FECALYSIS

FECALYSIS

●​ A ROUTINE test performed in clinical microscopy section

●​ SCREENING test to determine health of GUT

●​ Specimen: Stool / Feces

 Purposes / Reasons for Fecalysis
Macroscopic, microscopic, and chemical analyses for:

Early detection of GI bleeding ●​ May indicate colorectal cancer / colorectal carcinoma

●​ Screening method: FOBT

Liver & biliary duct disorders ●​ Determines the presence of obstruction in the bile duct

Maldigestion / malabsorption
syndromes

Pancreatic diseases

Inflammation

Diarrhea

Steatorrhea ●​ Excessive fats in the feces

Detection of pathogenic ●​ Culture & sensitivity — stool is difficult to culture due to the presence
bacteria and parasites of many normal flora
●​ Fecal slide in parasitology (part of microscopy section)
FECES

Normal fecal specimen ●​ Bacteria — normally present; from GIT normal flora; aid digestion
composition ●​ Cellulose
●​ Undigested foodstuffs
●​ GI secretions
●​ Bile pigments
●​ Cells from the intestinal walls
●​ Electrolytes
●​ Water

Excretion per day ●​ 100–200 g/24 hours

●​ >200 g/24 hours — diarrhea

○​ should be consulted with the doctor as its causes vary
■​ infection
■​ maldigestion syndrome
■​ malabsorption syndrome
📌COMPOSITION OF FECES
📍Water (3/4)
●​ Main composition of feces

●​ 60–80% of fecal volume

●​ Normal consistency: SOFT (not too hard and not watery)

●​ 9000 mL of ingested water + saliva + secretions enter digestive tract each day

●​ Normal condition:
○​ 500–1500 mL reaches the large intestine
○​ 150 mL excreted in the feces

●​ Dehydrated 🟰 ⬆️ water reabsorption

📍Solid (1/4)
●​ Undigested foodstuff and other substances normally present in stool

●​ 30% bacteria (mostly non-pathogenic)

○​ normal flora necessary for the degradation of substances
○​ bacterial metabolism
■​ strong odor associated with feces
■​ intestinal gas (flatus / flatulence)
○​ Escherichia coli: non-gas producer
○​ Bacteroides fragilis: anaerobic gas producer that provides flatus

●​ 50–60% intestinal secretions

○​ depends on the diet
○​ food residues such as seeds, fruits and vegetable skins, hairs, fibers, vegetable cells
and muscle fibers

●​ 10–20% fat droplets and other soluble substances

○​ undigested lipid
○​ digested lipid but not reabsorbed
○​ check for: triglyceride, cholesterol, fatty acids
📍Enzymes
●​ Origin: Directly from intestine

➡️ ➡️ ➡️
●​ Necessary for the degradation of substances such proteins, lipids, carbohydrates
○​ enzyme deficiency inability to digest inability to reabsorb certain foods

🟰
appearance of undigested food in the feces
○​ excess of undigested or reabsorbed materials symptoms of maldigestion and
malabsorption

Trypsin

➡️ Small intestine
Used for protein metabolism Chymotrypsin
Pancreas
Aminopeptidase

Lipase

Used for lipid metabolism Bile salt

Liver➡️Gallbladder
Small intestine
➡️
bile fluid — green fluid that acts a
surfactant to degrade cholesterol
📌ODOR OF FECES
Depends on: Diet

Normal odor: Foul to offensive

●​ Bacteria normally present in the gut

➡️ ➡️ strong odor
○​ contribute to the balance of organism in the gut
○​ degrade substances bacterial fermentation

Contribute to the odor of feces: Metabolic products of bacterial fermentation

●​ Skatole
●​ Indole
●​ Butyric acid

➡️
Pathogenic foul smelling feces:

➡️ ➡️ bloated patient
●​ Bacterial infection watery with streak of blood
●​ Over proliferation of normal flora accumulation of gas
📌pH OF FECES
Normal pH: 7–8 or 6.5 pH
●​ Neutral (near)
●​ Slightly alkaline
●​ Slightly acidic
* should not be <6 pH

Acidic feces: Carbohydrate fermentation Alkaline feces: Protein fermentation

CHO metabolism byproduct: organic acids CHON metabolism byproduct: toxic metabolites
●​ lactic acid ●​ ammonia
●​ pyruvic acid ●​ amines
●​ formic acid ●​ sulfides

CHO in intestine 🟰 broken down into glucose ➡️

⬆️
some are utilized by the bacteria during breakdown
●​ bacteria override the absorption
📌CONSISTENCY OF FECES
❌
Normal consistency: Soft to well formed

