copyright © 2014. f.a. davis company chapter 12 serous fluid

Copyright © 2014. F.A. Davis Company

CHAPTER 12CHAPTER 12

SEROUS FLUIDSEROUS FLUID


Upon completing this chapter, the reader will be able to

1.Describe the normal formation of serous fluid.2.Describe four primary causes of serous effusions.3.Differentiate between a transudate and an exudate, including etiology, appearance, and laboratory tests.4.Differentiate between a hemothorax and a hemorrhagic exudate.5.Differentiate between a chylous and a pseudochylous exudate.

Learning ObjectivesLearning Objectives


6. State the significance of increased neutrophils, lymphocytes, eosinophils, and plasma cells in pleural fluid.

7. Describe the morphologic characteristics of mesothelial cells and malignant cells.

8. List three common chemistry tests performed on pleural fluid, and state their significance.

9. State the common etiologies of pericardial effusions.10. Discuss the diagnostic significance of peritoneal lavage.

Learning Objectives Learning Objectives (cont’d)(cont’d)


11. Calculate a serum-ascites gradient, and state its significance.

12. Differentiate between ascitic effusions of hepatic and peritoneal origin.

13. State the clinical significance of the carcinoembryonic antigen and CA 125 tests.

14. List four chemical tests performed on ascitic fluid, and state their significance.

Learning Objectives Learning Objectives (cont’d)(cont’d)


• Line the closed body cavities– Pleural– Pericardial– Peritoneal

• Two membranes– Parietal: lines cavity wall– Visceral: lines organs in cavity

• Fluid between membranes– Serous fluid: named for each location

Serous MembranesSerous Membranes


• Purpose: provide lubrication between the two membranes• Ultrafiltrate of plasma• Produced by hydrostatic and oncotic (protein) pressure in

the capillaries lining the membranes• Normally, oncotic pressure is the same on both sides of

the membrane; hydrostatic pressure causes the production

• Small amounts of excess fluid are absorbed by lymphatic capillaries

FormationFormation


Formation and Absorption Formation and Absorption of Serous Fluidof Serous Fluid


• Disruption causes fluid buildup; termed effusion– Causes: hydrostatic pressure increased from

congestive heart failure; oncotic pressure decreased from hypoproteinemia; increased capillary permeability from inflammation, infection, malignancy; lymphatic obstruction from tumors

FormationFormation


• Disruption of the mechanisms of serous fluid formation and reabsorption

• Increased capillary hydrostatic pressure– Congestive heart failure, salt and fluid retention

• Decreased oncotic pressure– Nephrotic syndrome, hepatic cirrhosis– Malnutrition, protein-losing enteropathy

• Increased capillary permeability– Microbial infections, membrane inflammations– Malignancy

• Lymphatic obstruction– Malignant tumors, lymphomas, infection and inflammation, thoracic duct

injury

Pathological Causes of Effusions Pathological Causes of Effusions


• Collected by needle aspiration– Thoracentesis: pleural cavity– Pericardiocentesis: heart cavity– Paracentesis: peritoneal cavity

• Abundant fluid collected >100 mL• EDTA tube: hematology• Sterile heparinized or polyanethol sulfonate (SPS):

microbiology, cytology• Clotted or heparin: chemistry, serology

Specimen Collection Specimen Collection and Handlingand Handling


• Specimens for pH must be kept on ice• Concentrate fluid for microbiology and cytology

by centrifuging 100 mL• Chemical tests compared with blood tests drawn

at the same time

Specimen Collection Specimen Collection and Handling (cont'd)and Handling (cont'd)


• Primary classification of serous fluids• Transudates: systemic disorder disrupts filtration

and reabsorption, congestive heart failure, nephrotic syndrome

• Exudates: conditions affecting membranes, inflammation, infection, malignancy

• Differentiation important for further testing• Transudates = little further testing

Transudates and ExudatesTransudates and Exudates


Transudate Exudate

Appearance Clear Cloudy

Fluid:serum protein ratio <0.5 >0.5

Fluid:serum LD ratio <0.6 >0.6

White blood cell count <1000/µL >1000/µL

Spontaneous clotting No Possible

Pleural fluid cholesterol <45 to 60 mg/dL >45 to 60 mg/dL

Pleural fluid:serum cholesterol ratio <0.3 >0.3

Pleural fluid:bilirubin ratio <0.6 >0.6

Serum-ascites albumin gradient >1.1 <1.1

Laboratory Differentiation of Laboratory Differentiation of Transudates and Exudates Transudates and Exudates


