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MEDiscuss • Other Topics • Pleural effusion and ascites fluid analysis


  1. #1
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    Lightbulb Pleural effusion and ascites fluid analysis

    Pleural and ascites fluid are frequently analyzed for diagnosis. Much can be learnt about a patient's condition by these fluid analyses.

    Let's discuss the principles of fluid analysis here.

    Please use your own words and do not copy/paste from another source.

  2. #2
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    Pleural and ascitic fluid analysis

    Pleural fluid analysis:


    [FONT=Times New Roman]Microscopy[/FONT]
    • [FONT=Times New Roman]Red blood cell count >100,000 cells/mm3 suggests hemorrhagic fluid [/FONT]
    • [FONT=Times New Roman]White blood cell count >10,000 cells/mm3 certainly suggests infection [/FONT]
    [FONT=Times New Roman]Biochemistry[/FONT]
    [FONT=Times New Roman]By Light's criteria, which compare protein and LDH levels in pleural fluid with those in serum, an effusion is an exudate if it satisfies any one of the following:[/FONT]
    • [FONT=Times New Roman]If ratio of pleural fluid protein to serum protein is >0.5 [/FONT]
    • [FONT=Times New Roman]If pleural fluid lactate dehydrogenase (LDH) is >200 international units or two-thirds of the upper limit of normal [/FONT]
    • [FONT=Times New Roman]If ratio of pleural fluid LDH to serum LDH is >0.6 [/FONT]
    [FONT=Times New Roman](Historically, a protein content <3.0g/dL was thought to denote a transudate and >3.0g/dL an exudate)[/FONT]
    [FONT=Times New Roman]Bacteriology[/FONT]
    • [FONT=Times New Roman]Gram stain and culture establishes etiology of infection [/FONT]
    • [FONT=Times New Roman]Sensitivity testing guides therapy [/FONT]
    • [FONT=Times New Roman]Acid-fast smears and cultures can identify tuberculosis [/FONT]
    [FONT=Times New Roman]Cytology[/FONT]
    • [FONT=Times New Roman]Sample is collected in a 50mL heparinized bottle [/FONT]
    • [FONT=Times New Roman]Taking three samples maximizes chance of positive findings (to 80% of malignant cases) [/FONT]
    • [FONT=Times New Roman]malignant cells are found in two-thirds of effusions due to bronchogenic or breast cancer but in only 15% of those due to lymphoma [/FONT]
    [FONT=Times New Roman]Cause of abnormal result[/FONT]

    [FONT=Times New Roman]Visual inspection[/FONT]
    • [FONT=Times New Roman]Very clear fluid is likely to be transudate [/FONT]
    • [FONT=Times New Roman]Dark fluid likely is to be exudate [/FONT]
    • [FONT=Times New Roman]Turbid or milky fluid likely to be pus from empyema or chyle [/FONT]
    • [FONT=Times New Roman]Uniformly blood-stained fluid likely to be hemorrhagic [/FONT]



    [FONT=Times New Roman]Microscopy[/FONT]
    [FONT=Times New Roman]Red blood cell count >100,000 cells/mm3 may be due to:[/FONT]
    • [FONT=Times New Roman]Malignancy [/FONT]
    • [FONT=Times New Roman]Trauma [/FONT]
    • [FONT=Times New Roman]Pulmonary embolism [/FONT]
    • [FONT=Times New Roman]Bleeding diathesis [/FONT]
    [FONT=Times New Roman]If white cell count is raised with neutrophils >50%:[/FONT]
    • [FONT=Times New Roman]Acute pleuritis or other pyogenic infection [/FONT]
    [FONT=Times New Roman]If white cell count is raised with lymphocytes >90%:[/FONT]
    • [FONT=Times New Roman]Tuberculosis [/FONT]
    • [FONT=Times New Roman]Lymphoma or other malignancies [/FONT]
    [FONT=Times New Roman]If white cell count is raised with eosinophils >10%:[/FONT]
    • [FONT=Times New Roman]Asbestos effusions [/FONT]
    • [FONT=Times New Roman]Resolving infections [/FONT]
    • [FONT=Times New Roman]Pneumothorax [/FONT]
    [FONT=Times New Roman]If mesothelial cells are absent:[/FONT]
    • [FONT=Times New Roman]Tuberculosis [/FONT]
    [FONT=Times New Roman]Biochemistry[/FONT]
    [FONT=Times New Roman]Any one of the following criteria denotes an exudate:[/FONT]
    • [FONT=Times New Roman]Ratio of pleural fluid protein to serum protein is >0.5 [/FONT]
    • [FONT=Times New Roman]Pleural fluid lactate dehydrogenase (LDH) is >200 international units or two-thirds of the upper limit of normal [/FONT]
    • [FONT=Times New Roman]Ratio of pleural fluid LDH to serum LDH is >0.6 [/FONT]
    [FONT=Times New Roman]Glucose <60mg/dL:[/FONT]
    • [FONT=Times New Roman]Rheumatoid-related effusions [/FONT]
    • [FONT=Times New Roman]Tuberculosis [/FONT]
    • [FONT=Times New Roman]Empyema [/FONT]
    • [FONT=Times New Roman]Malignancy [/FONT]


    [FONT=Times New Roman]pH <7.2:[/FONT]
    • [FONT=Times New Roman]Malignancy [/FONT]
    • [FONT=Times New Roman]Tuberculosis [/FONT]
    • [FONT=Times New Roman]Empyema [/FONT]
    • [FONT=Times New Roman]Esophageal rupture [/FONT]
    [FONT=Times New Roman]Amylase - ratio of pleural fluid amylase to serum amylase >1.0:[/FONT]
    • [FONT=Times New Roman]Pancreatitis, malignancy, and esophageal rupture [/FONT]
    [FONT=Times New Roman]Bacteriology[/FONT]
    • [FONT=Times New Roman]Positive Gram stain or culture provides likely etiology of infection [/FONT]
    [FONT=Times New Roman]Cytology[/FONT]
    • [FONT=Times New Roman]Positive identification of malignant cells proves etiology [/FONT]
    [FONT=Times New Roman]Others[/FONT]
    • [FONT=Times New Roman]Antinuclear antibodies - ratio of pleural fluid antinuclear antibodies to serum antinuclear antibodies >1.0 suggests systemic lupus erythematosus [/FONT]
    • [FONT=Times New Roman]Rheumatoid factor >640 suggests rheumatoid-related effusion [/FONT]
    • [FONT=Times New Roman]Hyaluronic acid >1mg/mL is highly suggestive of mesothelioma (and other malignancies) [/FONT]
    • [FONT=Times New Roman]Adenosine deaminase >70 international units suggests tuberculosis [/FONT]