❌
●​ too hard
●​ watery
📌PRESENCE OF MUCUS
Normal amount of mucus in feces: Small
●​ Mucus is normally present in the feces
●​ GUT's 1st line defense against microorganism infiltration
○​ Prevents infection
○​ Prevents microorganism from becoming invasive
●​ GI tract has cell-producing mucus
○​ Protects the lining from enzymes and acids
●​ Small intestine: Abundant➡️ protects the lining
●​ Large intestine: Trace amount

Abnormal amount of mucus in feces: Excessive

➡️ bacteria ➕ mucus in feces

●​ Sign of irritable bowel syndrome
●​ Infection ➡️ excessive mucus production
○​ Salmonella — salmonellosis
○​ Shigella — shigellosis
SPECIMEN COLLECTION

Container ●​ Clean — not necessarily sterile except for culture & sensitivity
●​ Dry
●​ Non-breakable
●​ Leakproof
●​ Screw-capped
●​ Plastic / cardboard lined with wax
●​ Large: for multiple-day collection

Containers that have preservatives for ova and parasites must not be used
to collect specimens for other tests.
Type & amount Patients should be instructed about the amount required to submit
collected
Pea-sized (3 grams): Qualitative test
●​ FOBT
●​ blood
●​ Microscopic examination for leukocytes, muscle fibers, and fecal
fats
●​ random specimen
●​ plastic or glass containers with screw-tops

2- to 3-day collection: Quantitative tests

●​ gold standard for: Fecal fat analysis
●​ timed specimen: 3-day collection is the most representative specimen
●​ large container: Accommodates the specimen quantity and facilitates
emulsification before testing
Process of collection Patients should collect stool specimen in:
●​ A clean container, such as a bedpan or disposable container
●​ Transfer the specimen to the laboratory container

Requirements:

●​ Free from urine or toilet water contamination — chemical

disinfectants or deodorizers can interfere with chemical testing

●​ Dietary restrictions are before fecal specimen collection — for

some tests

Specimens should be examined right away

●​ Delay:
○​ Refrigeration
○​ Chemical preservatives
SPECIMEN PRESERVATION

Refrigeration ●​ Used for delay examination

●​ Never use freezer
●​ Chemical preservatives are alternative if refrigerator is not
available

Freezing in dry ice

Formalin (2%, 5%, 10%) ●​ Most commonly used chemical preservative (10% formalin)
●​ All purpose fixative for the recovery of protozoa and helminths
●​ 5% formalin: protozoan cysts
●​ 10% formalin: helminth eggs and larvae
●​ Direct examinations and concentration procedures
●​ Not for permanent smears
●​ Potential health hazard

Alcohol
20% Glycerin in saline
(Cumming method)

Merthiolate-Iodine ●​ Merthiolate / thimerosal

Formaldehyde (MIF) ●​ Used only for cyst form of parasite
solution ○​ Iodine should not be used for trophozoite preservation
●​ Useful for fixation of intestinal protozoans, helminth eggs
and larvae
●​ Mixed with immunofluorescence

Polyvinyl alcohol (PVA) ●​ Plastic resin, which serves to ADHERE a stool sample onto a
fixative slide
●​ Preservation of protozoan cysts and trophozoites for
permanent staining
●​ Contains HgCl2 which can cause potential health problems
MACROSCOPIC SCREENING

●​ Often the 1st indication of GI disturbances can be changes in the brown color and formed
consistency of the normal stool.

●​ Appearance of abnormal fecal color also may be caused by ingestion of highly pigmented foods
and medications, so a differentiation must be made between this and a possible pathological
cause.
📍Color
●​ Primary concern: Presence of blood in a stool specimen
○​ depending on the area of the intestinal tract from which bleeding occurs
○​ the color can range from bright red to dark red to black

📍Appearance
●​ Additional abnormalities may be observed during macroscopic examination

📍Size 🟰
●​ Size of colon Size of stool

📍Consistency
●​ Based on Bristol stool chart
○​ Used during evaluation of treatment for bowel disease
○​ 7 types: *From hardest to softest
■​ Ideal: Type 3 & Type 4
■​ Most optimal: Type 4
■​ Abnormal: Type 1, 2, 5, 6, 7
 Color / Appearance Possible Cause / Clinical Comments
Significance

Light to dark brown Normal

⬇️
Hgb degradation

⬇️
Intestinal oxidation of stercobilinogen

⬇️
Oxidation of fecal bilirubin to biliverdin

⬇️
Urobilin / stercobilin

Light to dark brown stool

Black Upper GI bleeding Blood from esophagus / stomach /

(melena)
⬇️
duodenum

3 days before appearance in the stool

⬇️
oxidation

black, tarry stools (melena)

Iron therapy
Medications
Bismuth (antacids)

