ascitic fluid seminar

ASCITIC & PLEURAL ASCITIC & PLEURAL FLUID ANALYSISFLUID ANALYSIS

ASCITIC FLUID ANALYSISASCITIC FLUID ANALYSIS

BACK GROUNDBACK GROUND

THE WORD ASCITES IS OF GREEK ORIGIN THE WORD ASCITES IS OF GREEK ORIGIN ( ASKOS ) & MEANS A BAG OR SAC. ( ASKOS ) & MEANS A BAG OR SAC.

ASCITES DESCRIBE THE CONDITION OF ASCITES DESCRIBE THE CONDITION OF PATHOLOGIC ACCUMULATION WITH IN PATHOLOGIC ACCUMULATION WITH IN CAVITY.CAVITY.

HEALTHY MEN HAVE LITTLE OR NO HEALTHY MEN HAVE LITTLE OR NO INTRA PERITONEAL FLUID.INTRA PERITONEAL FLUID.

WOMEN MAY HAVE AS MUCH AS 20 ML WOMEN MAY HAVE AS MUCH AS 20 ML DEPENDING UPON PHASE OF DEPENDING UPON PHASE OF MENSTRUAL CYCLE.MENSTRUAL CYCLE.

PATHO PHYSIOLOGYPATHO PHYSIOLOGY

UNDER FILLING THEORY – UNDER FILLING THEORY – Inappropriate sequestration of Inappropriate sequestration of fluid with in vascular bed.fluid with in vascular bed.

OVERFLOW THEORY – Abnormal OVERFLOW THEORY – Abnormal retention of sodium & water in retention of sodium & water in absence of volume.absence of volume.

PERIPHERAL ARTERIAL PERIPHERAL ARTERIAL VASODILATION THEORY – VASODILATION THEORY – Combination of both theories.Combination of both theories.

CAUSES OF ASCITESCAUSES OF ASCITES

A) NORMAL PERITONEUM.A) NORMAL PERITONEUM. 1) PORTAL HYPERTENSION (SAAG > 1) PORTAL HYPERTENSION (SAAG >

1.1 g/dl ) .1.1 g/dl ) . a) Hepatic congestion a) Hepatic congestion b) C.H.F.b) C.H.F. c) Constrictive pericarditis c) Constrictive pericarditis d) Budd chiari syndrome d) Budd chiari syndrome e) Cirrhosise) Cirrhosis f) Alcoholic hepatitisf) Alcoholic hepatitis g) Fulminant hepatic failure g) Fulminant hepatic failure h) Massive hepatic failureh) Massive hepatic failure


A) A) NORMAL PERITONEUMNORMAL PERITONEUM 2) HYPO ALUBINEMIA (SAAG < 2) HYPO ALUBINEMIA (SAAG <

1.1 g /dl )1.1 g /dl ) a) Nephrotic syndrome .a) Nephrotic syndrome . b) Protein losing enteropathy .b) Protein losing enteropathy . c) Severe malnutrition with c) Severe malnutrition with

anasarca .anasarca .


A) A) NORMAL PERITONEUMNORMAL PERITONEUM 3)MISCELLANEOUS (SAAG < 1.1 g/dl )3)MISCELLANEOUS (SAAG < 1.1 g/dl ) a) Chylous ascites.a) Chylous ascites. b) Pancreatic ascites .b) Pancreatic ascites . c) Bile ascites .c) Bile ascites . d) Nephrogenic ascites .d) Nephrogenic ascites . e) Urine ascites .e) Urine ascites . f) ovarian disease.f) ovarian disease.


B) B) DISEASED PERITONEUMDISEASED PERITONEUM 1) INFECTIONS ( SAAG <1.1 1) INFECTIONS ( SAAG <1.1

g/dl )g/dl ) a) Bacterial infections.a) Bacterial infections. b) Tubercular infections.b) Tubercular infections. c) Fungal infections .c) Fungal infections . d) H.I.V. infections.d) H.I.V. infections.


B) B) DISEASED PERITONEUMDISEASED PERITONEUM 2) 2) MALIGNANT CONDITIONSMALIGNANT CONDITIONS a) Peritoneal carcinomatosis.a) Peritoneal carcinomatosis. b) Primary mesothelioma.b) Primary mesothelioma. c) Pseudo myxoma peritonei.c) Pseudo myxoma peritonei. d) Hepatic cellular carcinomad) Hepatic cellular carcinoma..


B) B) DISEASED PERITONEUMDISEASED PERITONEUM 3) OTHER RARE CONDITIONS. 3) OTHER RARE CONDITIONS.

