6; for
exudates the ratio is >0.6.
c. Transudate glucose levels are equivalent to the plasma glucose levels; however, exudate glucose levels are
low compared to plasma glucose levels.

d. Amylase determination aids in the diagnosis of pancreatitis, bowel perforation, or metastasis.

e. Triglyceride testing can confirm a chylous effusion; cholesterol analysis is performed to assess a
pseudochylous effusion.

f. A pH value for pleural fluids is helpful for identifying effusions with abnormally low pH values.

g. Carcinoembryonic antigen (CEA) determination is useful in evaluating effusions from individuals who
have a past or current diagnosis of a CEA-producing tumor.

h. Assessment of spontaneous clotting.

5) Microbiological examination of serous fluids for bacteria or Mycobacteria includes

Gram’s stain,

bacterial culture, and sensitivity studies. Aerobic, anaerobic culture

Tbc, fungal culture

Ziehl-Nielson stain

6) Serological tests include antinuclear antibody and rheumatoid factor analyses to assess
immunologic disease.
Comparison of Exudates and Transudates Based on Laboratory Profile
Pleural Effusions
PLEURAL FLUID Types

• Hydrothorax
• Hemothorax
• Chylothorax
• Pyothorax or Empyema
TECHNIQUE of THORACENTESIS
(Insertion site)
• Through the back of chest wall
• Anterior mid-axillary line
• Distance from vertebrae 5-10cm
• Preferably 6-8th intercostal space
 EVALUATION of PLEURAL FLUID

1) Appearance ( Macroscopic)

Grossly purulent fluid: Empyema, pancreatitis, esophagus ruptured

Milky fluid: Chylothorax

Bloody: Hemothorax,traumatic, thoracentesis,malignancy, Tbc,uremia

Yellow-green fluid: Rheumatoid arthritis

Black fluid: Aspergillus nigrans

Brown fluid: Entamoeba histolyticum

2) Biochemical examination (routine)
Protein
LDH
Glucose
Amylase
Triglyceride
 EVALUATION of PLEURAL FLUID
3) Hematologic examination

4) Bacteriologic examination
Gram stain
Aerobic, anaerobic culture
Microorganisms include Staphylococcus aureus, Enterobacteriaceae, anaerobes, and Mycobacterium tuberculosis
Tbc, fungal culture
Ziehl-Nielson stain

5) Cytologic examination
Cellular analysis
6) Serologic testing of pleural fluid is used to differentiate effusions of immunologic origin from
noninflammatory processes.

Tests for antinuclear antibody (ANA) and rheumatoid factor (RF) are the most frequently performed.

7) Detection of the tumor markers carcinoembryonic antigen (CEA), CA 125 (metastatic uterine cancer),
CA15.3 and CA 549 (breast cancer), and CYFRA 21-1 (lung cancer) provide valuable diagnostic
information in effusions of malignant origin.
PLEURAL FLUID
• 0.1-0.2 ml/kg
• Clear appearance
• pH: 7.60-7.64
• Protein<1.5 g/dl
• Cell<1000/ ml
• Glucose=P glucose
• LDH<50% P LDH
Pericardial Fluid:
Appearance Normally, only a small amount (10 to 50 mL) of fluid is found between the pericardial serous
membranes.

Pericardial effusions are primarily the result of

• changes in the permeability of the membranes due to infection (pericarditis),
• malignancy,
• trauma-producing exudates.
• Metabolic disorders such as uremia, hypothyroidism, and autoimmune disorders are the primary causes of
transudates.

Tests performed on pericardial fluid are primarily directed at determining if the fluid is a transudate or an exudate

include the fluid:serum protein and lactic dehydrogenase (LD) ratios.

a count of greater than 1000 WBCs/սL with a high percentage of neutrophils can be indicative of bacterial
endocarditis.
Cytologic examination

• malignant cells is an important part of the fluid analysis.

• Cells most frequently encountered are the result of metastatic lung or breast carcinoma
and resemble those found in pleural fluid.
Bacterial cultures and Gram stains

• when endocarditis is suspected.

• Infections are frequently caused by previous respiratory infections including

Haemophilus, Streptococcus, Staphylococcus, Adenovirus, and Coxsackievirus.

• Effusions of tubercular origin are increasing as a result of AIDS.

• Therefore, acid-fast stains and chemical tests for adenosine deaminase are often
requested on pericardial effusions.
Peritoneal Fluid
Ascites Definition
♦ The word ascites is of Greek origin (askos) and means bag or
sac.
♦ Ascites describes the condition of pathologic fluid collection
within the abdominal cavity.

♦ Healthy men have little or no intraperitoneal fluid, but women

may normally have as much as 20 mL, depending on the
phase of their menstrual cycle.
 Peritoneal fluid
 It is a normal, lubricating fluid found in the peritoneal cavity.

 The fluid is mostly water with electrolytes, antibodies, white

blood cells, albumin, glucose and other biochemicals.

 Reduce the friction between the abdominal organs as they

move around during digestion.
Etiology of Ascites
Liver disease: Cirrhosis - Portal HTN secondary to chronic liver
diseases ( cirrhosis)

Cardiac: Congestive Cardiac Failure

Renal: Nephrotic syndrome

Peritoneal diseases: TB, peritoneal carcinomatosis, peritonitis:

infection (perforation), chemical (pancreatitis)

Hypoproteinemic states: malabsorption syndrome, protein losing

enteropathy
Ascites Diagnosis

Asymptomatic (fluid <100 - 400ml):

Mild ascites (doubtful cases): abdominal ultrasound (as little as 10-15 ml)

 symptomatic (fluid >400ml):

, presence of abdominal pain or discomfort, early satiety, pedal edema, weight gain and respiratory distress

 20cc enough for adequate testing.

Plain radiography, CT scan, MRI: also detect ascites but use only to detect underlying cause (like
pancreatitis, neoplasm etc.)
 Serum-Ascites Albumin Gradient

SAAG: serum albumin – ascitic fluid albumin (g/dL)

High gradient ( ≥1.1 g/dL) indicates portal hypertension

Low gradient (< 1.1 g/dL) indicates absence of PHT
Serum-Ascites Albumin Gradient

High gradient Low gradient

Cirrhosis  Tuberculosis
Cardiac ascites  Malignant
Myxedema  Nephrotic synd.
 Pancreatic ascites
 Biliary ascites
 Chylous ascites