Sputum, Sweat, Gastric Fluid

2/25/2013

1

Miscellaneous Body Fluids:

Sputum, Sweat, Gastric Fluid

Erika Gayle M. Lipana, RMT

SPUTUM

• Secretion of the goblet cells (lining the respiratory tract)

• No goblet cells in the alveoli • DUST CELLS oHallmark of sputum oMacrophages with carbon deposits

SPUTUM:

How to induce release?

1. Use of nebulized saline or distilled water 2. Chest percussion 3. Postural drainage 4. Aerosolized 15% NaCl and 10% glycerin

SPUTUM: Preservation

1. Refrigeration 2. Use of 10% formaldehyde (cannot

be used for bacteriologic purpose because of its bacteriostatic effect)

SPUTUM COLLECTION

FIRST MORNING SPECIMEN is the

BEST!

SPUTUM COLLECTION:

Obtaining a sputum sample • Mouth should be free from

foreign objects 1. Remove food. Gum or tobacco 2. Remove dentures 3. Gargle prior to collection

• Early morning specimen is the best

• Induce sputum if necessary 1. Nebulized hypertonic saline or distilled

water 2. Chest percussion 3. Postural damage

• Cough into sterile cup

Patient should be

instructed to cough up the

sputum which is then

collected in clean, sterile,

wide mouth bottle or

disposable plastic

containers. NEVER USE

PAPER CUPS!

Era

Stamp

2/25/2013

2

SPECIMEN COLLECTION: Special Circumstances

• Tuberculosis is suspected 1. Sputum collected in negative pressure

room

2. Early morning gastric aspirate 3. Bronchoscopy with bronchial lavage 4. 3 day successive collection (morning

sample only)

• Anaerobic culture specimen 1. Tracheal aspiration 2. Thoracentesis (insertion of a hollow needle

into the pleural cavity through the chest wall in order to withdraw fluid, blood pus, or air)

3. Direct lung puncture

• Viral culture specimens 1. Patient gargles and expectorates with

nutrient broth 2. Nasopharyngeal swab transported in viral

medium

SPECIMEN COLLECTION: Special Circumstances

• Fixation of sputum for cytology (prevents air drying) 1. Patient expectorates into a jar of 70% ethanol 2. Spread fresh sputum on slide and spray pap’s fixative

• Culture specimen transport to laboratory 1. Sputum gram stain assesses the sample for adequacy. 2. Anaerobic culture transported in an air tight container (should be

immediately for immediate plating) I. Bring to laboratory as quickly as possible II. Refrigerate sample if transport is delayed III. Consider washing specimen of oral flora

i. Rinse several times with saline ii. Discard supernatant (non-viscous saliva)

3. Aerobic culture specimen 4. Tuberculosis culture (maybe stored at room temperature for up to

48 hours)

SPECIMEN COLLECTION:

Preparation of sputum for laboratory examination

SPUTUM: Physical Characteristic

• QUANTITY o Very few in amount

or NOTHING AT ALL!

• CONSISTENCY o Watery (sialic acid is responsible for

sputum’s viscosity) o Blood-gelatinous sputum (Currant-

Jelly) • Klebsiella pneumoniae infection • Pneumococcal pneumonia

o Stringy Mucoid Sputum (may also appear frothy)

• Follows asthma exacerbation o Cloudy, mucoid sputum

• Chronic bronchitis o Three layered appearance

(stagnant, purulent sputum) • Bronchiectasis • Lung abscess


• Reaction o Slightly acidic o pH 6.5-7.0

• Turbidity o Frothy sputum or serous (air bubble, hemoglobin)

• Pulmonary eddema o Mucoid

• Bronchiectasis

• TB with cavities

o Foamy, clear materials • Saliva • Nasal secretions


Era

Stamp

2/25/2013

3

• Odor o Normally: ODORLESS o Abnormally:

• Sweetish o In pulmonary tuberculosis with cavities, bronchiectasis,

bronchomoniliasis • Putrid or foul

o Usually due to Fusobacteria & Spirochetes found in mouth, or anaerobic infections within the lung, lung abscess and necrotizing bronchogenic carcinoma

• Cheesy odor o In necrosis or malignant tumors and perforating

emphysema • Fecal Odor

o Rupture sunphrenic or liver abscess and in enteric gram negative products.