(SAAG < 1.1 g/dl )(SAAG < 1.1 g/dl ) a) Familiar Mediterranean fever.a) Familiar Mediterranean fever. b) Vasculitis.b) Vasculitis. c) Granulomatous peritonei.c) Granulomatous peritonei. d) Eosinophilic peritonei.d) Eosinophilic peritonei.

LAB. STUDIES/SPECIMEN LAB. STUDIES/SPECIMEN COLLECTIONCOLLECTION

Peritoneal fluid should be Peritoneal fluid should be sent for cell count , total sent for cell count , total protein , sugar ,albumin protein , sugar ,albumin level , culture , gram stain level , culture , gram stain & cytology for newly & cytology for newly onset ascites origin.onset ascites origin.

LAB STUDIESLAB STUDIES A minimum of 30 ml is necessary for complete evaluation.A minimum of 30 ml is necessary for complete evaluation. Samples should be collected in heparin tubes to prevent Samples should be collected in heparin tubes to prevent

clot formation.clot formation. Samples for glucose should be adequately preserved with Samples for glucose should be adequately preserved with

fluoride.fluoride. Samples for ph should be collected an aerobically into Samples for ph should be collected an aerobically into

heparinsed blood gas syringe .heparinsed blood gas syringe . Blood stained samples are not suitable for analysis of total Blood stained samples are not suitable for analysis of total

protein & LDH.protein & LDH. All samples should be centrifuged prior to analysis.All samples should be centrifuged prior to analysis. Ascitic fluid albumin should be determined along with Ascitic fluid albumin should be determined along with

blood sample for albumin.blood sample for albumin. SAAG > 1.1 g/dl indicates presence of portal HTN.SAAG > 1.1 g/dl indicates presence of portal HTN. Very low serum albumin ( <12 g/l ) may make gradient less Very low serum albumin ( <12 g/l ) may make gradient less

reliablereliable..

LAB STUDIESLAB STUDIES

ADDITIONAL TESTS ARE REQUIRED IF A ADDITIONAL TESTS ARE REQUIRED IF A SPECIFIC QUESTION IS BEING ASKED.SPECIFIC QUESTION IS BEING ASKED.

a) Amylase – suspected pancreatitis or gut a) Amylase – suspected pancreatitis or gut perforation.perforation.

b) Triglyceride – suspected Chylous ascites.b) Triglyceride – suspected Chylous ascites. c) Bilirubin – suspected biliary perforation .c) Bilirubin – suspected biliary perforation . d) Differentiating spont. Bacterial peritonitis from d) Differentiating spont. Bacterial peritonitis from

secondary infection - Ascitic fluid glucose < or = 2.8 secondary infection - Ascitic fluid glucose < or = 2.8 mmol / l .mmol / l .

- LDH greater than upper limit of normal for - LDH greater than upper limit of normal for serum.serum.

- total protein > 10 g /l - total protein > 10 g /l Above findings are suggestive of secondary peritonitis.Above findings are suggestive of secondary peritonitis.

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION QUANTITY QUANTITY APPEARANCE – clear , turbid or hemorrhagic.APPEARANCE – clear , turbid or hemorrhagic. COLOR – normal tinged yellow .A minimum of COLOR – normal tinged yellow .A minimum of

10000 RBC’s/ uL are required for Ascitic fluid to 10000 RBC’s/ uL are required for Ascitic fluid to appear PINK & more than 20000 RBC ‘s /uL are appear PINK & more than 20000 RBC ‘s /uL are required to appear as blood tinged.required to appear as blood tinged.

This may attribute to traumatic tap or malignancy.This may attribute to traumatic tap or malignancy. Bloody fluid from traumatic tap is heterogeneous Bloody fluid from traumatic tap is heterogeneous

bloody & fluid will clot.bloody & fluid will clot. Non traumatic bloody fluid is homogenously red & Non traumatic bloody fluid is homogenously red &

does not clot because it is already clotted & lysed.does not clot because it is already clotted & lysed. COAGULUM – SEEN IN TUBERCULOSIS.COAGULUM – SEEN IN TUBERCULOSIS.

