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1、Serousal Fluids,The closed cavities of body are lined by serosal membranes(pleura pericardium and pertoneum)The fluid is a plasma filtrate from capillaries of the parietal membraneThe fluid is reabsorbed through the lymphatics and venules of the visceral membraneThe small amounts of fluid facilitate
2、s movement of two membranesThe serosal fluids are plasma ultra filtration and mesothelial lining does not add any substanceFor laboratory assessment needle aspiration is done(Thoracocentesis Pericardiocentesis Paracentesis),Serousal Fluids,Evaluation of serous fluids directed first toward differenti
3、ating transudate from exudateTransudative effusions(usually bilateral in pleura)have mechanical process owning to systemic conditions,leading to increase capillary hydrostatic pressure or decreased plasma oncotic pressureExudative effusions(usually unilateral in pleura)have inflammatory process,asso
4、ciated with disorders of vascular permeability or interfere with lymphatic resorption,Transudate and Exudate,Serousal Fluids,Transudate ExudateAppearance Clear CloudySpecific gravity 1.015Total protein 3.0 gr/dlF/S protein ratio 0.5LD 200 IUF/S LD ratio 0.6Cell count 1000/ulSpontaneous clotting No Y
5、es,Total leukocyte and red cells counts are of limited use in the evaluation of serousal Fluids,Serousal Fluids,Transudates generally require no further work-up additional testing for cholestrol and albumin gradient may discriminate effusions with equivocal Lights criteria(the first three criteria)P
6、F/S protein ratio 0.5 PF/S LD ratio 0.6 Pleural Fluid LD 2/3 upper limit of serum Pleural Fluid cholestrol 45 mg/dl PF/S cholestrol ratio 0.3 Serum-pleural fluid albumin gradient 0.6,*Bilirubin measurement has not help as a strong discreminator,Pleural Fluid,Serousal Fluids,Indications of thoracocen
7、tesis:1.Any undiagnoesd pleural effusion 2.Therapeutic purposes in massive effusionsCollection:1.Heparinized tubes to avoid clotting 2.Except for an EDTA tube for all counts and differentialsInoculation into the blood culture medium at the bed side*If necessary fresh specimen for cytology may be sto
8、red up to 48 hours in the refrigerator with satisfactory results.,Pleural Fluid,Amylase:measurement of this enzyme is recommended for all pleural effusions with unknown ethiology Increased levels found in esophageal rupture PH value 7.3 is related to uncomplicated cases PH 110 mg/dl indicate a chylo
9、us effusion Values between 60-110 mg/dl are less certain and require lipoprotein electrophoresis for chylomicrons Pleural fluid TG 50 mg/dl indicate a pseudochylous effusion,seen in chronic inflammatory processAdenosine deaminase(ADA)is a rapid chemical evidence of Tb.ADA-2 from lymphocytes,Serousal
10、 Fluids,Pleural Fluid,Serousal Fluids,Formal cell counts have little practical valuePleural fluid Hct 50%of blood is a good evidence for hemothoraxA bloody pleural effusion(Hct 1%or RBC 100,000/ul)suggest trauma,malignancy and pulmonary infarctionDifferential cell count on an air-dried Romanowskis s
11、tain Filtration or automated concentration methods with Papanicolaou stain for cytologic evaluation Preparation of cell block is unnecessary except for effusions in which malignancy is a consideration,Pleural Fluid,Neutrophils:Predaminate in pleural fluid with inflammation.Over 10%of transudates als
12、o have a predominance of neutrophils but has no clinical significanceLymphosytes:Associated with transudate and no clinical significance*Most are small but medium,large and reactive variants may be seen*Nuceloi and nuclear cleaving are more prominent in effusions than in prepheral blood*Low grade NH
13、L or CLL may be difficult to distinguish from benign lymphocyte-rich serous effusions.In conjunction with cellular morphology,immunophenotyping by flowcytometry or immunocytochemistry is usually helpful,Serousal Fluids,Pleural Fluid,Eosinophils:an eosinophilic effusion is defined as having 10%eosino
