CHEMISTRYAustinCommunity教学讲解课件

UrinalysisandBodyFluidsCRgUnit4SerousBodyFluids.UrinalysisandBodyFluidsCRg1SerousFluidsSerousfluidssmallamountoffluidthatliesbetweenthemembranesliningthebodycavities(parietal)andthosecoveringtheorganswithinthecavities(visceral).actsaslubricant,providenutrients,removewastes.SerousFluidsSerousfluids.2SerousFluidsBodycavitiesPericardial-heartPleural-lungsPeritoneal–abdominalMembranesLinedwithmesothelialcellsParietal–linescavitywallVisceral–coversorganscontainedwithinSerousfluidsfillthespacebetween.SerousFluidsBodycavities.3SerousFluids“ultrafiltrate”oftheplasmacloselyresemblestheplasma(asopposedtoCSF)AppearancePossiblereason/conditionPaleyellow&clearNormalWhite,turbidWBCs/infectionBloodyRBCs/hemorrhageMilkyChyle–lymph&emulsifiedfatsViscousIncreasedhyaluronicacid/malignantmesothelialoma.SerousFluids“ultrafiltrate”4SerousFluidsProducedbyhydrostaticandoncotic(protein)pressureinthecapillariesliningthemembranesNormallyproducedataconstantrate.Production(☛parietalmembrane)Re-absorption(☛visceralmembrane)

.SerousFluidsProducedbyhydro5SerousFluidsProductionandre-absorptionareinfluencedby:ChangesinosmoticandhydrostaticpressureinthebloodConcentrationofchemicalconstituentsintheplasmaPermeabilityofbloodvesselsandthemembranes.SerousFluidsProductionandre6SerousFluidsTypesofserousfluidsPericardialfluid–aroundheartPleuralfluid(thoracicfluid)–lungcavityPeritoneal(asciticfluid)–abdominalcavityReasonsforanalysisInfectionsHemorrhagesmalignancies,andotherdisorders..SerousFluidsTypesofserousf7SerousFluidsSpecimenCollectionandHandlingNeedleaspirationParacentesisThoracentesisPericardiocentesisLavage(ie.peritoneallavage)Ringer’slactate/salineisinfusedintoabdomenthenretrievedforanalysis.Specimensometimescalledascitesfluid..SerousFluidsSpecimenCollecti8SerousFluids

-Composition&FormationEffusion

anincreaseintheserousfluidduetosomedisruptioninproduction&/re-absorptionprocesses.

Classificationofcauseofaneffusionisaidedbydeterminingifthefluidisa“transudate”oran“exudate”..SerousFluids

-Composition9SerousFluids

-EffusionTransudateaneffusionthatisaresultofasystemicdisorderthatdisruptsthebalanceoffluidproduction/fluidre-absorption.Examples:Pleuraltransudate–congestiveheartfailure;Pericardialtransudate–nephroticsyndrome,metastaticcancer.SerousFluids

-EffusionTra10SerousFluidsExudates

termtoclassifytheeffusionthatisaresultofaproblemwiththemembranesthemselves.Producedbyconditionsthatdirectlyinvolvethemembranesoftheparticularcavity,ex.infections,inflammation,andmalignanciesThoughtofasaninflammatoryprocessExudateexamples:Pleuralexudate–carcinoma,pneumonia,traumaPericardialexudate–infection,cardiovasculardisease(CV)trauma,cancer.SerousFluidsExudates.11DifferentiationBetweenTransudatesandExudatesCHARACTERISTIC/TESTTRANSUDATEEXUDATEColorPaleyellowAnyabnormalcolorClarityClearBloodycloudy,purulent,turbidSpecificgravity<1.015>1.015GlucoseEqualtoserumOver30mglessthanserumlevelProtein<3.0g/dL>3.0g/dLFluid/serumproteinratio<0.5>0.5Fibrinogen/SpontaneousclottingNoPossibleFluid/serumamylase<2.0>2.0Fluid/serumbilirubinratio<0.6>0.6Lactatedehydrogenase<60%ofserum>60%ofserumFluid/serumLDratio<0.6>0.6Cellcounts(total)<300/L>1000/L.CHARACTERISTIC/TESTTRANSUDAT12SerousFluidsSpecimenCollectionandHandlingEDTAtubeforcellcount&differentialHeparintubeforchemistries,serology,microbiologyandcytology.Sinceprocedurenotperformedunlessaneffusionexists,largeamountoffluidoftencollected.Bloodspecimensusuallycollectedatsametimeandcomparisonsoftestresultsmade..SerousFluidsSpecimenCollecti13SerousFluids-TestingoverviewVarietyoftestsusedtoaidindeterminingthecauseoftheeffusionAppearanceEvaluationofclottingabilitywhetherornotitwillformaclot,etc.CellcountsProteinlevelBothfluidandcurrentserumleveltomakecomparison:fluidprotein/serumproteinLDHenzymesBothfluidandcurrentserumleveltomakecomparison:fluidLDH/serumLDHCulturesSerology–rarelydoneonserousfluidsasbloodtestingisadequateCytology/Pathology–ifmalignancyissuspected..SerousFluids-Testingovervi14SerousFluidsHematology/GrossexaminationColor&clarityNV=yellow&clear(othertermsasforCSFaresometimesused,EXCEPT‘xanthrochromic’CellcountsameasforCSFDifferentialanycellinperipheralblood,mesothelialcells,malignantcells.SerousFluidsHematology/Gros15SerousFluids1991CAPCM20.SerousFluids1991CAPCM20.16Abdominalfluid