    [FONT=Times New Roman]Ascitic fluid analysis:[/FONT]


    [FONT=Times New Roman]Gross appearance:[/FONT]

    [FONT=Times New Roman]1) clear, straw coloured or light green [/FONT]
    [FONT=Times New Roman]Cirrhosis, CCF, nephrotic syndro[/FONT][FONT=Times New Roman]me [/FONT]

    [FONT=Times New Roman]2)hemorrhagic[/FONT]
    [FONT=Times New Roman]malignancy, TB, pancreatitis[/FONT]

    [FONT=Times New Roman]3)cloudy, turbid[/FONT]
    [FONT=Times New Roman]bacterial peritonitis[/FONT]

    [FONT=Times New Roman]4)deep green[/FONT]
    [FONT=Times New Roman]biliary leak[/FONT]

    [FONT=Times New Roman]5)milky white[/FONT]
    [FONT=Times New Roman]lymphatic obstruction [/FONT]

    [FONT=Times New Roman]Specific gravity:[/FONT]

    [FONT=Times New Roman]1) less than 1.016 in transudate[/FONT]
    [FONT=Times New Roman]2)more than 1.016 in exudate[/FONT]

    [FONT=Times New Roman]Protein:[/FONT]

    [FONT=Times New Roman]1)less than 2.5g/dl in transudate[/FONT]
    [FONT=Times New Roman]2)more than 2.5g/dl in exudate[/FONT]

    [FONT=Times New Roman]Glucose:[/FONT]

    [FONT=Times New Roman]low in malignancy, TB, peritonitis[/FONT]

    [FONT=Times New Roman]Amylase activity:[/FONT]

    [FONT=Times New Roman]more than 1000U/L in pancreatitis[/FONT]

    [FONT=Times New Roman]Microscopy:[/FONT]

    [FONT=Times New Roman]1) neutrophils[/FONT]
    [FONT=Times New Roman]less than 250mm3 in cirrhosis[/FONT]
    [FONT=Times New Roman]more than 250mm3 in bacterial peritonitis[/FONT]

    [FONT=Times New Roman]2)lymphocytes[/FONT]
    [FONT=Times New Roman]TB,malignancy[/FONT]

    [FONT=Times New Roman]3)ZN staining[/FONT]
    [FONT=Times New Roman]TB[/FONT]

    [FONT=Times New Roman]4) grams stain[/FONT]
    [FONT=Times New Roman]bacterial peritonitis[/FONT]

    [FONT=Times New Roman]5)cytological examinaiton[/FONT]
    [FONT=Times New Roman]malignancy[/FONT]

    [FONT=Times New Roman]Culture:[/FONT]

    [FONT=Times New Roman]1)pyogenic bacteria[/FONT]
    [FONT=Times New Roman]bacterial peritonitis[/FONT]

    [FONT=Times New Roman]2)Acid fast bacteria[/FONT]
    [FONT=Times New Roman]TB[/FONT]

  3. #3
    amy
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    [FONT=Arial]Pleural effusion fluid analysis[/FONT]
    [FONT=Arial][/FONT]
    [FONT=Arial]Exudative[/FONT]
    [FONT=Arial][/FONT]
    [FONT=Arial]This is due to local factor that influence the formation and absorption of fluid alteration ( eg : infection , malignancy )[/FONT]
    • [FONT=Arial]Pleural fluid/serum protein > 0.5 or absolute value > 3 g/dl. [/FONT]

    • [FONT=Arial]Pleural fluid/serum LDH > 0.6 or absolute value > 0.45 upper normal serum limit [/FONT]

    • [FONT=Arial]Pleural fluid specific gravity > 1.018 [/FONT]

    [FONT=Arial]Transudative[/FONT]
    [FONT=Arial][/FONT]
    [FONT=Arial]This is due to systemic factor that influence the formation and absorption of fluid alteration [/FONT]
    • [FONT=Arial]Pleural fluid/serum protein < 0.5 or absolute value < 3 g/dl. [/FONT]

    • [FONT=Arial]Pleural fluid/serum LDH < 0.6 or absolute value < 0.45 upper normal serum limit [/FONT]

    • [FONT=Arial]Pleural fluid specific gravity < 1.018 [/FONT]

    [FONT=Arial]Once an effusion is categorized as transudative or exudative, etiologic considerations narrow. Additional pleural fluid studies that help to establish a diagnosis include glucose, amylase, white blood cell counts with differential, and cytologic and microbiologic examination.[/FONT]

    [FONT=Arial]Ascites fluid analysis[/FONT]

    [FONT=Arial]The ascitic fluid should be analyzed for:[/FONT]
    1. [FONT=Arial]The serum-ascitic albumin gradient (SAAG)[/FONT][FONT=Arial] is calculated by subtracting the albumim concentration of the ascitic fluid from the albumin concentration of a serum specimen obtained on the same day. [/FONT]

    1. [FONT=Arial]The amylase concentration[/FONT][FONT=Arial] which is elevated in pancreatic ascites.[/FONT]

    1. [FONT=Arial]The triglyceride concentration[/FONT][FONT=Arial] which is elevated is chylous ascites. [/FONT]

    1. [FONT=Arial]White cell count [/FONT][FONT=Arial]when greater than 350/microliter is suggestive of infection. If most cells are polymorphonuclear, bacterial infection should be suspected. When mononuclear cells predominated , tuberculosis or fungal infection is likely. [/FONT]

    1. [FONT=Arial]Red cell count[/FONT][FONT=Arial] When greater than 50.000/microliter denotes hemorrhagic ascites, which usually is due to malignancy, tuberculosis or trauma. [/FONT]

    1. [FONT=Arial]Gram stain and culture[/FONT][FONT=Arial] which can confirm the diagnosis of bacterial infection. [/FONT]

    1. [FONT=Arial]pH[/FONT][FONT=Arial] when less than 7 suggests bacterial infection [/FONT]

    1. [FONT=Arial]Cytology[/FONT][FONT=Arial] can be positive in malignancy.[/FONT]
    [FONT=Arial]The serum-ascitic albumin gradient correlates directly with portal pressure, and patients with gradients greater than or equal to 1.1 g/dl have portal hypertension (transudative ascites) and patients with gradients lesser than 1.1 g/dl do not (exudative ascites). The total protein concentration of ascitic fluid and LDH activity has been traditionally used to classify ascitic fluid in exudate or transudate [/FONT]




  4. #4
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    Pleural Fluid And Ascites Fluid Analysis