• Appearance• Transudate versus exudate tests first

– Transudates: seldom tested further– Exudates: microbiology, cytology, and tests for

general symptoms– Differentials performed routinely on cytocentrifuged

specimens • White blood cells (WBCs), normal tissue cells, malignant

cells

General Laboratory TestsGeneral Laboratory Tests


• Additional transudate versus exudate tests– Pleural fluid cholesterol <60 mg/dL versus >60 mg/dL– Fluid-serum cholesterol ratio <0.3 versus >0.3– Fluid-serum bilirubin ratio <0.6 versus >0.6

• Appearance– Normal: clear, pale yellow– Turbid: WBCs, inflammation, infection– Milky: chylous material from thoracic duct leakage,

pseudochylous material from chronic inflammations

Pleural FluidPleural Fluid


• Bloody: hemothorax (trauma), hemorrhagic effusion (membrane) damage

• Differentiate: do a hematocrit on fluid– >50% blood HCT is hemothorax: more blood– Membrane damage: low blood

• Differentiate chylous and pseudochylous– Chylous is triglycerides; stain with Sudan III– Pseudochylous is cholesterol; polarize and crystals also

seen in wet bright-field view

Pleural Fluid Pleural Fluid (cont’d)(cont’d)


Appearance Disease

Clear, pale yellow Normal

Turbid, white Microbial infection (tuberculosis)

Bloody Hemothorax, hemorrhagic effusion, pulmonary emboli, tuberculosis, malignancy

Milky Chylous material from thoracic duct leakage Pseudochylous material from chronic inflammation

Brown Rupture of amoebic liver abscess

Black Aspergillus

Viscous Malignant mesothelioma (increased hyaluronic acid)

Correlation of Pleural Fluid Correlation of Pleural Fluid Appearance and Disease Appearance and Disease


• Differential: primary cells are neutrophils, lymphocytes, macrophages, eosinophils, mesothelial cells, plasma cells, and malignant cells• Macrophages (scavengers) often the highest

• ↑ Neutrophils: bacterial infection, pancreatitis, pulmonary infarction

• ↑ Lymphs: TB, viral infections, autoimmune disorders, malignancy

• Eosinophils: trauma introducing air and blood, allergic reactions, parasites

Hematology TestsHematology Tests


Hematology Tests Hematology Tests (cont’d)(cont’d)

• Mesothelial cells: single cell layer lines membranes, common to see in serous fluid, pleomorphic, dark blue cytoplasm, round nuclei, normal and reactive; “fried egg appearance”

• Reactive cells may be multinucleated



• Lack of mesothelial cells is significant in tuberculosis (TB), exudate covers membranes



• Pleural fluid: primary cancer cells

• Adenocarcinoma cells are large and irregular; small cell or oat cell carcinoma cells are small like lymph cells, mesothelioma cells are large



• Metastatic breast carcinoma cells seen in clumps

• Small cell carcinoma


• Glucose: decreased in inflammations and infections, have blood comparison

• pH: <7.0 indicates need for chest tubes, <6.0 indicates esophageal rupture (gastric fluid)

• Adenosine deaminase elevated in TB and malignancy

• Amylase: elevated in esophageal rupture and malignancy

Chemistry TestsChemistry Tests


Test Significance

Glucose Decreased in rheumatoid inflammation

Decreased in purulent infection

Lactate Elevated in bacterial infection

Triglyceride Elevated in chylous effusions

pH Decreased in pneumonia not responding to antibiotics

Markedly decreased with esophageal rupture

ADA Elevated in tuberculosis and malignancy

Amylase Elevated in pancreatitis, esophageal rupture, and malignancy

Significance of Chemical Testing Significance of Chemical Testing of Pleural Fluidof Pleural Fluid


• Gram stains and aerobic and anaerobic cultures on fluid, TB smears, and cultures

• Serology tests for autoimmune disorders• Tumor markers for metastatic malignancy