–plasmacells/multiplemyeloma.Abdominalfluid

–plasmacell17MesothelialcellsUniquetoserousfluids,originatefromliningofperitoneal,pleural,andpericardialcavities.LargeroundcellwithabundantbluecytoplasmandpurplenucleuswhichmaybeeccentricCellsometimesdescribedashavinga"friedegg"appearance.-usuallyaresingleormaybeinsheetsNucleusroundtooval&hasasmoothoutline,takesup@1/3-½ofthespace.Smoothsphericalnuceoimaybeseen..MesothelialcellsUniquetoser18MesothelialcellsPleomorphicIf‘reactive’mayappearinclusters,haveprominentnucleoliandbemultinucleatedNucleusstilldistinctandroundwithuniformstainingcharacteristics.Aclusterofreactivemesosmayresemblemalignantcellclusters,butthemesosdisplay"cellwindows."Reactivemesothelialcells.MesothelialcellsPleomorphicRe19SerousFluidsMacrophageengulfedCandidiaspeciesinapleuralfluid,mesothelialcells..SerousFluids.20SerousFluidsMalignantcellsAfrequentconcerninanyserousfluidduetopossibilityofcancerofanyorganand/ormetastasisofCAfromonelocationtoanother.Cellshaveirregularsize,shape,andstainingcharacteristicsofnucleusandcytoplasm.Usuallydeeplybasophilic,moldedorballedupclustersofcellswithlittledistinctionfromonecelltothenext.Maybevacuolated..SerousFluidsMalignantcells.21SerousFluidsMalignantcellsCharacteristicsIrregularshapeUnevenchromatindistributionProminentlargeirregularnucleoli,CommunitybordersIncreasednuclei/cytoplasmratio.Alwayssendsuspiciouscellstocytology/pathology.SerousFluidsMalignantcells.22SerousFluidMalignantcellsACSP7,Case1peritonealfluid,malignancy.SerousFluidMalignantcellsAC23SerousFluidMalignantcellsASCP9Case2pleuralfluid42yearold,breastcancer.SerousFluidMalignantcellsAS24ASCP10Case3,asciticfluid,62yearoldadmittedforGIbleedingSerousFluidMalignantcells.ASCP10Case3,asciticfluid,25ASCP12Case4,30yearoldwithbackpainandinabilitytowork.Pleuraleffusionfluid–malignanttumoronspinalcordSerousFluidMalignantcells.ASCP12Case4,30yearoldwi26sheetsofatypicalcellswithirregularnuclearcontours,nuclearhyperchromasia,basophiliccytoplasm,andjaggedoutlineofcellborders.Squamouscellcarcinoma(x400,Diff-Quikstaining)SerousFluidMalignantcells.sheetsofatypicalcellswith27SerousFluids-LEcellsSeeninpatientswithSystemicLupusErythmatosis(SLE)asystemicdiseaseinwhichanautoantibodyattacksthepatientsorgansandbodysystemsLEcellisaneutrophilthathasengulfedahomogeneousmassofpurplestainingnuclearmaterial.SerousFluids-LEcellsSeenin28SerousFluidsChemistryTotalprotein,andratiotoserumproteinLDHandratiotoserumLDHGlucoseAmylase&Lipase–pancreaticdisordersBilirubin-peritonealfluidsuspicionofperforatedGIorgallbladderAlkalinephosphatase-peritonealfluid