    [FONT=Times New Roman]PLEURAL FLUID ANALYSIS[/FONT]
    [FONT=Times New Roman]The fluid is evaluated for the following:[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]TRANSUDATE VERSUS EXUDATE[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman] TRANSUDATE[/FONT]
    [FONT=Times New Roman]Transudative pleural effusions are caused by systemic factors that alter the balance of the formation and absorption of pleural fluid[/FONT]
    [FONT=Times New Roman]Eg: Congestive Cardiac Failure[/FONT]
    [FONT=Times New Roman] Nephrotic Syndrome[/FONT]
    [FONT=Times New Roman] Cirrhosis[/FONT]
    [FONT=Times New Roman]EXUDATE[/FONT]
    [FONT=Times New Roman]Exudative pleural effusions are caused by alterations in local factors that influence the formation and absorption of pleural fluid.[/FONT]
    [FONT=Times New Roman]Eg : A) Above the diaphragm[/FONT]
    [FONT=Times New Roman] -Tuberculosis[/FONT]
    [FONT=Times New Roman] -Pyogenic infections : pneumonia,lung abscess, bronchiectasis,septicaemia[/FONT]
    [FONT=Times New Roman] -Viral and fungal infections[/FONT]
    [FONT=Times New Roman] -Pulmonary infection[/FONT]
    [FONT=Times New Roman] -Neoplasms[/FONT]
    [FONT=Times New Roman] -Chest wall affections –trauma,tuberculous osteitis[/FONT]
    [FONT=Times New Roman] -Post myocardial infarction syndrome[/FONT]
    [FONT=Times New Roman] -Rupture of esophagus[/FONT]

    [FONT=Times New Roman] B) Below the diaphragm[/FONT]
    [FONT=Times New Roman] -Ameobic liver abscess[/FONT]
    [FONT=Times New Roman] -Subdiaphragmatic abscess [/FONT]
    [FONT=Times New Roman] - Acute pancreatitis[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman] C) Systemic disorders :[/FONT]
    [FONT=Times New Roman] -collagen disease : SLE , Rheumatoid arthritis, polyarthritis[/FONT]
    [FONT=Times New Roman] -septicaemia[/FONT]
    [FONT=Times New Roman] -drug allergy[/FONT]
    [FONT=Times New Roman] -bleeding disorders[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]SPECIFIC FEATURES OF DIFFERENT PLEURAL EFFUSIONS[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]1) GROSS[/FONT]

    [FONT=Times New Roman]A) Purulent[/FONT]
    [FONT=Times New Roman]B) Haemorrhagic[/FONT]
    [FONT=Times New Roman]C) Milky[/FONT]
    [FONT=Times New Roman]D) Greenish : pseudomonas,streptococcus,pneumococcus[/FONT]
    [FONT=Times New Roman]E) Gold Paint : myxedema[/FONT]
    [FONT=Times New Roman]F) Anchovy sauce pus –ruptured amebic liver abscess[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]2) MICROSCOPIC[/FONT]

    [FONT=Times New Roman]A) Lymphocytic predominance : [/FONT]
    [FONT=Times New Roman]Chronic conditions like TB,resolving pneumonia,fungal infections,[/FONT]
    [FONT=Times New Roman]Carcinoma and myxedema.[/FONT]
    [FONT=Times New Roman]B) Polymorphic predominance : Acute conditions like acute bacterial [/FONT]
    [FONT=Times New Roman]Infections and rheumatic fever.[/FONT]
    [FONT=Times New Roman]C) Eosinophilic predominance[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]3) BIOCHEMICAL INVESTIGATIONS[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]A) proteins more than 3gm%-exudate; less than 3gm%-transudate[/FONT]
    [FONT=Times New Roman]B) sugar diminished in rheumatoid arthritis[/FONT]
    [FONT=Times New Roman]C) LDH increased in tuberculosis effusion[/FONT]
    [FONT=Times New Roman]D) Amylase increased pancreatitis,rupture of esophagus and salivary [/FONT]
    [FONT=Times New Roman]Gland abscess.[/FONT]
    [FONT=Times New Roman]E) Adenosine deaminase activity increased in tuberculous effusion.[/FONT]
    [FONT=Times New Roman]F) Hyaluronidase is increased in mesothelioma of pleura.[/FONT]
    [FONT=Times New Roman]G) Light’s criteria using serum and pleural fluid protein and LDH ratio[/FONT]
    [FONT=Times New Roman]Used to differentiate transudate from exudate.[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]Transudative :[/FONT]

    [FONT=Symbol]· [/FONT][FONT=Times New Roman]Pleural fluid/serum protein < 0.5 or absolute value < 3 g/dl. [/FONT]
    [FONT=Symbol]· [/FONT][FONT=Times New Roman]Pleural fluid/serum LDH < 0.6 or absolute value < 0.45 upper normal serum limit [/FONT]
    [FONT=Symbol]· [/FONT][FONT=Times New Roman]Pleural fluid specific gravity < 1.018 [/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]Exudative :[/FONT]