• COLOR Normally, the color is greatly influenced by pus, as well as nature of the disease and the sputum itself.

o Colorless or transluscent or opaque • When made of mucus only

o White or yellow • When pus is present, seen in advance pulmonary

tuberculosis, chronic bronchitis, jaundice and lobar pneumonia

o Gray • When pus and epithelial cells are present

o Bright green or greenish • When bile is present as in jaundice, rupture of the liver

abscess into the lungs and infection caused by Pseudomonas aeruginosa


• COLOR o Red or bright red

• When there is fresh blood or new hemorrhage. If blood streaks are present, it is indicative of pulmonary tuberculosis or bronchiectasis

o Anchovy sauce or rusty brown • When old blood is present, seen in pneumonia, pulmonary

gangrene, rupture of amoebic abscess of the liver into the lung or pigmented cells in chronic passive congestion, due to cardiac pigment after hemorrhage from the lung pulmonary infarction.

o Prune-juice • Pneumonia and chronic cancer of the lungs

o Rusty red • Lobar pneumonia


• COLOR o Olive green or grass green

• Cancer

o Black • Indicates inhalation of dust or dirt, carbon, charcoal, in cases like anthracosis and heavy smokers.

o Yellow green

• Due to destruction of neutrophils and release of verdo peroxidase


• Cheesy masses o Fragments of necrotic tissue,

pulmonary tissue or bits cartilaginous rings, from pin-point to pin size.

o Present in so-called nummular sputum from a tuberculosis cavity, pulmonary gangrene, abscess of the lungs and actinomyccosis.

• Curschmann’s spiral o Seen in bronchial asthma o Yellowish-white, spirally twisted

mucoid strands

SPUTUM: Macroscopic Structures

• Bronchial cast o These are branching

tree-like casts of the bronci, seen in lobar pneumonia, fibrinous bronchitis and diphtheria

• Dittrich’s bodies o Yellow of gray caseous

masses, seen in asthma, putrid bronchitis

o Pinhead o Emits a foul odor when

crushed


Era

Stamp

2/25/2013

4

• Lung stone o Bronchioliths or pneumoliths o Small calcified nodules or stagnant

contents of cavities or dilated bronchi or calcified tuberculosis tissue. Sometimes the core is a small foreign body or a fungal growth.

• Foreign bodies o Include concretions formed in the

bronchi made of calcium carbonate and phosphate and aspirated substances such as: pollen, seeds, dust

• Parasites o Echinococcus granulosus, Toxaplasma

canis, paragonimus westermanii


Must be treated first with KOH or NaOH to dissolve the mucus. • Elastic fibers

o Normally present in the walls of the alveoli, bronchioles and the blood vessels

• Curschmann’s spiral o Yellow, wavy threads o Usually coiled into balls,

seen in bright colorless wit central lines.

SPUTUM: Microscopic Examination

• Crystals o Indicates stasis and decomposition of the sputum in the

body or in a n old specimen that is often unsatisfactory

• Charcot Leyden crystals

o Seen in bronchial asthma, arises from the disintegration of eosinophil

o Stains black in hematoxylin and red with eosin o Often octahedral and/or hexagonal in shape

• Hematoidin

o Rhombic and brownish red o Arranged in rosettes o Resulted down from breaking down of old blood

and are found in pulmonary infections, lung abscess, pulmonary infarction



• Crystals o Cholesterol crystals

• Colorless, thin, rhombic plates with notched corner. This indicates stasis with fatty degeneration of exudates and are often in lung abscess and emphysema

o Fatty acid crystal • Long, colorless needles,

arranged in seeves. • Also indicates stasis with

fatty degeneration of exudates and are often in lung abscess and emphysema


• Heart failure cell o Blood pigmented cells, chiefly

hemosiderin o Appears as round grayish or

colorless o Diffuse staining o Found in congestive heart failure

• Carbon-Laden crystals o Contain carbon and are less

important o Appears as angular black

granules both intracellular and extracellular

o Seen in anthracosis, heavy tobacco smokers and in people living in smoky atmosphere


Era

Stamp

2/25/2013

5

• Myelin globules o With little or no clinical significance o Colorless, round, oval or ear-shaped globules of various

sizes

o Reported in order to minimize confusions with more important structures like Blastomyces.

o Resembles fat droplets and yeast-like fungi o Large structures show peculiar concentric or irregular

spiral markings o Abundant in the scanty morning sputum of health persons

and may be found in closely packed sputum o Absent or scarce in specimens with inflammatory exudates.