suspicionofperforatedintestinepH&ammonia.SerousFluidsChemistry.29SerousFluidsMicrobiologyGramstain&acidfastCultures–aerobic&anaerobic.SerousFluidsMicrobiology.30SerousFluids–pericardialfluid1987CAPCM21Pericardialfluid,intracellularbacteria.SerousFluids–pericardialfl31SerousFluids–peritonealfluid1992CAPCM41Peritonealfluid.Seg,macro,yeast.SerousFluids–peritonealflu32SerousFluidsQualitycontrolnocommercialcontrolsuseserumcontrols..SerousFluids.33SummarySerousfluidsareserum-likeultrafiltratesofplasmaVolumesaremaintainedbytissueandcapillarypressuresEffusionsareexcessiveaccumulationsoffluids–andcanoccurinthepericardium,pleuralandabdominalcavities.Laboratorytestingisrequiredtodifferentiateexudatesfromtransudates.Variouscausescontributetotheaccumulationoffluidsintheserousbodycavities.LaboratorytestingHematology(physicalproperties,cellcountsanddifferential)Chemistry(serum&fluidvaluesarecompared.QCissameasforserum)Serology–rarelyCytology–ifsuspiciouscellsareseenduringdifferential.SummarySerousfluidsareserum34UrinalysisandBodyFluidsCRgUnit4SynovialFluid.UrinalysisandBodyFluidsCRg35SynovialFluidCompositionandformationSecretedbycellsofsynovialmembraneVeryviscous,clearultrafiltrateofplasmaContainsHyaluronicacidMucopolysaccharidesLimitedamountofplasmaproteinGlucose&uricacidlevelsequivalenttoplasma.SynovialFluidCompositionand36SynovialFluidFunctions–suppliesnutrients-lubricationofjointReasonsforanalysisInfectionHemorrhageDegenerativedisorders(arthritis)Inflammatorydisease(SLE).SynovialFluidFunctions.37SynovialFluidCollectionArthrocentesis.SynovialFluidCollection.38SynovialFluidCollectionTubesHeparin–chemistries,immunologicaltestsSteriletube–culturingandcrystalevaluationEDTA–hematology.SynovialFluidCollection.39LaboratoryTestingMacroscopicMicroscopicChemicalOtherVolumeCellcountsProteinAerobiccultureColor&ClarityDifferentialGlucoseAnaerobiccultureInclusionsCrystalsUricAcidViscosityCytologyLacticAcidClottingLDHMucinClotRheumatoidFactor.LaboratoryTestingMacroscopicM40ClassificationofSynovialFluidNormalNon-InflammatoryDegenerativejointdiseasesInflammatoryImmunologicdisorders(ielupus,RA,goutcrystals,ETC)SepticMicrobialinfectionsHemorrhagicTraumaticinjury,tumors,hemophilia,anticoagulantoverdose,etc..ClassificationofSynovialFlu41SynovialFluid-LaboratoryproceduresHematologyPhysicalpropertiesColor&clarity=lightyellow/straw&clearAbnormalcolors/clarityasforotherfluids*BloodyHemarthrosisTraumatictapWhite/opaquewithturbidityIndicatepuscellsordebrisXanthrochromiatermnotused!.SynovialFluid-Laboratorypr42PhysicalpropertiesViscosityScreening–‘StringTest’dropfrompipetteEvaluatesviscosityNormal=@5+cmlongbeforebreakingRope’stestformucinclotmeasuresdegreeofhyaluronatepolymerizationGood/normal=tightropeymassPoor=appearsfriableorfailstoformSynovialFluid-Laboratoryprocedures.PhysicalpropertiesSynovialF43HematologyCellcounts0RBCs/uL<200WBC/uLMustlethemacytometersitlongertoallowcellstosettlebeforecounting.IfdilutionneededmustusesalineIfyouusediluentwithanacid,suchasUnopettes,thesamplewillclot.SynovialFluid-Laboratoryprocedures.HematologySynovialFluid-Lab44Celldifferential-Wright’sstainCellsofperipheralcirculationneutrophils7%,lymphocytes24%,Monocytes48%,macrophages10%,andsynovialliningcells4%.SynovialFluid-Laboratoryprocedures.Celldifferential-Wright’s45Synovialliningcells(looksomewhatsimilartomesothelialcells)SynovialFluid-Laboratoryprocedures.SynovialliningcellsSynovial46LEcellsTartcellsSynovialFluid-Laboratoryprocedures.LEcellsSynovialFluid-Labor47OthercellsReitercells

