FAECAL ANALYSIS

Joseph T. Sabido

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Or Analysis of Faecal matter, just to be formal...

What's faecal Analysis???

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*Necessary evil*

Faeces
end product of body metabolism provide valuable diagnostic information

Routine Faecal Examination (macroscopic, microscopic & chemical analysis)

for early detection of the ff: gastrointestinal bleeding liver and biliary duct disorders maldigestion/ malabsorption syndrome inflammation causes of diarrhoea and steatorrhea

Physiology

Normal Faecal Specimen contains:

bacteria cellulose undigested foodstuffs gastrointestinal secretions bile pigments cells from the intestinal walls electrolytes water

*Flatus
Intestinal gas

Carbohydrates
resistant to digestion pass through the upper intestine metabolised by bacteria in lower intestine producing large amount of flatus

Alimentary tract
tubular passage of mucous membrane and muscle extending about 8.3 meters from mouth to anus; functions in digestion and elimination.

Small Intestine
The narrow, winding, upper part of the intestine where digestion is completed and nutrients are absorbed by the blood. It extends from the pylorus to the caecum and consists of the duodenum, the jejunum, and the ileum.

Digestive Enzymes
trypsin chymotrypsin amino peptidase lipase

Bile salts
Aid in the digestion of fatty acids

Fluid within the AT

ingested fluid 2000 mL saliva - 1500 mL gastric 1500 mL liver 1000 mL pancreatic 1000 mL intestinal secretions 2000 mL (water and electrolytes)

Under Normal Conditions 500 to 1500 mL reaches the large intestine 150 mL excreted in the faeces Water and Electrolytes absorbed in both the small and large intestine * faecal electrolyte content is similar to that of plasma

Large intestine
The large intestine is the portion of the digestive system most responsible for absorption of water from the indigestible residue of food. The ileocaecal valve of the ileum (small intestine) passes material into the large intestine at the caecum. Material passes through the ascending, transverse, descending and sigmoid portions of the colon, and finally into the rectum. From the rectum, the waste is expelled from the body.

Large Intestine
It is capable of absorbing an approximate volume of 3000 mL of water. If the amount of water reaching the large intestine exceeds the normal volume (9000 mL,) it is excreted with the solid faecal material, producing diarrhoea Constipation: Provides time for additional water to be reabsorbed from the faecal material, producing small, hard stools.

Disorders
Disorders often associated with the Alimentary tract

Diarrhoea
Increase in daily stool weight (above 200 g) with increased liquidity and frequency of more than 3 times a day.

Four Factors in diarrhoea classification Duration of the illness Mechanism Severity Stool characteristics

Acute diarrhoea (less than 4 weeks) Chronic diarrhoea (more than 4 weeks)

Major Mechanisms of Diarrhoea

A. Secretory Diarrhoea Bacterial and protozoan infections produce increased secretion of water and electrolytes which override the reabsorptive ability of the large intestine.

Causes
Enterotoxin-producing organisms Other causes

- Escherichia coli - Clostridium spp - Vibrio cholera - Salmonella spp - Shigella spp - Staphylococcus spp - Campylobacter protozoa - Cryptosporidium

- Drugs - Stimulant laxatives - Hormones - Inflammatory bowel disease - Endocrine disorders - Neoplasms - Collagen vascular disease

B. Osmotic Diarrhoea Incomplete breakdown or reabsorption of food presents an increased faecal material to the large intestine Retention of water and electrolytes in the large intestine

Causes: Disaccharidase deficiency (lactose intolerance) Malabsorption (celiac sprue) Poorly absorbed sugars (lactose, sorbitol, mannitol) Laxatives Magnesium - contains antacids Amoebiasis Antibiotic administration

C. Altered Motility Conditions of enhanced motility (hypermotility) or slow motility (constipation) Can be caused by Irritable bowel Syndrome