GROSS EXAMINATIONGROSS EXAMINATION

TURBIDTURBID --APPENDICITISAPPENDICITIS

-PANCREATITIS-PANCREATITIS

-BOWEL RUPTURE-BOWEL RUPTURE

-INFECTED -INFECTED INTESTINEINTESTINE

AMBERAMBER - - HEPATIC VEIN HEPATIC VEIN

OBSTRUCTIONOBSTRUCTION

- CIRRHOSIS- CIRRHOSIS

-NEPHROTIC -NEPHROTIC SYNDROMESYNDROME

-C.C.F-C.C.F


GREENISHGREENISH --PERFORATION PERFORATION

INTESTINEINTESTINE

-CHOLECYSTITIS-CHOLECYSTITIS

-PERFORATED -PERFORATED GALL BLADDERGALL BLADDER

-APPENDICITIS-APPENDICITIS

MILKYMILKY -PARASITIC -PARASITIC

INFECTIONINFECTION

-NEPHROTIC -NEPHROTIC SYNDROMESYNDROME

-CARCINOMA-CARCINOMA

-LYMPHOMA-LYMPHOMA


BLOODY BLOODY - - HEMORRHAGIC HEMORRHAGIC PANCREATITISPANCREATITIS

- ORGAN RUPTURE- ORGAN RUPTURE

MICROSCOPIC MICROSCOPIC EXAMINATIONEXAMINATION

A) CELL COUNT – Normal Ascitic fluid contains fewer than A) CELL COUNT – Normal Ascitic fluid contains fewer than 250 neutrophils / uL 250 neutrophils / uL

Approx. 90 % of patients with S.B.P will have leukocyte Approx. 90 % of patients with S.B.P will have leukocyte count > 500 / uL over 50 % of which are neutrophils.count > 500 / uL over 50 % of which are neutrophils.

EOSINOPHILLIA (>10 % ) EOSINOPHILLIA (>10 % )

-chronic inflammatory processes asso with chronic -chronic inflammatory processes asso with chronic peritoneal dialysis.peritoneal dialysis.

-congestive heart failure.-congestive heart failure.

-Vasculitis-Vasculitis

-lymphoma.-lymphoma.

-ruptured hydatid cyst.-ruptured hydatid cyst.

NEUBEAURS CHAMBERNEUBEAURS CHAMBER

DIAGRAM OF CHAMBERDIAGRAM OF CHAMBER


SPECIMENSPECIMEN DILUTION FACTORDILUTION FACTOR

1)1) CLEAR SAMPLECLEAR SAMPLE CHAMBER CHARGED CHAMBER CHARGED WITHOUT ANY WITHOUT ANY DILUTIONDILUTION

2)2) TURBID SAMPLETURBID SAMPLE SAMPLE DILUTED SAMPLE DILUTED WITH NORMAL WITH NORMAL SALINE IN 1: 20 SALINE IN 1: 20 RATIORATIO

CELL COUNTCELL COUNT

1) 1) UNDILUTED SPECIMENSUNDILUTED SPECIMENS

WBC/cu mm = COUNTED WBC/cu mm = COUNTED CELLS/4 X 10.CELLS/4 X 10.

. 2) . 2) DILUTED SPECIMENSDILUTED SPECIMENS

WBC/ cu mm = COUNTED WBC/ cu mm = COUNTED CELLS/4 X10 X 20CELLS/4 X10 X 20

CHEMICAL EXAMINATION CHEMICAL EXAMINATION PROTEINPROTEIN

QUALITATIVE.QUALITATIVE. RIVALTA’S QUALITATIVE TESTRIVALTA’S QUALITATIVE TEST..

1)1) PLACE 200 mL OF WATER IN A CYLINDER.PLACE 200 mL OF WATER IN A CYLINDER.

2)2) ADD 2 DROPS OF GLACIAL ACETIC ACID AND MIX.ADD 2 DROPS OF GLACIAL ACETIC ACID AND MIX.

3)3) ALLOW 2 OR 3 DROPS OF FLUID TO BE EXAMINED TO ALLOW 2 OR 3 DROPS OF FLUID TO BE EXAMINED TO FALL INTO SOLUTION.FALL INTO SOLUTION.

.INTERPRETATION : - .INTERPRETATION : -

1)1) IF FLUID IS AN EXUDATE , A DISTINCT CLOUD IS IF FLUID IS AN EXUDATE , A DISTINCT CLOUD IS OBSERVED IN THE WAKE OF THE FALLING DROP.OBSERVED IN THE WAKE OF THE FALLING DROP.

2)2) IN CASE OF TRANSUDATE , NO SUCH TURBIDITY IS SEEN.IN CASE OF TRANSUDATE , NO SUCH TURBIDITY IS SEEN.

CHEMICAL EXAMINATION -CHEMICAL EXAMINATION -PROTEINPROTEIN

NAME OF METHOD – BIURET NAME OF METHOD – BIURET METHODMETHOD

PRINCIPLEPRINCIPLE – – Protein reacts with Protein reacts with cupric ions in alkaline medium to cupric ions in alkaline medium to form violet colored complex .The form violet colored complex .The intensity of color produced is directly intensity of color produced is directly proportional to protein present in proportional to protein present in specimen which can be measured on specimen which can be measured on a photometer at 530 nm.a photometer at 530 nm.