    • [FONT=Times New Roman]Pleural fluid/serum protein > 0.5 or absolute value > 3 g/dl. [/FONT]
    • [FONT=Times New Roman]Pleural fluid/serum LDH > 0.6 or absolute value > 0.45 upper normal serum limit [/FONT]
    • [FONT=Times New Roman]Pleural fluid specific gravity > 1.018 [/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]ASCITES FLUID ANALYSIS[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman] Etiology[/FONT]
    [FONT=Times New Roman]The main causes of ascites include the following conditions:[/FONT]
    • [FONT=Times New Roman]Hepatic - cirrhosis, veno-occlusive disease [/FONT]
    • [FONT=Times New Roman]Cardiac - right ventricular failure, constrictive pericarditis [/FONT]
    • [FONT=Times New Roman]Renal - nephrotic syndrome, renal failure [/FONT]
    • [FONT=Times New Roman]Malignancy - ovarian, gastric, colorectal carcinoma [/FONT]
    • [FONT=Times New Roman]Infection - tuberculosis [/FONT]
    • [FONT=Times New Roman]Pancreatitis [/FONT]
    • [FONT=Times New Roman]Lymphatic - congenital anomaly, trauma [/FONT]
    • [FONT=Times New Roman]Malnutrition [/FONT]
    • [FONT=Times New Roman]Myxoedema [/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]Investigation[/FONT]
    [FONT=Times New Roman]A diagnostic peritoneal tap allows peritoneal fluid to be sent for:[/FONT]
    • [FONT=Times New Roman]Protein estimation [/FONT]
    • [FONT=Times New Roman]A transudate has a total protein < 30 g/l - cirrhosis, heart failure [/FONT]
    • [FONT=Times New Roman]An exudate has a total protein > 30 g/l - carcinomatosis, infection [/FONT]
    • [FONT=Times New Roman]Cytology [/FONT]
    • [FONT=Times New Roman]Bacteriology [/FONT]
    • [FONT=Times New Roman]Biochemistry - amylase, CEA [/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]SPECIFIC FEATURES IN DIFFERENT ASCITES FLUID[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]GROSS :[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]Clear- transudative[/FONT]
    [FONT=Times New Roman]Turbid- purulent-abdominal infections,pyemia,septocaemia,rupture or perforation of organ,ruptured amoebic abscess,pelvic inflammatory disease [/FONT]
    [FONT=Times New Roman]Straw- ccf,nephritic syndrome,cirrhosis[/FONT]
    [FONT=Times New Roman]Haemorrhagic-malignancy,tuberculosis,trauma,pancreatitis[/FONT]
    [FONT=Times New Roman]Deep green : biliary leak[/FONT]
    [FONT=Times New Roman]Milky white : Lymphatic obstruction[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]MICROSCOPY[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]Lymphocytic predominance – Tuberculosis,.[/FONT]
    [FONT=Times New Roman]Polymorphic predominance : Bacterial peritonitis[/FONT]
    [FONT=Times New Roman]Gram stain : bacterial peritonitis[/FONT]
    [FONT=Times New Roman]ZN staining : Acid fast bacilli-tuberculosis [/FONT]
    [FONT=Times New Roman]Cytology : malignancy[/FONT]
    [FONT=Times New Roman]Culture : bacterial peritonitis[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]BIOCHEMICAL[/FONT]
    [FONT=Times New Roman][/FONT]
    [FONT=Times New Roman]Proteins: > 3gm/dl – exudative[/FONT]
    [FONT=Times New Roman] <3gm/dl –transudative[/FONT]
    [FONT=Times New Roman]Specific gravity : >1.015-exudative[/FONT]
    [FONT=Times New Roman] <1.015 transudative[/FONT]
    [FONT=Times New Roman]Glucose : decreased in malignancy,TB and bacterial peritonitis[/FONT]
    [FONT=Times New Roman]Amylase : >1000U/l inpancreatitis[/FONT]
    [FONT=Times New Roman]Carcinoembryonic antigen(CEA) : Colorectal carcinoma[/FONT]

  5. #5
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    Pleural effusion fluid analysis

    Pleural fluid is collected in the pleural space.
    A sample of pleural fluid is obtained by a procedure called thoracentesis.

    Transudative effusions are caused by some combination of increased hydrostatic pressure and decreased oncotic pressure in the pulmonary or systemic circulation. Heart failure is the most common cause, followed by cirrhosis with ascites and hypoalbuminemia, usually from the nephrotic syndrome.

    Exudative effusions are caused by local processes leading to increased capillary permeability resulting in exudation of fluid, protein, cells, and other serum constituents. Causes are numerous, the most common being pneumonia, malignancy, pulmonary embolism, viral infection, and TB.

    Normal pleural fluid has the following characteristics:
    • clear ultrafiltrate of plasma
    • pH 7.60-7.64
    • protein content less than 2% (1-2 g/dL)
    • fewer than 1000 WBCs per cubic millimeter
    • glucose content similar to that of plasma
    • lactate dehydrogenase (LDH) level less than 50% of plasma and sodium
    • potassium and calcium concentration similar to that of the interstitial fluid
    Exudative
    • Pleural fluid/serum protein > 0.5 or absolute value > 3 g/dl.
    • Pleural fluid/serum LDH > 0.6 or absolute value > 0.45 upper normal serum limit
    • Pleural fluid specific gravity > 1.018
    Transudative
    • Pleural fluid/serum protein < 0.5 or absolute value < 3 g/dl.
    • Pleural fluid/serum LDH < 0.6 or absolute value < 0.45 upper normal serum limit
    • Pleural fluid specific gravity < 1.018
    Ascites fluid analysis
    Ascites is the presence of excess fluid in the peritoneal cavity.
    Causes
    1. Peritoneal source
      1. TB
      2. Bacterial, fungal or parasitic disease
      3. Cancer
      4. Vasculitis
      5. Whipple's Disease
      6. Familial Mediterranean fever
      7. Endometriosis
      8. Starch peritonitis
    2. Extra-peritoneal source
      1. Cirrhosis
      2. CCF
      3. Budd Chiari Syndrome
      4. Hypoalbuminemia
        1. Nephrotic Syndrome
        2. Protein-losing enteropathy
        3. Malnutrition
      5. Ovarian disease (e.g. Meigs' Syndrome)
      6. Pancreatic disease
      7. Chylous
    Gross Appearance of Ascites
    • · Translucent or yellow - Normal/sterile
    • · Brown -Hyperbilirubinemia, Gallbladder or biliary perforation
    • · Cloudy or turbid – Infection
    • · Pink or blood tinged - Mild trauma at the site
    • · Grossly bloody - Malignancy or Abdominal trauma
    • Milky ("chylous") – Cirrhosis, Thoracic duct injury, Lymphoma
    Analysis
    • Cell count: Leukocyte>500/cc or absolute neutrophil >250/cc suggests infection.
    • Protein < 1g/dL in spontaneous peritonitis; >1 g/dL in secondary peritonitis.
    • Glucose <50 mg/dL or increased LDH in secondary peritonitis.
    • Albumin serum-ascites gradient = serum albumin - ascitic albumin
      - Gradient of > 1.1 g/dL suggests portal hypertension; seen in cirrhosis, alcoholic hepatitis, CHF, massive liver metastasis, fulminant liver failure, portal-veiin thrombosis, Budd-Chiari synd, veno-occlusive disease, fatty liver of pregnancy, myxedema.
      - Gradient of < 1.1 g/dL seen in peritoneal carcinomatosis, TB, pancreatic ascites, biliary ascites, nephrotic synd, bowel obstruction or infarction, serositis.
    • Gram stain & C/S
    • Amylase in pancreatic or perforation.
    • Cytology or TB smear & culture

  6. #6
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    Pleural effusion and Ascities fluid analysis

    [FONT=Comic Sans MS]Pleural effusion [/FONT]
    [FONT=Comic Sans MS]- accumulation of serous fluid within the pleural space.[/FONT]

    [FONT=Comic Sans MS]This can be caused by:[/FONT]

    [FONT=Times New Roman][FONT=Comic Sans MS]1) Accumulation of fluid occurs due to local factors which influence the formation and absorption of pleural fluid[/FONT]. [/FONT][FONT=Comic Sans MS]----- exudative pleural fluid.[/FONT]