• Actinomyces hominis o Small and yellowish structures

with sulphur granules which can be seen with unaided eye

o Similar structure with Actinomyces bovis under LPO

o consist of a network of threads having more or less radial arrangement

o Seen better by running small amount of eosin in alcohol solution and glycerin under the cover glass

o Seen in Actinomycotic pulmonary infection


• Moulds and yeasts o Hyphae are rods usually jointed

or branched and often arranged in meshwork (mycelium)

o Spores are highly refractive spheres and ovoid

o Seen in pneumomycosis specifically infection by Aspergillus fumigatus

o Grows in sputum upon long standing of tuberculosis specimen

• Creola Bodies o Cluster of ciliated columnar cells

found in the sputum of asthmatic patients.


• Blood Cells o Leukocyte

• Major blood present in sputum • Markedly increased when pus is

present • Eosinophil are commonly seen in

allergic patients (asthma) and can be demonstrated by Wright’s stain

o Erythrocytes • Present in lung hemorrhage,

pulmonary tuberculosis, and Paragonimus westermanii infection

• Detected by Guaiac or benzidine tests or presence of blood derivatives such as hemosiderin


SWEAT • The common eccrine glands function in

the regulation of the body temperature. They are innervated by cholinergic nerve and are a type of exocrine gland. Sweat has been analyzed for its multiple inorganic and organic contents, but with one notable exception, has not proven a clinically useful model. The exception is the analysis of sweat for chloride and sodium levels in the diagnosis of CYSTIC FIBROSIS

CYSTIC FIBROSIS • Also known as mucoviscidosis • An autosomal, recessive inherited disease that

affects the exocrine glands and causes electrolyte and mucous abnormalities

Era

Stamp

2/25/2013

6

CYSTIC FIBROSIS Methods/ Diagnosis • Pilocarpine NitrateIontophoresis by Gibson and

Cooke

Principle: Pilocarpine is introduced into skin by iontophoresis to stimulate locally increased sweat gland secretion. The resulting sweat is absorbed by filter paper or gauze, diluted with water and analyzed for sodium and chloride determination

METHODS/ DIAGNOSIS:

Pilocarpine NitrateIontophoresis by Gibson and Cooke

• Site of Iontophoresis o Sweat should only be collected

from the arms or legs o The area for stimulation must

be free from skin lesion o The skin should be cleaned with

distilled water, washed followed by drying with paper tissue

• Gauze pad o Place a weighed gauze pad on patient’s back overnight, that pad is

sealed tightly to prevent evaporation and removed in the morning. The pad is then weighed, diluted with water and analyzed for sodium and chloride

• Macro duct collection COLOR

Methods/ Diagnosis

Brown Ochronosis

Red Rifampin overdose

Blue Occupation exposure to copper

Blue-black Idiopathic Chronhidrosis

Sodium • It should approximate the chloride concentration,

so it is measured to provide better quality control

* Discrepancies for sodium and chloride is influenced by air bubbles (decrease concentration) and temperature fluctuations

Electrolytes • Use the osmometer method for measuring sweat

electrolytes provides a means for evaluation of young infants without subjecting them to the Rigos traditional sweat collection method

• The test should be performed on infants older than 8 days because newborn infants consistently have high electrolyte concentrations

• Because the sweat osmolarity is measured on an undiluted sample, cre must be taken to include the water that condences on the plastic cover or values will be falsely elevated

Era

Stamp

2/25/2013

7

Electrolytes

Reference Ranges:

SODIUM CHLORIDE

Normal < 70 mEq/L < 50 mEq/L

Abnormal > 90 mEq/L > 60 mEq/L

Equivocal 70-90 mEq/L 50-60 mEq/L

Electrolytes Test for Sweat Chloride AgNO3 Method Cotlove Chloridometer Test Results: Adults generally have higher sodium and chloride concentrations in their sweat than children. Also, sweat test results in adults can vary widely. This is especially true in women, because the amount of salt in their sweat can vary with the phase of their menstrual cycle. Enough sweat must be collected to get accurate results. Normal values may vary from lab to lab. Sweat chloride must be measured to diagnose cystic fibrosis. Some labs also measure sodium. Normal and abnormal sweat sodium values vary slightly from sweat chloride values.

