Stool Analysis What is the stool or feces? Waste residue of indigestible material (cellulose during the previous 4 days) 2. Bile pigments and salts 3. Intestinal secretions, including mucus 4. Leukocytes that migrate from the bloodstream 6. Bacteria and Inorganic material(10-20%) chiefly calcium and phosphates. Undigested and unabsorbed food. 5. Epithelial cells that have been shade

Random Collection 1. Universal precaution 2. Collect stool in a dry,clean container uncontaminated with urine or other body secretions, such as menstrual blood 4. Collect the stool with a clean tongue blade or similar object. 5. Deliver immediately after collection

Ova and parasites collection Warm stools are best for detecting ova or parasites. Do not refrigerate specimen for ova or parasites. If the stool should be collect in 10 % formalin or PVA fixative, storage temperature is not critical. Because of the cyclic life cycle of parasites, three separate random stool specimens are recommended.

Enteric pathogen collection Some coliform bacilli produce antibiotic substances that destroy enteric pathogen.Refrigerate specimen immediately. 2. A diarrheal stool will usually give accurate results. 3. A freshly passed stool is the specimen of choice. Stool specimen should be collected before antibiotic therapy, or as early in the course of the disease. If blood or mucous is present, it should be included in the specimen

Interfering factors Patients receiving tetracyclines, anti-diarrheal drugs, barium, bismuth, oil, iron , or magnesium may not yield accurate results. 2. Bismuth found in toilet tissue interferes with the results. 3. Do not collect stool from the toilet bowl.A clean, dry bedpan is the best. 4. Lifestyle, personal habbits, environments may interfere with proper sample procurement. บิสมัส เตตร้า เหล็กทำให้อีเปลี่ยนสี, น้ำมันทำให้เกิด false steatorrhea Anti-diarrheal drug ทำให้ลักษณะของ stool เปลี่ยนจากจริง

Normal values in stool Analysis Macroscopic examination Normal value Amount 100-200 g / day Colour Brown Odour Varies with pH of stool and depend on bact- erial fermentation Consistency Plastic, not unusual to see fiber, vegetable skins. Size and shape Formed Gross blood,Mucous,Pus, Parasites None มีความยืดหยุ่น

Normal values in stool analysis Microscopic examination Normal values Fat (Colorless, neutral fat (18%)and fatty acid crystals and soaps) Undigested food None to small amount Meat fibers, Starch, Trypsin None Eggs and segments of parasites None Yeasts None Leukocytes None

Normal values in stool analysis Chemical examination Normal values Water Up to 75 % pH 6.5-7.5 Occult blood Negative Urobilinogen 50-300 g/24hr Porphyrins Coporphyrins:400-1200g/24hr Uroporphyrins:10-40 mg/24hr Nitrogen <2.5 g/24hr

Normal values in stool analysis Chemical examination Normal values Bile Negative in adults:positive in children Trypsin 20-950 units/g( positive in small amounts in adults; present in greater amounts in normal children. Osmolarity used 200-250 mOsm with serum osmol- arity to calculate osmotic gap Sodium 5.8-9.8 mEq / 24hr

Normal values in stool analysis Chemical examination Normal values Chloride 2.5-3.9 mEq / 24 hr Potassium 15.7-20.7 mEq /24 hr Lipids ( fatty acid) 0-6 g / 24 hr

Clinical Implications 1. Fecal consistency may be altered in various disease states Diarrhea mixed with mucous and red blood cells is associated with 1. Typhus 2. Typhoid 3. Cholera 4. Amebiasis 5. Large bowel cancer ไข้ไทฟอยด์ อหิวาตกโรค อมีบาฝังตัวในลำไส้ มะเร็งทางเดินอาหารขนาดใหญ่

Clinical Implications b. Diarrhea mixed with mucus and white blood cells is associated with 1. Ulcerative colitis 2. Regional enteritis 3. Shigellosis 4. Salmonellosis 5. Intestinal tuberculosis แผลในโคลอน (ขอบเรียบ) โรคทางเดินอาการอักเสบประจำถิ่น วัณโรคลงทางเดินอาหาร/ ฝีในท้อง