REAGENTSREAGENTS

BIURET REAGENTBIURET REAGENT

PROTEIN STANDARD 6G/DL BOVINE PROTEIN STANDARD 6G/DL BOVINE ALBUMINALBUMIN

SAMPLE BLANK REAGENTSAMPLE BLANK REAGENT

PROCEDUREPROCEDURE

TESTTEST STANDARSTANDARDD

BLANKBLANK

PROTEIN PROTEIN REAGENTREAGENT

5.0 ML5.0 ML 5.0 ML5.0 ML 5.0 ML5.0 ML

SAMPLESAMPLE 0.05 ML0.05 ML - - --PROTEIN PROTEIN STANDARSTANDARDD

- - 0.05 ML0.05 ML --

DISTILLED DISTILLED WATERWATER

-- -- 0.05 ML0.05 ML

PROCEDUREPROCEDURE

MIX THOROUGHLY & KEEP AT ROOM MIX THOROUGHLY & KEEP AT ROOM TEMPERATURE FOR EXACTLY 10 TEMPERATURE FOR EXACTLY 10 MINUTES.MINUTES.

CALCULATIONCALCULATION ASCITIC FLUID PROTEIN = O.D TEST ASCITIC FLUID PROTEIN = O.D TEST

/O.D STANDARD X 6/O.D STANDARD X 6

S.A.A.GS.A.A.G

SERUM ALBUMIN ASCITIES GRADIENTSERUM ALBUMIN ASCITIES GRADIENT

SAAG is best single test for classifying SAAG is best single test for classifying ascites into portal HTN (SAAG ascites into portal HTN (SAAG >1.1G/DL) & non portal HTN (SAAG >1.1G/DL) & non portal HTN (SAAG <1.1 G/DL ).<1.1 G/DL ).

SAAG = SERUM ALBUMIN – ASCITIC SAAG = SERUM ALBUMIN – ASCITIC FLUID ALBUMINFLUID ALBUMIN

MEASUREMENT OF SAAGMEASUREMENT OF SAAG

NAME – BROMOCRESOL GREEN NAME – BROMOCRESOL GREEN METHODMETHOD

PRINCIPLE PRINCIPLE – – Albumin present in serum Albumin present in serum binds with bromocresol green at ph 4.1 to binds with bromocresol green at ph 4.1 to form green colored complex , intensity of form green colored complex , intensity of which can be measured colorimetric by which can be measured colorimetric by using 640 nm ( or a red filter ).using 640 nm ( or a red filter ).

Normal serum albumin = 3.3 – 4.8 g/dlNormal serum albumin = 3.3 – 4.8 g/dl

REAGENTSREAGENTS

BROMOCRESOL REAGENTBROMOCRESOL REAGENT

ALBUMIN STANDARD (4.0 G/DL )ALBUMIN STANDARD (4.0 G/DL )

SAMPLE BLANK REAGENTSAMPLE BLANK REAGENT

PROCEDUREPROCEDURE

TESTTEST STANDARSTANDARDD

BLANKBLANK

BROMO -BROMO -CRESOLCRESOL

5.0 ML5.0 ML 5.0 ML5.0 ML 5.0 ML5.0 ML

SERUM/ SERUM/ FLUIDFLUID

0.05 ML0.05 ML - - --

ALBUMIN ALBUMIN STANDARSTANDARDD

-- 0.05 ML0.05 ML --

DISTILLED DISTILLED WATERWATER

-- -- 0.05 ML0.05 ML

PROCEDUREPROCEDURE

MEASURE INTENSITY OF TEST / MEASURE INTENSITY OF TEST / STANDARD BY SETTING BLANK AT STANDARD BY SETTING BLANK AT 100 % T USING 640 NM.100 % T USING 640 NM.