    [FONT=Comic Sans MS]CAUSES: [/FONT]
    • [FONT=Comic Sans MS]malignancy (e.g bronchial carcinoma, lymphoma, metastatic tumor)[/FONT]
    • [FONT=Comic Sans MS]Inflamatorry processes:-[/FONT]
    1. [FONT=Comic Sans MS]Infections (e.g. TB, pneumonia)[/FONT]
    2. [FONT=Comic Sans MS]Pulmonary embolic disease[/FONT]
    3. [FONT=Comic Sans MS]Collagen vascular disease (e.g. rheumatoid arthritis)[/FONT]
    4. [FONT=Comic Sans MS]Subdiaphragmatic process[/FONT]
    5. [FONT=Comic Sans MS]Asbestosis[/FONT]
    6. [FONT=Comic Sans MS]Pancreatitis[/FONT]
    7. [FONT=Comic Sans MS]Hypothyroidism[/FONT]
    [FONT=Comic Sans MS]2) Accumulation of fluid occurs due to systemic factors which alter the balance of the formation and absorption of pleural fluid-----------transudative pleural effusion[/FONT]


    [FONT=Comic Sans MS]CAUSES:[/FONT]
    1. [FONT=Comic Sans MS]Decrease plasma oncotic pressure[/FONT]
    2. [FONT=Comic Sans MS]Nephrotic syndrome[/FONT]
    3. [FONT=Comic Sans MS]Cirrhosis[/FONT]
    4. [FONT=Comic Sans MS]Increase hydrostatic pressure[/FONT]
    5. [FONT=Comic Sans MS]Congestive heart failure[/FONT]
    [FONT=Comic Sans MS]The procedure for collection of pleural fluid is called thoracenthesis.[/FONT]
    [FONT=Comic Sans MS]The fluid collected is evaluated for the following: [/FONT]
    • [FONT=Comic Sans MS]Cell count and differential culture and sensitivity[/FONT]
    • [FONT=Comic Sans MS]Chemical composition including proteins, albumin, amylase, pH, glucose and lactate dehydrogenase[/FONT]
    • [FONT=Comic Sans MS]Gram staining and culture and sensitivity to identify possible bacterial infections [/FONT]
    • [FONT=Comic Sans MS]Cytology to identify cancer cells, but may also identify some infective organisms [/FONT]
    [FONT=Comic Sans MS]Features of pleural fluid:[/FONT]

    [FONT=Comic Sans MS]1) Appreance[/FONT]
    [FONT=Comic Sans MS]A) Serous[/FONT]
    [FONT=Comic Sans MS]-amber cloured - TB[/FONT]
    [FONT=Comic Sans MS]- straw coloured - Cardiac failure[/FONT]
    [FONT=Comic Sans MS]B) Milky - obstruction of thoracic duct [/FONT]
    [FONT=Comic Sans MS]C) Blood stained - malignancy, acute pancreatitis[/FONT]
    [FONT=Comic Sans MS]D) Greenish - pseudomonas,pneumococcus, streptococus[/FONT]
    [FONT=Comic Sans MS]F) Anchovy sauce pus – ruptured amebic liver abscess[/FONT]

    [FONT=Comic Sans MS]2) microscopy[/FONT]

    [FONT=Comic Sans MS]A)Polymorphic predominance : [/FONT]
    [FONT=Comic Sans MS]- Seen in actue conditions:[/FONT]
    [FONT=Comic Sans MS]Acute bacterial Infections and Rheumatic .[/FONT]
    [FONT=Comic Sans MS]B) Lymphocytic predominance : [/FONT]
    [FONT=Comic Sans MS]- Seen in chronic conditions:[/FONT]
    [FONT=Comic Sans MS]TB, resolving pneumonia, fungal infections, carcinoma, Rheumatoid Disease, [/FONT]
    [FONT=Comic Sans MS]SLE[/FONT]
    [FONT=Comic Sans MS]C) Eosinophilic predominance[/FONT]
    [FONT=Comic Sans MS]- Seen in pulmonary infarction[/FONT]

    [FONT=Comic Sans MS]3) biochemical [/FONT]
    [FONT=Comic Sans MS]Transudative [/FONT][FONT=Comic Sans MS]:[/FONT]

    [FONT=Comic Sans MS]· Pleural fluid/serum protein < 0.5 or absolute value < 3 g/dl. [/FONT]
    [FONT=Comic Sans MS]· Pleural fluid/serum LDH < 0.6 or absolute value < 0.45 upper normal serum limit [/FONT]
    [FONT=Comic Sans MS]· Pleural fluid specific gravity < 1.018 [/FONT]

    [FONT=Comic Sans MS]Exudative :[/FONT]
    • [FONT=Comic Sans MS]Pleural fluid/serum protein > 0.5 or absolute value > 3 g/dl. [/FONT]
    • [FONT=Comic Sans MS]Pleural fluid/serum LDH > 0.6 or absolute value > 0.45 upper normal serum limit [/FONT]
    • [FONT=Comic Sans MS]Pleural fluid specific gravity > 1.018 [/FONT]
    Ascities
    - accumulation of freefluid in the peritoneal cavity.