Clinical Implications C. ”Pasty” stool is associated with a high fat content in the stool: 1. A significant increase of fat is usually detected on gross examination 2. With common bile duct obstruction, the fat gives the stool a putty- like appearance. 3. In cystic fibrosis, the increase of neutral fat gives a greasy, “butter stool” appearance. มีพังผืดเกิดขึ้นในถุงน้ำดี

Stool Odor Normal value Varies with pH of stool and diet. Indole and sketole are the substances that produce normal odor formed by intestinal bacteria putrefaction and fermentation. Clinical implication. A foul odor is caused by degradation of undigested protein. A foul odor is produced by excessive carbohydrate ingestion. A sickly sweet odor is produced by volatile fatty acids and undigested lactose

Stool pH Normal value : Neutral to acid or alkaline Clinical implication 1. Increased pH ( alkaline) a. protein break down b. Villous adenoma c.Colitis d.Antibiotic use 2. Decreased pH ( acid) a. Carbohydrate malabsorption b. Fat malabsorption c. Disaccharidase deficiency สลายโปรตีนมากๆ จะมียูเรียและแอมโมเนียทำให้เป็นด่าง ทางเดินอาหารส่วนปลายอักเสบ มะเร็งต่อมเมือกที่วิลไล มีการหมักคาร์โบไฮเดรตโดยแบคทีเรียได้กรดแลกติก มีการย่อยไขมัน หมักกรดไขมันได้กรดคีโตนส์ ทำนองเดียวกับคาร์บมาลแอบสอร์บ

Stool color Normal value : Brown Clinical implication: 1. Yellow to yellow-green : severe diarrhea 2. Green : severe diarrhea เขียวเพราะน้ำดีดูดกลับไม่ทัน ไม่มีเวลาให้แบคทีเรียย่อย bile Black: resulting from bleeding into the upper gastrointestinal tract (>100 ml blood) การที่มีเลือดออกในทางเดินอาหารส่วนบนเหล็กจะถูกกรดออกซิไดซ์ได้สีดำ 3. Tan or Clay colored : blockage of the common bile duct. 4. Pale greasy acholic (no bile secretion) stool found in pancreatic insufficiency. การบลอกทำให้ไม่มีน้ำดี สีอึเลยไม่มีสี แสดงถึงการที่ไขมันไม่ถูกย่อย

Stool color(con) 4. Maroon-to-red-to-pink : possible result of bleeding from the lower gastrointestinal tract (eg. Tumors, hemorrhoids, fissures,inflammatory process) 5. Blood streak on the outer surface of usually indicates hemorrhoids or anal abnormalities. 6. Blood in stool can arise from abnormalities higher in the colon. In some case the transit time is rapid blood from stomach or duodenum can appear as bright or dark red or maroon in stool. เนื้องอก, ริดสีดวง, ร่องตูดแหก, มีการอักเสบ ริดสีดวง, รูก้นผิดปกติ

Blood in Stool Normal value : Negative Clinical Implication : 1. Dark red to tarry black indicates a loss of 0.50 to 0.75 ml of blood from the upper GI tract. 2. Positive for occult blood may be caused by a. Carcinoma of colon b. Ulcerative colitis c. Adenoma d. Diaphramatic hernia e. Gastric carcinoma f. Diverticulitis g. Ulcers มะเร็งของโคลอน แผลขอบเรียบที่โคลอน ใส้เลื่อนที่กระบังลม มะเร็งกระเพาะอาการ ลำไส้พันกันทำให้เน่าตาย