Irritable Bowel syndrome A functional disorder in which the nerves and muscles of the bowel are extra sensitive Causes cramping, bloating, flatus, diarrhoea, constipation Triggered by certain food, chemicals, emotional stress and exercise

Rapid Gastric Emptying Dumping Syndrome Describes hypermotility of the stomach and the shortened gastric emptying half-time, which causes the small intestine to fill too quickly with undigested food. Hallmark for Early Dumping Syndrome

Normal Gastric Emptying Half-Time (around 35-100 minutes) Controlled by: Fundic tone Duodenal feedback Gastrointestinal Hormones

Rapid Gastric Emptying Gastric emptying time of less than 35 minutes. Caused by disturbances in the gastric reservoir or in the transporting function Divided into two: Early dumping syndrome and Late Dumping

Dumping Syndrome Hypoglycemia is often a complication Causes of DS: Gastrectomy Gastric bypass surgery Post-vagotomy status Bollinger-Ellison syndrome duodenal ulcer disease Diabetes melitus

COMMON TESTS FOR DIARRHOEA Secretory Stool Cultures Ova and Parasite examinations Rotavirus Immunoassay Osmotic Microscopic Faecal Fats Muscle Fibre Detection Qualitative Faecal Fats Trypsin Screening Quantitative Faecal Fats Clinitest D-Xylose tolerance test Lactose tolerance test Faecal Electrolytes Stool pH Faecal Osmolality

Faecal Leukocytes

Malabsorption
Abnormal nutrient absorption or digestion of fats, meat fibres and carbohydrates Often leads to malnutrition and anaemia Urine D-Xylose is low.

Maldigestion

Impaired digestion due to lack of digestive enzymes

Colorectal Cancer

Causes increased blood loss in the Gastrointestinal Tract Detected via Occult Blood Testing

Cystic Fibrosis
Disease of Accessory organ Hereditary disease that affects mucous secretion in the pancreas and lungs Decreased pancreatic enzymes (trypsin/chymotrypsin/elastase)

Steatorrhoea
Detection of Steatorrhea: For the diagnosis of pancreatic insufficiency and small bowel disorders Pancreatic disorders that increase the production of pancreatic enzymes: Cystic Fibrosis Chronic Pancreatitis Carcinoma

Present maldigestion and malabsorption conditions Distinguished by the D-Xylose test (Normal D-Xylose Test indicates pancreatitis)

Specimen Collection
The Proper How-Tos in Collecting Faecal Specimen

Collect the specimen in a clean container (e.g. Bed pan or disposable container) then transfer to the laboratory container Wide-mouth, chemically clean, and sterile bottles Kits for the collection of specimens to be screened for occult blood paper can be floated in the toilet bowl to collect the specimen (only to be used when collecting specimen using the kit in which they are included)

Containers with preservatives for ova and parasites (must not be used for other tests) Interferences: Urine contamination: destroys protozoa in stool Water contamination: interferes with lab testing Failure to adhere to diet recommendation: affects the faecal specimen Enemas and Barium Sulphate: affects stool samples for microscopy (fat, fibres, parasites)

Laboratory Examinations

Microscopic Examination
Size, shape, consistency, color Presence or blood, mucous, pus, tissue, food residues or parasites

Appearance
Small, hard dark balls Voluminous, odorous, floating

Usual Causes

Constipation Malabsorption of fats or protein Irritable bowel Loose, contains mucus, syndrome, diffuse but no blood superficial inflammation, Villous adenoma Loose, contains mucus and blood Sticky, black, tarry Inflammatory bowel syndromes, Typhoid, shigellae, amoebae, carcinoma Upper GI tract haemorrhage

Appearance

Usual Causes
Non-invasive infections (cholera, toxigenic, E. coli, staphylococcal food poisoning) Osmotic Catharsis (disaccharidase deficiency, binge-type overeating) Diverticulitis or other abscesses Necrotic tumor Parasites Bile duct obstruction Barium Ingestion