    [FONT=Times New Roman]Causes:[/FONT]
    [FONT=Times New Roman]Common causes[/FONT]
    • [FONT=Times New Roman]Malinant disease[/FONT][FONT=Times New Roman]- hepatic, [/FONT][FONT=Times New Roman]peritoneal malinancies[/FONT]
    • [FONT=Times New Roman]Cardiac failure[/FONT]
    • [FONT=Times New Roman]Hepatic cirrhosis[/FONT]
    [FONT=Times New Roman]Uncommon causes[/FONT]
    • [FONT=Times New Roman]Hypoproteinemia - [/FONT][FONT=Times New Roman]nephotic syndrome,[/FONT][FONT=Times New Roman]protein loosing enterpathy,[/FONT][FONT=Times New Roman]malnutrition[/FONT]
    • [FONT=Times New Roman]Hepatic venous occlusion[/FONT][FONT=Times New Roman]- Budd- chiari syndrome ,[/FONT][FONT=Times New Roman]Veno- occlusive disease[/FONT]
    • [FONT=Times New Roman]Pancreatitis[/FONT]
    • [FONT=Times New Roman]Lymphatic obstruction[/FONT]
    • [FONT=Times New Roman]Infection- TB[/FONT]
    [FONT=Comic Sans MS]Investigations:[/FONT]
    [FONT=Comic Sans MS]
    1. Diagnostic peritoneal tap is sent for :
    [/FONT]
    • [FONT=Comic Sans MS]Protein estimation [/FONT]
    [FONT=Comic Sans MS]- A transudate has a total protein < 30 g/l - cirrhosis, heart failure [/FONT]
    [FONT=Comic Sans MS]- An exudate has a total protein > 30 g/l - carcinomatosis, infection [/FONT]
    • [FONT=Comic Sans MS]Serum ascities < 11g/l[/FONT]
    • [FONT=Comic Sans MS]Cytology [/FONT]
    • [FONT=Comic Sans MS]Microscopy, bacteriology [/FONT]
    • [FONT=Comic Sans MS]Biochemistry - total albumin, amylase, CEA [/FONT]
    [FONT=Comic Sans MS]2. Apperance [/FONT]
    • [FONT=Comic Sans MS]Cirrhosis - clear/ straw coloured/ light green[/FONT]
    • [FONT=Comic Sans MS]Malignant disease - bloody[/FONT]
    • [FONT=Comic Sans MS]Infection - cloudy[/FONT]
    • [FONT=Comic Sans MS]Biliary communicatiob - heavy bile stained[/FONT]
    • [FONT=Comic Sans MS]Lymphatic onstruction - milky white[/FONT]
    [FONT=Comic Sans MS]3. Miroscopy[/FONT]
    • [FONT=Comic Sans MS]Lymphocytic predominance – Tuberculosis,[/FONT]
    • [FONT=Comic Sans MS]Polymorphic predominance : Bacterial peritonitis[/FONT]
    • [FONT=Comic Sans MS]Gram stain : bacterial peritonitis[/FONT]
    • [FONT=Comic Sans MS]ZN staining : Acid fast bacilli-tuberculosis [/FONT]
    • [FONT=Comic Sans MS]Cytology : malignancy[/FONT]
    • [FONT=Comic Sans MS]Culture : bacterial peritonitis[/FONT]
    [FONT=Comic Sans MS]4. Biochemical [/FONT]
    • [FONT=Comic Sans MS]Proteins: < 3gm/dl – transudative , [/FONT][FONT=Comic Sans MS]>3gm/dl – exudative[/FONT]
    • [FONT=Comic Sans MS]Specific gravity : <1.015-transudative , [/FONT][FONT=Comic Sans MS]> 1.015 exudative[/FONT]
    • [FONT=Comic Sans MS]Glucose : decreased in malignancy,TB and bacterial peritonitis[/FONT]
    • [FONT=Comic Sans MS]Amylase : >1000U/l inpancreatitis[/FONT]
    • [FONT=Comic Sans MS]Carcinoembryonic antigen(CEA) : Colorectal carcinoma[/FONT]

  7. #7
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    Pleural and ascites fluid analysis:

    Pleural fluid analysis:

    Normally, very small amounts of pleural fluid are present in the pleural spaces, and fluid is not detectable by routine methods. When certain disorders occur, excessive pleural fluid may accumulate and cause pulmonary signs and symptoms.

    Thoracentesis and Fluid analysis
    • Thoracentesis is a diagnostic procedure done in patients who have abnormal amounts of fluid accumulation in the pleural space.
    • The procedure is usually done at the bedside under local anesthesia.
    The needle is placed through the chest wall into the pleural space and fluid is then withdrawn into a syringe.

    Utility of test results:
    1) Exudate vs. transudate:
    (a) Fluid/serum protein ratio > 0.5
    (b) Fluid/serum LDH ration > 0.6
    (c) Fluid LDH > 2/3 upper normal serum LDH; exudates have 1 or more; transudates none these characteristics
    2) If LDH only is abnormal - consider malignancy or Para pneumonic effusion
    3) Protein may confuse: e.g., CHF
    4) <3 g/dl, but might be 3-4 g/dl if patient uses diuretics, or is chronic or recurrent
    5) WBC: rarely diagnostic alone; > 50,000 in Para pneumonic effusion, usually empyema; > 10,000 very inflammatory
    (a) Early, acute, PMN predominant
    (b) Later mononuclear - high counts suggest TB, carcinoma, lymphoma, sarcoidosis
    (c) Eosinophilia - 10% suggest benign, self- limited; commonly with air or blood in pleural space; consider: hemothorax, pulmonary infarction, pneumothorax, previous thoracentesis, parasitic diseases, fungi, drugs, asbestos; rare with TB or malignancy. In 1/3 "idiopathic"
    (d) Basophilia - 10%, rare; suggest leukemia
    6) Mesothelial cells - paucity of cells occurs with chronic diffuse pleural lesions, e.g., TB, malignancy, empyema rheumatoid effusion, pleurodesis. If > 5%, essentially rules out TB
    7) Bloody (> 100,000 cells/mm3): malignancy, trauma, pulmonary embolism, post-cardiac injury, asbestos pleurisy
    8) Cytology: yields nearly 90% with malignancy as cause

    Causes of pleural transudates
    • Congestive heart failure
    • Cirrhosis
    • Atelectasis
    • Nephrotic syndrome
    • Peritoneal dialysis
    • Myxedema
    • Constrictive pericarditis

    Causes of pleural exudates
    • Parapneumonic illness
    • Malignancy (carcinoma, lymphoma, mesothelioma)
    • Pulmonary embolism
    • Collagen vascular disease (rheumatic disease, lupus)
    • Tuberculosis
    • Asbestos-related illness
    • Pancreatitis, pseudocyst
    • Trauma
    • Postcardiac injury syndrome
    • Esophageal perforation
    • Radiation pleuritis
    • Drug-induced reactions
    • Chylothorax
    • Meig's syndrome


    Ascites fluid analysis

    Ascites is the presence of excess fluid in the peritoneal cavity. It is a common clinical finding with a wide range of causes, but develops most frequently as a part of the decompensation of previously asymptomatic chronic liver disease.

    Causes of ascites
    A) Incresased hydrostatic pressure
    • Cirrhosis
    • Hepatic vein occlusion(Budd-Chiari syndrome)
    • Inferior vena cava obstruction
    • Constrictive pericarditis
    • Congestive heart failure

    B) Decreased colloid osmotic pressure
    • End-stage liver disease with poor protein synthesis
    • Nephrotic syndrome with protein loss
    • Malnutrition
    • Protein-losing enteropathy

    C) Increased permeability of peritoneal capillaries
    • Tuberculous peritonitis
    • Bacterial peritonitis
    • Malignant disease of the peritoneum

    D) Leakage of fluid into the peritoneal cavity
    • Bile ascites
    • Pancreatic ascites(secondary to a leaking pseudocyst)
    • Chylous ascites
    • Urine ascites

    E) Miscellaneous causes
    • Myxedema
    • Ovarian disease(Meigs' syndrome)
    • Chronic hemodialysis

    Ascitic Fluid Analysis:
    The ascitic fluid should be analyzed for:
    1) The serum-ascitic albumin gradient (SAAG) is calculated by subtracting the albumim concentration of the ascitic fluid from the albumin concentration of a serum specimen obtained on the same day.
    2) The amylase concentration which is elevated in pancreatic ascites.
    3) The triglyceride concentration which is elevated is chylous ascites.
    4) White cell count when greater than 350/microliter is suggestive of infection. If most cells are polymorphonuclear, bacterial infection should be suspected. When mononuclear cells predominated , tuberculosis or fungal infection is likely.
    5) Red cell count When greater than 50.000/microliter denotes hemorrhagic ascites, which usually is due to malignancy, tuberculosis or trauma.
    6) Gram stain and culture which can confirm the diagnosis of bacterial infection.
    7) pH when less than 7 suggests bacterial infection
    8) Cytology can be positive in malignancy.