Mucous in Stool Normal value : Negative for mucous Clinical Implication: 1. Translucent gelatinous mucous clinging to the surface of formed stool occurs in a. Spastic constipation b. Mucous colitis c. Emotionally disturbed patients d. Excessive straining at stool 2. Bloody mucous clinging to the surface suggests a. Neoplasm b. Inflammation of the rectal canal เบ่งแรงๆ เมือกจากการอักเสบ อารมย์ เก็บอึนานไป ไม่ชอบถ่าย เนื้องอก ภาวะอักเสบที่ไส้ตรง

Mucous in Stool (con) 3. Mucous with pus and blood is associated with a. Ulcerative colitis b. Bacilliary dysentery c. Ulcerating cancer of colon d. Acute diverticulitis e. Intestinal tuberculosis ติดเชื้อแบซิไล แผลที่เกิดจากมะเร็งโคลอน ลำไส้พันกันเฉียบพลัน

Fat in Stool Normal value : fat in stool will account for up to 20 % of total solids. Lipids are measured as fatty acids (0-6.0 g/24hr) Clinical Implication : 1. Increased fat or fatty acids is associated with the malabsorption syndromes a. Nontropical sprue b. Crohn’s disease c. Whipple’s disease d. Cystic fibrosis e. Enteritis and pancreatic diseases f. Surgical removal of a section of the intestine ลำไส้ตีบตันเนื่องจากผนังหนาขึ้นและ มีเยื่อมีเซนทรีมากขึ้น

Urobilinogen in Stool Normal value : 125-400 Ehrlich units / 24 hr 75-350 Ehrlich units/100 g Clinical Implication: Increased values are associated with Hemolytic anemias Decreased values are associated with a. Complete biliary obstruction b. Severe liver disease, infectious hepatitis c. Oral antibiotic therapy that alters intestinal bacteria flora d. Infants are negative up to 6 months of age

Bile in Stool Normal value : Adults –negative : Children may be positive Clinical Implication: 1. Bile may be present in diarrheal stools. 2. Increased bile levels occur in Hemolytic anemia

Trypsin in Stool Normal value : Positive in small amounts in 95 % of normal persons. Clinical Implication : Decreased amounts occur in Pancreatic deficiency Malabsorption syndromes Screen for cystic fibrosis

Leukocytes in Stool Normal value : Negative Clinical Implication 1. Large amounts of leukocytes a. Chronic ulcerative colitis b. Chronic bacilliary dysentery c. Localized abscess d. Fistulas of sigmoid rectum or anus 2. Mononuclear leukocytes appear in Typhoid ท้องเสียเรื้อรังจากการติดแบซิไล แผลลำไส้อักเสบเรื้อรัง มีฝีหนอง ลำไส้กลืนกันบริเวณซฺกมอยด์โคลอน หรือที่ทวาร

Leukocytes in Stool (con) 3. Polymorphonuclear leukocytes appear in a. Shigellosis b. Salmonellosis c. Yersinia d. Invasive Escherichia coli diarrhea e. Ulcerative colitis 4. Absence of leukocytes is associated with a. Cholera b. Non specific diarrhea c. Viral diarrhea d. Amebic colitis e. Noninvasive E.coli diarrhea f. Toxigenic bacteria Staphylococci spp., Clostidium Cholera g. Parasites-Giardia,

Porphyrins in Stool Clinical Implication: Normal value : Coproporphyrin 400-1200 g / 24hr Urophorphyrin 10-40 g / 24 hr. These values vary from Lab to Lab. Clinical Implication: Increased fecal coproporphyrin is associated with a. Coproporphyria (hereditary) b. Porphyria variegata c. Protoporphyria d. Hemolytic anemia 2. Increased fecal protoporphyrin is associated with a. Porphyria veriegata b. Protoporphyria c. Acquired liver disease

Stool Electrolytes Normal values : Sodium 5.8-9.8 mEq / 24 hr Chloride 2.5-3.9 mEq / 24 hr Potassium 15.7-20.7 mEq /24 hr Clinical Implication : Idiopathic proctocolitis Sodium and Chloride Normal Potassium Cholera Sodium and Chloride