CALCULATION CALCULATION SERUM/ASCITIC FLUID ALBUMIN = O.D SERUM/ASCITIC FLUID ALBUMIN = O.D

TEST/O.D STD X 4TEST/O.D STD X 4

CHEMICAL EXAMINATION - CHEMICAL EXAMINATION - GLUCOSEGLUCOSE

ORTHO TOLUDINE METHODORTHO TOLUDINE METHOD

PRINCIPLE PRINCIPLE – – Glucose reacts with ortho toludine Glucose reacts with ortho toludine in hot acidic medium to form green colored in hot acidic medium to form green colored complex , intensity of which is measured by complex , intensity of which is measured by photometer at 620 – 660 nmphotometer at 620 – 660 nm

CHEMICAL EXAMINATION-CHEMICAL EXAMINATION-GLUCOSEGLUCOSE

GLUCOSE OXIDASE METHODGLUCOSE OXIDASE METHOD GLUCOSE + h2o +o2 = gluconic acid =h2o2GLUCOSE + h2o +o2 = gluconic acid =h2o2 Aldehyde group of glucose is oxidized to Aldehyde group of glucose is oxidized to

form GLUCONIC ACIDform GLUCONIC ACID UNDER PEROXIDASE h2o2 = h2o + o2. UNDER PEROXIDASE h2o2 = h2o + o2.

o2 reacts with h – aminophenazone in o2 reacts with h – aminophenazone in presence of phenol to form pink colored presence of phenol to form pink colored complex.complex.

Intensity read at 530 nm Intensity read at 530 nm

CINICAL SIGNIFICANCE - CINICAL SIGNIFICANCE - GLUCOSEGLUCOSE

IN UNCOMPLICATED ASCITES , USUALLY SIMILAR IN UNCOMPLICATED ASCITES , USUALLY SIMILAR TO SERUM.TO SERUM.

DECREASED IN MOST CASES OF T.B PERITONITIS DECREASED IN MOST CASES OF T.B PERITONITIS & ABDOMINAL CARCINOMATOSIS& ABDOMINAL CARCINOMATOSIS

IN LATER S.B.P (but not in early ) ASCITIC FLUID IN LATER S.B.P (but not in early ) ASCITIC FLUID GLUCOSE LEVEL DROPS TO AS LOW AS ZERO GLUCOSE LEVEL DROPS TO AS LOW AS ZERO mg / dl DUE TO BACTERIAL CONSUMPTION.mg / dl DUE TO BACTERIAL CONSUMPTION.

PLEURAL FLUID PLEURAL FLUID ANALYSISANALYSIS

Ascitic & pleural fluid analysisAscitic & pleural fluid analysis

PLEURAL FLUIDPLEURAL FLUID

The pleural cavity is potential space lined The pleural cavity is potential space lined by mesothelium of visceral & parietal by mesothelium of visceral & parietal pleura.pleura.

The normal pleural cavity contains The normal pleural cavity contains approx 1 ml of fluid.approx 1 ml of fluid.

This represents the balance between the This represents the balance between the hydrostatic/ oncotic forces in parietal hydrostatic/ oncotic forces in parietal pleural vessels & external lymphatic pleural vessels & external lymphatic drainage.drainage.

Pleural effusion results from disruption of Pleural effusion results from disruption of this balance.this balance.

CAUSES OF PLEURAL EFFUSIONCAUSES OF PLEURAL EFFUSION

TRANSUDATETRANSUDATESS

C.H.FC.H.F HEPATIC CIRRHOSISHEPATIC CIRRHOSIS ATELECTASISATELECTASIS HYPOALBUMINEMIAHYPOALBUMINEMIA NEPHROTIC SYNDROMENEPHROTIC SYNDROME PERITONEAL DIALYSISPERITONEAL DIALYSIS MYXEDEMAMYXEDEMA CONSTRICTIVE CONSTRICTIVE

PERICARDITISPERICARDITIS

EXUDATESEXUDATESA)INFECTIONA)INFECTION

-BACTERIAL PNEUMONIA-BACTERIAL PNEUMONIA

-TUBERCULOSIS-TUBERCULOSIS

-HISTOPLASMOSIS-HISTOPLASMOSIS

-VIRAL PNEUMONIA-VIRAL PNEUMONIA

-MYCOPLASMA PNEUMONIA-MYCOPLASMA PNEUMONIA

B)NEOPLASMSB)NEOPLASMS

C)NON INFECTIOUS C)NON INFECTIOUS INFLAMMATORY DISEASESINFLAMMATORY DISEASES

CAUSES OF PLEURAL CAUSES OF PLEURAL EFFUSIONEFFUSION

FLUID FROM EXTRA PERITONEAL FLUID FROM EXTRA PERITONEAL SOURCESSOURCES A) Pancreatitis (increased amylase A) Pancreatitis (increased amylase ))

B) Ruptured esophagus (increased B) Ruptured esophagus (increased amylase + low ph ).amylase + low ph ).

C) Urinothorax (increased creatinine C) Urinothorax (increased creatinine +low ph ).+low ph ).