– Carcinoembryonic antigen: gastrointestinal malignancy

– CA125: uterine and ovarian malignancy

Microbiology and Serology TestsMicrobiology and Serology Tests


Pleural Fluid Testing AlgorithmPleural Fluid Testing Algorithm


• Normally small amount: 10 to 50 mL• Permeability of membranes from infection

(pericarditis, endocarditis), malignancy, trauma produces exudates

• Transudates: hypothyroidism, uremia, immune disorders

• Detect by cardiac tamponade (compression) heard by physician

Pericardial FluidPericardial Fluid


• Appearance: normal clear, pale yellow• Turbid: infection, malignancy (also blood

streaked)• Bloody: accidental puncture, anticoagulants• Milky: chylous and pseudochylous material• Fluid-serum protein and LD ratios for transudate

versus exudate differentiation• WBCs >1000/μL is bacterial endocarditis

Pericardial Fluid Pericardial Fluid (cont’d)(cont’d)


• Malignant cells are metastatic from lung and breast

• Gram stains and cultures for endocarditis often caused by previous respiratory infections

• TB smears and cultures done in AIDS




• Metastatic giant mesothelioma cell also seen in pleural fluid as a primary malignancy in persons with asbestos contact


Test Significance

Appearance

Clear, pale yellow Normal, transudate

Blood streaked Infection, malignancy

Grossly bloody Cardiac puncture, anticoagulants

Milky Chylous and pseudochylous material

Differential

Increased neutrophils Bacterial endocarditis

Malignant cells Metastatic carcinoma

Carcinoembryonic antigen Metastatic carcinoma

Gram stain and culture Bacterial endocarditis

Acid-fast stain Tubercular effusion

Adenosine deaminase Tubercular effusion

Significance of Pericardial Significance of Pericardial Fluid Testing Fluid Testing


• Effusion between the peritoneal membranes is called ascites

• Fluid is often called ascitic fluid• Transudates: hepatic origin (cirrhosis)• Exudates: bacterial peritonitis from intestinal

perforation, ruptured appendix, and malignancy

Peritoneal FluidPeritoneal Fluid


• Performed to detect early abdominal bleeding and need for surgery

• Blunt trauma injuries• Normal saline injected into cavity, withdrawn,

and red blood cell (RBC) count performed• RBC count >100,000 indicates blunt trauma case• Radiographic procedures also available

Peritoneal LavagePeritoneal Lavage


• More difficult than pleural and pericardial fluids• Serum-ascites gradient is best differentiation• Serum and fluid albumin levels are measured;

fluid level is subtracted from serum level; difference (gradient) > than 1.1 is a transudate (hepatic origin)

• Serum albumin 3.8 – fluid albumin 1.2 = 2.6 = hepatic transudate

Transudates and ExudatesTransudates and Exudates


• Normal: clear, pale yellow• Turbid: bacterial and fungal infections• Green-brown color = bile• Milky: chylous and pseudochylous with trauma and

lymphatic blockage• WBC count: normal 350 cells/μL• Absolute neutrophil count: >50% of total WBC count or

greater than 250 cells indicates infection• Lymphocytes elevated in TB

AppearanceAppearance


Cellular Examination Cellular Examination

• Cells: WBCs, mesothelial cells, macrophages (lipophages)

• Yeast cells and Toxoplasma gondii

• Malignant cells, often contain mucin vacuoles


Cellular Examination Cellular Examination (cont’d)(cont’d)

• Malignant cells of prostate, gastrointestinal, and ovarian origin


Cellular Examination Cellular Examination (cont’d)(cont’d)

• Psammoma bodies benign or cancer of thyroid and ovaries


• Glucose: below plasma levels = peritonitis and malignancy

• ↑ Amylase: pancreatitis, gastrointestinal perforation

• ↑ Alkaline phosphatase: intestinal perforation• ↑ BUN, creatinine: ruptured bladder, accidental

perforation

Chemical TestsChemical Tests


• Gram stains and aerobic and anaerobic cultures• Anaerobic cultures: inoculate blood culture

bottle at bedside• Acid-fast smear, adenosine deaminase and

culture for TB

Microbiology TestsMicrobiology Tests


• Tumor markers – CEA – CA 125

• Presence of CA 125 antigen with a negative CEA suggests the source is from the ovaries, fallopian tubes, or endometrium

• Presence of CEA antigen suggests source is gastrointestinal

Serological TestsSerological Tests

copyright © 2014. f.a. davis company chapter 12 serous fluid

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