Voluminous, watery, little formed material

Loose, contains pus and or necrotic tissue Pasty, grayish-white, little odour

The Colours of Faeces

Colour
Brown, dark brown, yellowbrown Very dark brown

NonPathologic pathologic
Normal oxidation of bile pigments
Prolonged exposure to air, diet high in meat

None

None Bleeding from GI tract

Black

Iron, Bismuth ingestion

Grey

Steatorrhoea Chocolate, cocoa (consistency usually ingestion mushy/frothy)

Colour
Very light grey

NonPathologic pathologic
Diet high in milk products, Barium ingestion Diet high in Spinach, other greens Bile duct obstruction Rapid transit time, preventing oxidation of bile pigments

Green/ Yellowgreen

Red

Laxatives, Bleeding from GI vegetable origin, tract diet high in beets

Its the same world, only a thousand times smaller

Microscopic Examination

Performed to detect the presence of Leukocytes associated with microbial diarrhoea and undigested fibres and fats associated with steatorrhoea

Abnormal findings
Faecal Leukocytes (neutrophils): Dysentry Eosinophils: Amoebic infections Large amounts of epithelial cells/large amount of mucous: irritated mucosa

Faecal Leukocytes
Seen in conditions that affect the Intestinal Mucosa Microscopic screening is performed as a preliminary test to determine whether diarrhoea is being caused by invasive bacterial pathogens Diarrhoea caused by Staphylococcus aureus and Vibrio spp. Do not cause the appearance of faecal neutrophils

Specimen staining and Staining reagents used: Specimens can be examined as wet preparations stained with Methylene blue (faster procedure but difficult to interpret) or as dried smears with Wrights or Gram Stain (provide permanent slides for evaluation. All slide preparations must be performed with fresh specimens A lactoferrin latex agglutination test is available for the detection of fecal leukocytes and remains sensitive on refrigerated and frozen specimens

Interpretation: Indicative of invasive bacteria: Under high power objective, as few as three neutrophils Using oil immersion, finding of any neutrophil has approximately 70% sensitivity. Presence of Lactoferrin latex agglutination

Muscle Fibres
Presence of striated muscle fibres are seen in patients with maldigestion (cystic fibrosis and hypermotility,) pancreatic insufficiency, in biliary obstruction and gastrocolic fistulas

Procedure: Patients should be instructed to include red meat in their diet prior to the collection of specimen Specimens should be examined not later than 24 hours after collection Emulsify a small amount of stool in 2 drops of 10% alcoholic eosin, which enhances muscle fibre striations Coverslip then let stand for 3 minutes The entire slide should be examined within 5 minutes in high power objective Count the number of undigested fibers.

Appearance of the fibers Undigested fibers: visible striations running both vertically and horizontally Partially digested fibers: striations in only one direction Digested fibers: no visible striations Manner of reporting: Increased: >10 fibers/hpf = creatorrhoea

Qualitative Faecal Fat Testing

Steatorrhoea
Increased fecal fat Present in conditions that decrease pancreatic enzymes and in malabsorption. Pale and greasy looking stool with foul odour. Mineral oils and creams cause false positive.

Qualitative Tests
Used to monitor patients undergoing treatment for malabsorption disorders. Sudan III is routinely used for staining. Two parts: Neutral fat stain and Split fat stain

Stains: Sudan III, Sudan IV and Oil Red O TAG (neutral fats) Sudan III in 95% Ethanol Normal: <60 orange-red fat globules/hpf (small/medium) Fatty acids With acetic acid, preheated before staining Normal: <100 orange-red fat globules/hpf (<4m)

Cholesterol Cholesterol is stained with Sudan III after heating and as the specimen cools, it forms crystals that can be identified microscopically Soap and fatty acids do not stain directly with Sudan III, therefore, a second slidemust be examined after the specimen has been mixed with acetic acid and heated.