PLEURAL FLUID EXUDATEPLEURAL FLUID EXUDATE

LIGHT’S CRITERIALIGHT’S CRITERIA PLEURAL PROTEIN/SERUM PROTEIN > OR = 0.5PLEURAL PROTEIN/SERUM PROTEIN > OR = 0.5 PLEURAL LDH /SERUM LDH > OR = 0.6PLEURAL LDH /SERUM LDH > OR = 0.6 PLEURAL FLUID LDH = > OR = 2/3 rd UPPER LIMIT OF PLEURAL FLUID LDH = > OR = 2/3 rd UPPER LIMIT OF

NORMAL SERUM LDH.NORMAL SERUM LDH.

OTHER CRITERIAOTHER CRITERIA PLEURAL FLUID CHOLESTEROL = > 45 mg / Dl.PLEURAL FLUID CHOLESTEROL = > 45 mg / Dl. PLEURAL CHOLESTEROL /SERUM CHOLESTEROL > OR = PLEURAL CHOLESTEROL /SERUM CHOLESTEROL > OR =

0.3.0.3. SERUM PLEURAL FLUID ALBUMIN GRADIENT < OR = 1.2 g SERUM PLEURAL FLUID ALBUMIN GRADIENT < OR = 1.2 g

/dl./dl. PLEURAL BILIRUBIN / SERUM BILIRUBIN > OR = 0.6PLEURAL BILIRUBIN / SERUM BILIRUBIN > OR = 0.6

PLEURAL FLUID ANALYSISPLEURAL FLUID ANALYSIS

SPECIMEN COLLECTED IN THREE SPECIMEN COLLECTED IN THREE ASEPTIC TUBESASEPTIC TUBES

1)ONE WITH SODIUM FLOURIDE FOR SUGAR/ 1)ONE WITH SODIUM FLOURIDE FOR SUGAR/ PROTEIN ESTIMATION.PROTEIN ESTIMATION.

2) 2) PLAIN TUBE FOR OBSERVATION OF CLOT & PLAIN TUBE FOR OBSERVATION OF CLOT & BACTERIOLOGYBACTERIOLOGY..

3)EDTA TUBE FOR MICROSCOPIC EXAMINATION.3)EDTA TUBE FOR MICROSCOPIC EXAMINATION.

TRANSUDATE /EXUDATETRANSUDATE /EXUDATE

TRANSUDATETRANSUDATE EXUDATEEXUDATE

11 Non inflammatory processNon inflammatory process Inflammatory processInflammatory process

22 Clear, serous ,light yellowClear, serous ,light yellow Clear or cloudy , serous , Clear or cloudy , serous , purulent , hemorrhagic, chylous purulent , hemorrhagic, chylous or flocculentor flocculent..

33 Specific gravity < 1.018Specific gravity < 1.018 Specific gravity > 1.018Specific gravity > 1.018

44 Clot absentClot absent Clots spontaneous.Clots spontaneous.

55 Protein < 2.5 g / dLProtein < 2.5 g / dL Protein > 3.5 g / dLProtein > 3.5 g / dL

66 Few lymphocytes & endothelial Few lymphocytes & endothelial cellscells

Many neutrophils in acute & Many neutrophils in acute & small lymphocytes in chronic small lymphocytes in chronic inflammation.inflammation.

77 Bacteria usually absentBacteria usually absent Bacteria usually present.Bacteria usually present.

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION NORMALNORMAL CLOUDYCLOUDY

BLOODY FLUIDBLOODY FLUID

CHYLOUSCHYLOUS

PSEUDOCHYLOUSPSEUDOCHYLOUS

PALE/STRAW COLOREDPALE/STRAW COLORED BACTERIAL/ VIRAL BACTERIAL/ VIRAL

INFECTIONINFECTION TRAUMATRAUMA MALIGNANCYMALIGNANCY TUBERCULOSISTUBERCULOSIS PULMONARY INFARCTPULMONARY INFARCT PANCREATITISPANCREATITIS LYMPHOMALYMPHOMA CARCINOMA LUNGCARCINOMA LUNG TRAUMATRAUMA TUBERCULOSISTUBERCULOSIS RHEUMATIC ARTHRITISRHEUMATIC ARTHRITIS MYXEDEMAMYXEDEMA