GASTRIC JUICE Composition: 99% H2O, 1% solid • 0.2-0.4% HCl

o production by the parietal cells (oxyntic cells); for the activation of Pepsinogen

• Gastrin o Hormone stimulating secretion of HCl

• Zollinger-Ellison o High secretion of gastrin due to gastrin-secreting

tumor oxygenating from the pancreas

• Digestive enzymes o Produced by the chief cells (Zymogen or peptic cells)

• Pepsin (protein)

• Lipase (fats) • Rennin (to curdle milk)

Composition:

• Electrolytes o H+ (1 million times greater than blood) o Na, Cl, Mg, Ca, Fe

• Mucin o From the goblet or mucous cells to prevent autodigestion of

the stomach

• Intrinsic factor of Castle o For the absorption of Vitamin B12 to prevent Pernicious

Anemia

Collection o Intubation (fasting patient) o Ewald’s or Boa’s Method (best evacuated tube)

GASTRIC JUICE

GASTRIC JUICE: Commonly Used Stimulants

• Pentagastrin o Stimulant of choice o Synthetic compound resembling gastrin

o Produce more rapid response o No discomfort o Specimens are collected at 15 minutes interval for 1 hour

following the administration

• Histalog o When used, collection must continue for 2 hours because

maximum output is delayed

• Histamine TUBELESS METHOD

o Diagnex blue test o Patient is given an Azure A dye

Gastric Juice: Physical Characteristics

Quantity 20-50 mL

Color Grayish or bile-stained; colorless

Odor Sloightly sour or odorless

Reaction Acidic (pH 1.6-1.8)

Specific Gravity 1.001- 1.010

Consistency Watery

Mucus Small amount

Sediment Normally non

Era

Stamp

2/25/2013

8

Gastric Juice: Chemical Characteristics

1˚ acidity = 0.00365% HCl

• Free HCl o 25˚-50˚ or 20-40 mEq/L o Tests:

• Topfer’s • Boa’s • Gunzberg

• Total acidity o 50˚-75˚

o Composed of free HCl, combined HCl, acid salts and organic acids like lactic acid, butyric acid and amino acids

o Tests: • Topfer’s • Phenolpthalein

• Combined HCl (Acid-metaprotein) o N.V. = 10-15˚

o Composed of HCl which combines loosely with the protein in the absence of free HCl

• Lactic acid o Normally absent o Indicates advanced gastric cancer o Maybe found in the stomach from the fermentation of CHO

or from the production of lactic acid-forming bacteria like Boas-oppler bacilli

• Occult blood o Normally none o Seen in peptic ulcers and gastric carcinoma


• Bile o Small amount

• Renin o Absence indicates organic disease o Tests:

• Reitman • Riegel

• Pepsin o Absence indicates organic disease o Tests:

• Bauer • Hammerschlag


Definition of Terms • Euchlorhydria

o Normal acidity

• Hyperchlorhydria o Increased free HCl around 60˚

o Seen in: Peptic ulcers like duodenal and gastric ulcers

• Hypochlorhydria o Decreased free HCl o Seen in: Gastric syphilis, Gastric cancer, Chronic gastritis

• Achlorhydria o Absence of free HCl o Seen in: Pernicious Anemia, Gastric cancer, pellagra

• Achylia gastrica o Absence of HCl and renin in gastric juice

• Anacidity o Inability to produce a pH less than 6.0 following gastric stimulation

Era

Stamp

Sputum, Sweat, Gastric Fluid

Documents

Transcript of Sputum, Sweat, Gastric Fluid