MalignantcellsOrganismsSynovialFluid-Laboratoryprocedures.OthercellsSynovialFluid-La48MicroscopicexamforcrystalsUseregularandpolarizedlightCrystalsmaybeintra-cellularorextra-cellularMonosodiumurate–goutartheritisCalciumpyrophosphate–pseudogoutCholesterol–nonspecific;chronicinflammatoryApatite–calcificartheritis(mineralchangeincartilage)Corticosteroid–druginjectionsSynovialFluid-Laboratoryprocedures.MicroscopicexamforcrystalsS49ChemistriesTotalproteinNV=1.07–2.13g/dLIncreasesseenininflammatoryconditionsandfollowingjointhemorrhage.Glucose-similartocurrentbloodlevelDecreasedininflammationorsepsisLactate–assistindifferentiationofsepticandinflammatoryarthritisUricacid–increasedingoutyarthritis.ifgoutissuspected,butnocrystals,mayneeduricacidlevel.SynovialFluid-Laboratoryprocedures.ChemistriesSynovialFluid-L50MicrobiologyGramstain,acidfaststain&culturesCertainorganismsassociatedwithagegroupsChildren-H.influenzaeAdults16-50–Staph.,Strep.Pneumoniae,Streppyogenes,NeisseriagonorrheaAdults>50–Staph.aureusSynovialFluid-Laboratoryprocedures.MicrobiologySynovialFluid-L51SerologySerumresultsmorereliable,sonotoftendonefordiagnosisofRAorLEAutoantibodiesComplementlevelsQC–nocommercialcontrolsavailable,useserumcontrolsifappropriateSynovialFluid-Laboratoryprocedures.SerologySynovialFluid-Labor52SynovialfluidclassificationClassificationofSynovialFluidbyTestResultsNormalNon-inflammatoryInflammatorySepticHemorrhagicVolume<3.5(mL)>3.5(mL)>3.5(mL)>3.5(mL)>3.5(mL)ColorStrawStraw/yellowYellowVariableRedClarityClearClearCloudyCloudyVariableViscosityHighHighLowVariableLowCellcount/uL<200200-2,0002,000-75,000>100,000Sameasbld.%PMNs<25%<25%>50%>75%Sameasbld.Gramstain/cultureNegativeNegativeNegative>50%PosNegativeCrystalsNegativeNegativeFrequentlyNegativeNegativeAssociatedconditionDegenerativejointdiseaseImmunologicdisorders-LE,RA,Gout,pseudogoutNon-gonococcalorgonoccalsepticarthritisTrauma,hemophilia,Anticoagulantoverdose,etc..Synovialfluidclassification53ReviewofKeyPointsSynovialfluidanalysisPlasmaultrafiltratesecretedbysynovialmembraneHyalurinicacidandmucopolysaccharidesmakeitviscousLubricatesandnourishesjointsInfection,hemorrhage,degenerative&inflammatorydiseasesarereasonsforanalysisCollectionisbyarthrocentesisEDTA(hematology),heparinized(chemistriesandserology)andsterile(culturesandcrystals)arecollectedStrawyellow,clearandviscousarenormalcharacteristics0RBCand<200WBC/uLarenormalCellcountsrequiringdilutionmustbemadewithsaline.Anyperipheralcirculatingcellcanbeseenaswellassynovialliningcellsinnormalpatients.Abnormalsareclassifiedasnon-inflammatory,inflammatory,septicorhemorrhagic.ReviewofKeyPointsSynovialf541989CAPCM23Synovialfluid,segs,¯ophagesSynovialFluid-Laboratoryprocedures.1989CAPCM23Synovialfluid,55Lupuserythematosus(LE)cellsJustbelowcenteroffieldNeutrophilhasengulfedahomogenousnuclearmass.ASCP130synovialfluidwithLEcellSynovialFluid-Laboratoryprocedures.Lupuserythematosus(L