CHYLOUS/PSEUDOCHYLOUSCHYLOUS/PSEUDOCHYLOUS

CHYLOUSCHYLOUS PSEUDOCHYLOUSPSEUDOCHYLOUS

1)ONSET1)ONSET SUDDENSUDDEN GRADUALGRADUAL

2)APPEAR2)APPEARANCEANCE

MILKY WHITE / YELLOW MILKY WHITE / YELLOW or BLOODYor BLOODY

MILKY / GREENISH/ MILKY / GREENISH/ METALLIC SHINEMETALLIC SHINE

3)MICROS3)MICROSCOPICCOPIC

LYMOHOCYTESLYMOHOCYTES MIXED CELLULAR MIXED CELLULAR REACTION REACTION /CHOLESTEROL /CHOLESTEROL CRYSTALSCRYSTALS

4)TRIGLYC4)TRIGLYCERIDESERIDES

> OR = 110 MG / DL> OR = 110 MG / DL < 50 MG / DL< 50 MG / DL

5)LIPO 5)LIPO PROTEINSPROTEINS

CHYLOMICRONS CHYLOMICRONS PRESENTPRESENT

CHYLOMICRONS ABSENTCHYLOMICRONS ABSENT

CLOT TESTCLOT TEST

THE PLAIN TUBE IS OBSERVED FOR THE PLAIN TUBE IS OBSERVED FOR CLOT.CLOT.

NORMAL NORMAL = DOES NOT CLOT. = DOES NOT CLOT.

INFLAMMATION/INCREASED INFLAMMATION/INCREASED FIBRINOGEN FIBRINOGEN = CLOTS. = CLOTS.

SPECIFIC GRAVITYSPECIFIC GRAVITY

BY HAND REFRACTOMETER OR BY HAND REFRACTOMETER OR WEIGHT METHOD.WEIGHT METHOD.

EXUDATE EXUDATE > 1.018. > 1.018.

TRANSUDATE TRANSUDATE < 1.018 < 1.018


SPECIMENSPECIMEN DILUTION FACTORDILUTION FACTOR

1)1) CLEAR SAMPLECLEAR SAMPLE CHAMBER CHARGED CHAMBER CHARGED WITHOUT ANY WITHOUT ANY DILUTIONDILUTION

2)2) TURBID SAMPLETURBID SAMPLE SAMPLE DILUTED SAMPLE DILUTED WITH NORMAL WITH NORMAL SALINE IN 1: 20 SALINE IN 1: 20 RATIORATIO

CELL COUNTCELL COUNT

1) 1) UNDILUTED SPECIMENSUNDILUTED SPECIMENS

WBC/cu mm = COUNTED WBC/cu mm = COUNTED CELLS/4 X 10.CELLS/4 X 10.

. 2) . 2) DILUTED SPECIMENSDILUTED SPECIMENS

WBC/ cu mm = COUNTED WBC/ cu mm = COUNTED CELLS/4 X10 X 20CELLS/4 X10 X 20

CELLULAR DIFFERENTIAL CELLULAR DIFFERENTIAL OF PLEURAL EFFUSIONOF PLEURAL EFFUSION

NEUTROPHILLIANEUTROPHILLIA

1)BACTERIAL PNEUMONIA1)BACTERIAL PNEUMONIA

2)PULMONARY INFARCTION2)PULMONARY INFARCTION

3)PANCREATITIS3)PANCREATITIS

4)SUBPHRENIC ABSCESS4)SUBPHRENIC ABSCESS

5)EARLY T.B.5)EARLY T.B.

6)TRANSUDATE.6)TRANSUDATE.


LYMPHOCYTOSIS ( > 50 % )LYMPHOCYTOSIS ( > 50 % ) 1) T.B (MESOTHELIAL CELLS ARE 1) T.B (MESOTHELIAL CELLS ARE

RARE ).RARE ).

2)VIRAL INFECTION.2)VIRAL INFECTION.

3)MLIGNANCY.3)MLIGNANCY.

4)TRUE CHYLOTHORAX.4)TRUE CHYLOTHORAX.

5)RHEUMATOID PLEURITIS.5)RHEUMATOID PLEURITIS.

6)S.L.E.6)S.L.E.

7)UREMIC EFFUSION.7)UREMIC EFFUSION.

8)TRANSUDATES (APPROX. 50 % )8)TRANSUDATES (APPROX. 50 % )


EOSINOPHILLIA.( > 10 % )EOSINOPHILLIA.( > 10 % ) 1)PNEUMOTHORAX.1)PNEUMOTHORAX.

2)TRAUMA.2)TRAUMA.

3)PULMONARY INFARCTION.3)PULMONARY INFARCTION.

4)C.H.F.4)C.H.F.

5)INFECTION ( PARASITIC , FUNGI ).5)INFECTION ( PARASITIC , FUNGI ).

6)HYPERSENSITIVITY SYNDROME.6)HYPERSENSITIVITY SYNDROME.

7)DRUG REACTION.7)DRUG REACTION.