    A. Transudative ascites (Serum Albumin - Ascites Albumin >1.1 gm/dl)
    • Liver cirrhosis
    • Congestive heart failure
    • Hepativ vein obstruction (Budd Chiari syndrome)
    • Nephrotic syndrome
    • Meig's ovarian tumor syndrome
    • Constrictive pericarditis
    • Inferior vena cava obstruction
    • Viral hepatitis with submassive or massive hepatic necrosis

    B. Exudative ascites (Serum Albumin - Ascites Albumin <1.1 gm/dl)
    • Neoplastic diseases involving the peritoneum: Peritoneal carcinomatosis, Lymphomatous disorders
    • Tuberculous peritonitis
    • Pancreatitis
    • Post surgery talc or starch powder peritonitis
    • Transected lymphatics following portal caval shunt surgery
    • Myxedema
    • Sarcoidosis
    • Lymphatic obstruction: a. Intestinal lymphangiectasia, b. Lymphoma
    • Pseudomyxoma peritonei
    • Struma oovarii
    • Amyloidosis
    • Prior abdominal trauma with ruptured lymphatics
    • Hemodialysis CRF related ascites

    C. Disorders simulating ascites
    • Pancreatic pseudocyst
    • Hydronephrosis
    • Ovarian cyst
    • Mesenteric cyst
    • Obesity

  8. #8
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    Pleural Fluid Analysis
    1. Physical characteristics

    a. Color
    b. Turbidity
    c. Odor
    d. Presence of particulate matter

    2. Chemical characteristics - total protein content, specific gravity

    3. Cell counts - total nucleated cell count, red cell count, hematocrit

    4. Classify effusion

    5. Cytologic evaluation

    a. Is the effusion inflammatory or not?

    (1) Inflammatory effusions have 50% neutrophils

    (2) Causes of inflammatory effusions

    (a) Pyothorax, FIP
    (b) Chronic chylothorax
    (c) Neoplasia, lung lobe torsion

    b. Is the effusion septic?

    (1) Look for bacteria and degenerate neutrophils
    (2) Pyothorax is an example of septic pleural effusion

    c. Are neoplastic cells present?

    (1) Lymphoma is the only neoplastic pleural effusion that can be
    diagnosed via cytology alone
    (2) Other tumor cells (eg, metastatic adenocarcinoma) are easily
    confused with reactive mesothelial cells
    (3) Mesothelial cells exfoliate in response to mere presence of
    pleural effusion and may appear malignant
    (4) If nonlymphoid neoplasia is suspected on cytologic
    examination, it must be confirmed by finding similar cells from
    a mediastinal or pulmonary mass

    III. PATTERNS OF PLEURAL EFFUSION

    A. Pure Transudate

    1. Fluid characteristics

    a. Transparent (like water)
    b. Low total protein content, nucleated cell count
    c. With time effusion becomes modified
    (1) Cell count increases
    (2) Small lymphocytes, mesothelial cells, occasional neutrophil

    2. Diagnosis look for cause of hypoalbuminemia
    a. Severe hepatic dysfunction
    b. Protein losing enteropathies
    c. Glomerular disease

    B. Hemorrhagic Effusion (Hemothorax)

    1. Fluid characteristics
    a. Red, opaque effusion; clears on centrifugation
    b. Packed cell volume is usually at least 25% that of peripheral blood
    c. Cell counts similar to whole blood
    d. Cytologic evaluation 6 erythrocytes, mature neutrophils, and
    macrophages (may exhibit erythrophagocytosis)

    2. Causes of hemothorax
    a. Trauma (rib fracture, post thoracotomy)
    b. Coagulopathies (factor deficiences)
    c. Neoplasia (hemangiosarcoma, adenocarcinoma, others)
    d. Lung-lobe torsion

    3. Diagnosis
    a. Rule out trauma by history/physical examination

    b. Often have bleeding that involves other organs with coagulopathy
    (1) Melena, hematuria
    (2) Epistaxis
    (3) Hyphema/retinal hemorrhage
    (4) Hemarthrosis

    c. Perform coagulation studies
    (1) Platelet count, fibrinogen
    (2) Screening tests (PT, PTT)
    (3) PIVKA (Vitamin K antagonism)

    4. Treatment

    a. Treat underlying disease
    b. Transfusions (whole blood, plasma)

    C. Inflammatory Effusion
    1. Septic inflammation (pyothorax)

    a. Etiologic agents

    (1) Bacteroides spp, Fusobacterium spp (anaerobes) and
    Pasteurella multocida (aerobe) most common
    (2) Actinomyces spp, Nocardia spp most common

    b. Route of infection
    (1) Penetrating chest wounds
    (2) Perforation of mediastinal structures
    (3) Migrating foreign bodies
    (4) Direct extension from pneumonia

    c. Fluid characteristics
    (1) Reddish-brown to yellow
    (2) Opaque; clears on centrifugation
    (3) Exudative characteristics (Table 1)
    (4) Cytology - degenerative neutrophils, bacteria

    d. Diagnosis -submit samples for aerobic/anaerobic bacterial culture

    e. Treatment
    (1) Thoracostomy tube
    (a) Drain exudate (continuous vs. intermittent)
    (b) Thoracic lavage (twice daily using saline, LRS)

    (2) Antimicrobials
    (a) Ideally based on culture results
    (b) Treat for extended period
    (c) Empirical (awaiting culture or negative culture)
    i) Anaerobes -penicillins, metronidazole,
    clindamycin, chloramphenicol
    ii) Actinomyces, Pasteurella - penicillin
    iii) Nocardia - trimethoprim-sulfa