Intestinal malabsorption: normal neutral fats, increased soap and fatty acids Maldigestion leading to steatorrhoea: increased neutral fats

Chemical Testing for Faeces

Blood in faeces
Bleeding in the upper GI tract may produce black, tarry stool, and bleeding in the lower GI tract may result in overly bloody stool. Any bleeding in excess of 2.5mL/150g of stool os considered pathologic Melena: a very large amount of faecal blood Appears a black, tarry stool

Colonic bleeding causes red or maroon stools Streaks of bright red blood on the stool surface denotes: Haemorrhoidal bleeding Ulcerative colitis Friable adenomas Superficially eroded carcinomas

Tests for Blood

Faecal Occult Blood Testing (FOBT) is used as a mass screening procedure for the early detection of colorectal cancer. It is the most frequently encountered screening test for occult blood and is based on the detection of pseudoperoxidase activity of haemoglobin. This is the same principle as that of the reagent strip test for urinary blood, but uses a different indicator chromogen.

Guiac Testing Most common Utilises a Guiac-impregnated paper in cardboard holder Blue colouration indicates presence of either Haemoglobin, peroxidase or pseudoperoxidase Less sensitive Others: Benzidine, Orthotoluidine, and immunological tests (more susceptible to false positive results)

Quantitative Faecal Fat Testing

Used as confirmatory test for steatorrhoea Requires a collection of a 3-day specimen Patient must be maintain a regulated intake of fat (100g/day) prior to and during the collection Paint can can make an excellent collection container.

Routinely used and is the Gold standard

Van de Kamer Titration

Faecal lipids are converted to fatty acids and titrated to neutral endpoint with sodium hydroxide Fat content is reported as grams of fat or the coefficient of fat retention per 24 hours Normal values are based on 100g/day

Acid Steatocrit
Rapid test to estimate the amount of fat excretion, having a 72-hour stool collection Reliable tool to monitor a patients response to therapy and screen for steatorrhoea in paediatric populations

Near-Infrared Reflectance Spectroscopy

A rapid procedure that requires less stool. Requires 48 to 72 hour stool collection Result is based on the measurement and computed processing of signal data from reflectance of faecal surface, which is scanned with infrared light between 1400nm and 2600nm

Foetal Haemoglobin

Blood in vormitus or stool Source must be differentiated if either ingested from the mother (maternal HbA), or from own GIT (foetal HbF) Avoid black or tarry specimen Apt Test (vomitus/stool + H2O) + dilute NaOH HbF - no change in colour (pink) HbA - yellow or brown

Faecal Enzymes

Trypsin
Gelatin test is done, which is an insensitive procedure that detects only sever cases of pancreatic insufficiency When present in stool, it digests the gelatin on the paper, inability to digest indicates a deficiency in trypsin production

Chymotrypsin
More resistant to intestinal degradation and a more sensitive indicator of less sever cases Capable of gelatin hydrolysis but is most frequently measured by spectrophotometric methods

Elastase 1
Strongly resistant to degradation Accounts for about 6% of all secreted pancreatic enzymes Can be measured by immunoassay using ELISA kit. Provides a sensitive indicator of exocrine pancreatic insufficiency Uses a single stool sample.

Faecal Carbohydrates

Disaccharides
Osmotically active Triggers movement of large amounts of H2O to intestines CHO in stool = fluids and electrolytes = diarrhoea Seen in Celiac disease (impaired CHO reabsorption) Ph 7-8 normal pH5.5 Lactose intolerance ( sugar digesting enzymes) Congenital disaccharide deficiencies

Tests for Carbohydrates

Faecal Carbohydrate Testing (faecal diarrhoea assessment and inflammatory necrotising enterocolitis) Copper reduction test Ph paper

D-Xylose Test
Useful screening test for carbohydrate malabsorption If given orally, the amount excreted in a urine sample collected five hours after administration can be measured >3g D-Xylose in Urine: Normal <3g D-Xylose in Urine: intestinal malabsorption Renal disease may cause reduced D-Xylose urinary excretion

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