8)RHEUMATOLOGIC DISEASES.8)RHEUMATOLOGIC DISEASES.

9)HODGKIN’S DISEASE.9)HODGKIN’S DISEASE.

10)IDIOPATHIC10)IDIOPATHIC

CHEMICAL EXAMINATIONCHEMICAL EXAMINATION

PROTEINPROTEIN RIVALTA’S QUALITATIVE RIVALTA’S QUALITATIVE

METHOD.METHOD. BIURET METHODBIURET METHOD

PLEURAL PROTEIN = O.D. PLEURAL PROTEIN = O.D. TEST/O.D.STD X 4.TEST/O.D.STD X 4.

PROTEIN >3 G/DL = EXUDATE.PROTEIN >3 G/DL = EXUDATE. PROTEIN <3 G/DL = TRANSUDATE.PROTEIN <3 G/DL = TRANSUDATE.


GLUCOSE.GLUCOSE.

Normally equal to serum level.Normally equal to serum level.

Determined by orthotoludine Determined by orthotoludine method.method.


DECREASED PLEURAL GLUCOSEDECREASED PLEURAL GLUCOSE : - : - 1)RHEUMATOD PLEURITIS.1)RHEUMATOD PLEURITIS.

2)PURULENT PARAPNEUMONIC EXUDATE.2)PURULENT PARAPNEUMONIC EXUDATE.

3)MALIGNANCY.3)MALIGNANCY.

4)T.B.4)T.B.

5)NON PURULENT BACTERIAL INFECTION.5)NON PURULENT BACTERIAL INFECTION.

6)LUPUS PLEURITIS.6)LUPUS PLEURITIS.

7)ESOPHAGEAL RUPTURE.7)ESOPHAGEAL RUPTURE.


LACTATE : -INCREASED INLACTATE : -INCREASED IN

1)BACTERIAL PLEURAL INFLAMMATION.1)BACTERIAL PLEURAL INFLAMMATION.

2)T.B. PLEURAL INFECTION.2)T.B. PLEURAL INFECTION.

3)MALIGNANT EFFUSION.3)MALIGNANT EFFUSION.


AMYLASE AMYLASE : - elevation above serum : - elevation above serum levels usually 1.5 – 2.0 times indicate : -levels usually 1.5 – 2.0 times indicate : -

1) PANCREATITIS.1) PANCREATITIS.

2) ESOPHAGEAL RUPTURE.2) ESOPHAGEAL RUPTURE.

3) MALIGNANT EFFUSION.3) MALIGNANT EFFUSION.

NOTE: NOTE: Elevated amylase from last two Elevated amylase from last two causes is of SALIVARY ISOFORMcauses is of SALIVARY ISOFORM..

MICROBIOLOGIC MICROBIOLOGIC EXAMINATIONEXAMINATION

DONE BY PREPARING TWO SMEARS DRIED IN AIR , HEAD DONE BY PREPARING TWO SMEARS DRIED IN AIR , HEAD FIXED & STAINED WITH GRAM STAIN & Z.N. STAIN.FIXED & STAINED WITH GRAM STAIN & Z.N. STAIN.

CONFIRMED REPORT ONLY AFTER CULTURE.CONFIRMED REPORT ONLY AFTER CULTURE.

BACTERIA MOST COMMONLY ASSO WITH BACTERIA MOST COMMONLY ASSO WITH PARAPNEUMONIC EFFUSION .PARAPNEUMONIC EFFUSION .

1) S.AUREUS1) S.AUREUS

2) S.PNEUMONIA2) S.PNEUMONIA

3) BETA HEMOLYTIC GROUP A STREPTOCOCCI.3) BETA HEMOLYTIC GROUP A STREPTOCOCCI.

4) GAMMA STREPTOCOCCI4) GAMMA STREPTOCOCCI

5) 5) SOME GRAM NEGATIVE BACILLI.SOME GRAM NEGATIVE BACILLI.

REFERENCESREFERENCES

HENRY’S CLINICAL DIAGNOSIS & HENRY’S CLINICAL DIAGNOSIS & MANAGEMENT BY LAB. METHODS.MANAGEMENT BY LAB. METHODS.

GODKAR’S T.B. OF MEDICAL LAB. GODKAR’S T.B. OF MEDICAL LAB. TECHNOLOGY.TECHNOLOGY.

MILLER’S CLINICAL PATHOLOGY.MILLER’S CLINICAL PATHOLOGY. VARIOUS WEB SITES.VARIOUS WEB SITES.

THANKSTHANKS BY : - BY : - DR RAVI JAINDR RAVI JAIN

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