14、phils*The most common causes are related to the presence of air or blood in the pleural cavity*Most are exudates*in about 35%of patients the ethiology is unknown*though not of much assistance in diagnosing an effusion,eosinophilia does appear to independently associated with longer survival,Serousal
15、 Fluids,Pleural Fluid,Mesothelial cells:Are common in pleural fluid from inflammatory process.*Rare in patients with Tb pleurisy,empyema,RA and patients who have pleurodesis*Fibrin deposition and fibrosis occurring in these conditions prevent exfoliation of mesothelial cells*Carcinoma cells may form
16、 easily recognized tumor clusters or closely mimic mesothelial cells a panel of immunocytochemistry stains may be necessary for conformation,Serousal Fluids,Pleural Fluid,Serousal Fluids,Pleural Fluid,Serousal Fluids,Pleural Fluid,Up to 50 ml Fluid normally present in peritoneal cavityPeritoneal eff
17、usion is called AscitesLaboratory criteria for dividing ascitic fluid into transudate and exudate is not well defined as it is for pleural fluidDiagnostic peritoneal lavage(DPL)have limited use:1.Rapid screening for significant abdominal hemorrhage 2.Evaluation of hollow viscus injuries Peritoneal d
18、ialysis:submitted to check for infection Peritoneal washing:performed intra operatively to document early intra abdominal spread of gynecologic and gastric Ca.,Serousal Fluids,Peritoneal Fluid,Total leukocyte useful in spontaneous bacterial peritonitis(SBP)Approximately 90%of(SBP)have leukocyte coun
19、t 500/ul and over 50%neutrophiles Eosinophilia 10%most commonly associates with chronic peritoneal dialysis.Also in CHF,vasculitis,lymphoma and ruptured hydatid cystOverall sensitivity of cytology for malignant ascitis is 40-65%Peritoneal carcinomatosis accounts for two thirds of malignant effusions
20、Immunocytochemical stains are useful in characterizing atypical cells,Serousal Fluids,Peritoneal Fluid,Amylase activity in normal peritoneal fluid is similar to blood levels A fluid amylase level greater than three times of serum value is good evidence of pancreas-related ascitis and also in GI perf
21、oration Increased peritoneal BUN and Cr+increased serum BUN+normal serum Cr(due to back diffusion of urea)suggests bladder ruptureCEA sensitivity 40-50%specificity 90%using cut off point of 3 ng/mlIncrease CEA in peritoneal washing suggest a poor prognosis of gastric CaCA-125 extremely high in epith
22、elial Ca of ovary,follopian tube or endometrium,Serousal Fluids,Peritoneal Fluid,Serousal Fluids,Peritoneal Fluid,Serousal Fluids,Peritoneal Fluid,Serousal Fluids,Peritoneal Fluid,10-15 ml fluid normally present in pericardial spaceCauses of pericardial effusion:1)infection 2)neoplasm 3)MI 4)hemorrh
23、age 5)methabolic 6)RAHIV infected patients commonly have asymptomatic pericardial effusion In HIV associated cardiac temponade 45%are idiopathic,Tb and bacterial infections each accounts for 20%of cases Large effusions(350 ml)most often caused by malignancy or uremiaBlood-like fluid represent hemorr
24、hagic effusion or aspiration of blood from the heartHct comparable to peripheral and blood gas analysis help to differentiate,Serousal Fluids,Pericardial Fluid,Postpericardiotomy syndrome common but nonspecific complication of cardiac surgery,days to weeks following the injury Exudative pericardial
25、effusion developed in over 80%of cases Presence of antimyocardial Abs suggests an immune mediated processHct and RBC count have limited value in differential diagnosis of pericardial effusions.Total WBC 10,000/ul suggests bacterial,Tb or malignant pericarditis Metastatic Ca of lung and breast are most frequent cause of malignant pericardial effusion,Serousal Fluids,Pericardial Fluid,Thank You,