    2. Non-septic inflammation

    a. Causes
    (1) Feline infectious peritonitis
    (2) Chylothorax
    (3) Lung-lobe torsion
    (4) Neoplasia (eg, pulmonary adenocarcinoma)

    b. Fluid characteristics

    (1) Exudate - cell counts usually not as high as septic effusions
    (2) Cytology - non-degenerate neutrophils

    c. Diagnosis - evaluate suspected underlying disease

    d. Treatment - underlying disease

    D. Modified Transudate (Obstructive Effusion)

    1. Fluid characteristics

    a. Serosanguineous, modified transudate
    b. Cytology 6 erythrocytes, lymphocytes, small numbers of neutrophils,
    macrophages, and mesothelial cells

    2. Causes

    a. Congestive heart failure
    b. Lung lobe torsion (although usually hemorrhagic/inflammatory)
    c. Neoplasia (especially mediastinal lymphoma)
    d. Diaphragmatic hernia

    3. Diagnosis
    a. Physical examination 6 signs of cardiac disease
    b. Cardiovascular evaluation - ECG, echocardiography

    4. Treatment - directed at underlying cause

    E. Chylothorax

    1. Fluid characteristics

    a. White to pink, opaque, does not clear on centrifugation
    b. After standing or refrigeration, forms cream layer on top due to
    accumulation of chylomicrons
    c. Total protein content, cell counts characteristic of exudate
    d. Cytologic evaluation
    (1) Predominant cell in some cases is the small lymphocyte
    (2) Non-degenerate neutrophils may predominate if chronic
    Last edited by muhammed yousuf; July 28th, 2007 at 03:32 PM.

  9. #9
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    Pleural effusion and ascites fluid analysis

    Pleural fluid analysis:
    Transudate:
    • Appearance - clear
    • protein - absolute value - <3.0g/dl, fluid : serum ratio - <0.5
    • lactic dehydrogenase - absolute value - <200iu/L, fluid : serum ratio - <0.6
    • Glucose - >60mg/dl
    • leucocytes - total <1000/mm3, differential - >50% lymphocytes or mononuclear cells
    • erythrocytes - <5000/mm3
    Exudate:
    • Appearance - clear, cloudy or hemorrhagic
    • protein - absolute value - >3.0g/dl, fluid : serum ratio - >0.5
    • lactic dehydrogenase - absolute value - >200iu/l, fluid : serum ratio - >0.6
    • Glucose - <0.6mg/dl
    • leucocytes - total - >1000/mm3, differential - >50% polymorphs or lymphocytes
    • erythrocytes - variable
    Low glucose concentration (<60mg/dl) suggest - empyema, malignancy, TB
    very low glucose concentration(<15mg/dl) is characteristic of rheumatoid effusion
    pleural fluid erythrocytes count exceeding 100000/mm3 are most often seen in malignancy and pulmonary embolism.
    pleural fluid amylase is elevated in patients with pancreatic disease and esophageal rupture.

    Ascites fluid analysis:
    The ascitic fluid should be analyzed for:
    • The serum-ascitic albumin gradient (SAAG) is calculated by subtracting the albumim concentration of the ascitic fluid from the albumin concentration of a serum specimen obtained on the same day.
    • The amylase concentration is elevated in pancreatic ascites.
    • The triglyceride concentration is elevated in chylous ascites.
    • White cell count when greater than 350/microliter is suggestive of infection. Bacterial infection should be suspected if predominant cells are polymorphonuclear cells. Suspect TB or fungal infection if mononuclear cells is predominant.
    • Red cell count greater than 50.000/microliter denotes hemorrhagic ascites, which usually is due to malignancy, tuberculosis or trauma.
    • Gram stain and culture can confirm the diagnosis of bacterial infection.
    • pH less than 7 suggests bacterial infection
    • Cytology can be positive in malignancy.
    Types of Ascites according to the level of the serum-ascites albumin gradient:

    - High Gradient ( > or = 1.1 g/dl)
    • Cirrhosis
    • Alcoholic Hepatitis
    • Cardiac Failure
    • Fulminant Hepatic Failure
    • Portal-vein Thrombosis
    - Low Gradient ( < 1.1 g/dl)
    • Peritoneal Carcinomatosis
    • Pancreatic ascites
    • Biliary ascites
    • Peritoneal Tuberculosis
    • Nephrotic Syndrome
    • Serositis
    • Bowel obstruction or infarction

  10. #10
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    Principles of fluid analysis.

    Pleural effusion.
    -Perform diagnostic thoracentesis
    -Measure the pleural fluid protein and LDH.

    If the pleural fluid or serum protein > 0.5 and the serum LDH >0.6 , its > 2/3rd upper normal serum limit

    Hence, its Exudate cause and its requires further investigation.

    If the following criteria was not met, then its transudate causes such as, chronic heart failure, cirrhosis or nephrosis.

    In the exudate causes, further investigation such as

    -Pleural fluid glucose
    -Pleural fluid amylase
    -Pleural fluid cytology
    -Obtain differential count
    -Culture stain
    -Marker for tuberculosis.

    - If serum amylase is elevated, consider esophageal rupture, pancreatic pleural effusion or even malignancy

    - If glucose is < 60mg/dl, consider malignancy, bacterial infections, rheumatoid pleuritis.

    - There are times where by diagnosis cant be obtained, in this cases, consider pulmonary embolus, if it is still not the diagnosis perform a pleural fluid marker for tuberculosis.

    - If there is difficulty in obtaining the diagnosis still, consider thoracoscopy or open pleural biopsy.


    Ascites fluid

    -Diagnostic paracentesis about 50- 100 ml is essential, using a 22 gauge needle in linea alba 2 cm below the umbilicus.

    - Routine evaluation includes inspection, protein albumin, glucose, cell count, and differential, culture and cytology. In selected cases check amylase, LDH, triglycerides, and also culture for TB.

    - Ascites due to CHF( example pericardial constriction) may require evaluation by right- sided heart catheterization.
    - Differential diagnosis:- more than 90% of cases due to cirrhosis, neoplasm, CHF and tuberculosis.

    - Fluid characteristics can be divided into many causes based upon mainly the appearance, the protein content, serum- ascities albumin gradient, RBC and WBC.

    - Example, in a case of cirrhosis, appearance is straw colour, protein is < 2.5g/dl, serum ascities albumin gradient > 1.1, RBC is low, and WBC < 250

    - Spontaneous bacterial peritonitis, which is one of the complication of ascities can be diagnosed by doing a fluid analysis, where by there will be low ascetic protein concentration. Diagnostic suggesting by ascetic fluid when the PMN count ( polymorphonuclear) > 250 miu/L. It is comfirmed by positive culture of usually Enterobacteriaceae, group D streptococci, Streptococcus pneumoniae, S. viridans.

    - Efficacy of the treatment demonstrated by marked decrease in ascetic PMN count after 48 hours.

 

 
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