Charcoal Used as antidote

Red Lower GI bleeding
(hematochezia)
⬇️ time red color 🟰 fresh blood
to appear and retains its original

Beets and food coloring

Rifampin Treatment for TB

Pale yellow, white, gray

(alcoholic stool)
Bile duct obstruction
⬇️
Blockage of the bile duct

⬇️
Conjugated bilirubin cannot pass the bile duct

❌ urobilin⬇️/ stercobilin
❌ brown coloration
Barium sulfate

Green Biliverdin

Oral antibiotics
⬇️
Taking oral antibiotics

oxidation of fecal bilirubin to biliverdin

Green vegetables ⬆️ amounts of green vegetables or food

coloring
Butter-like Cystic fibrosis Exocrine glands cannot produce digestive
(consistency)
⬇️
enzymes & fluids

⬇️
Pancreas cannot produce lipase

⬇️
Lipids are excreted out

Very shiny & soft consistency

Bulky / Frothy Bile duct obstruction

presence of protein and lipids
Pancreatic disorders

Steatorrhea Excessive lipid excretion

Mucus, blood-streaked Colitis Inflammation of the inner lining of the

mucus colon
Inflammation or irritation
Dysentery Amoebic dysentery (E. histolytica)
Damage to the intestinal walls
➡️
Malignancy Tumor ➡️ Obstruction
Severe dehydration ➡️ Very hard feces
Constipation
➡️ Damage to GIT lining
Ribbon-like / flattened / Intestinal constriction Narrowing of intestinal lumen
pencil-like
Spastic colitis Increase in spontaneous contractions
(motility) of muscles in intestine

Obstruction in lower colon Obstruction of the normal passage of

material through the intestine

Syphilis

Rice watery Cholera

Pea soup Typhoid

Scybalous (Goat droppings) Constipation

Spastic colitis

Decreased fluid intake

Smaller caliber Cancer, ulcer, tumor ➡️

Obstruction within the colon
Very small & long (pencil-like) stool

Larger caliber Hirschsprung’s disease Massive enlargement of colon ➡️

Large stool
BRISTOL STOOL CHART
MICROSCOPIC EXAMINATION

Microscopic screening of fecal smears — performed to detect the presence of:

●​ Fats
●​ Undigested muscle fibers and fats associated with steatorrhea
●​ WBCs / Leukocytes associated with microbial diarrhea
📌FATS
●​ Not all fats are absorbed by the intestine
●​ Some of them are excreted which is generally normal

Normal:
●​ Free fat diet: 1–4 g/day
●​ Fatty diet: 5 g/day

📍Steatorrhea
●​ Increased fats in the stool
●​ Amount of fat: >6 g/day
●​ Indicates:
○​ Deficiency of lipase in fibrocystic disease of the pancreas
○​ Deficiency of bile salts in obstructive jaundice
○​ Lymphatic obstruction in abdominal TB
●​ Tests:
○​ Screening / Qualitative test: Microscopic examination of free fat globules
■​ Fat globules can be either triglycerides / fatty acids
○​ Definitive test / Quantitative test: Fecal fat determination
■​ Gold standard: Van de Kamer test
 QUALITATIVE / SCREENING TEST FOR FECAL FAT DETERMINATION

I. Neutral Fat Stain Checks for: Triglyceride / Triacylglycerol (TAG) globules

Reagent:
●​ 95% ethyl alcohol (ETOH)
●​ Absolute ethanol

Principle: Suspension + 95% ETOH + 2 drops of Sudan III

Several orange-red neutral

➡️
fat globules present in a Used to determine: Maldigestion syndromes
fecal suspension stained ●​ Triglycerides are not broken down unable to digest
with Sudan III

Notes: Count the number of orange droplets

Result:
●​ Steatorrhea: >60 droplets/hpf
○​ indicates that triglycerides are not broken down
II. Split Fat Stain Checks for: Fatty acid globules
Reagent: 36% acetic acid
Principle: Emulsified stool + 36% acetic acid + 2 drops of Sudan III
Used to determine: Malabsorption syndromes
●​ Normal: Fatty acid is liberated once triglyceride is broken down
●​ Problem: Fatty acid was not absorbed in the intestine which can cause
steatorrhea

Notes:
●​ Fatty acid is normally seen in the stool
●​ Count 100 droplets
●​ In 100 droplets, determine the MAJORITY of SIZE of the globule

Result:
●​ Normal: <4 um (100 droplets)
●​ Slightly increased: 1–8 um (100 droplets)
●​ Increased: 6–75 um (100 droplets)
○​ possibly indicates steatorrhea
 QUANTITATIVE / DEFINITIVE TESTS FOR FECAL FAT DETERMINATION

I. Van de Kamer ●​ Gold standard for fecal fat

Titration ●​ For DEFINITIVE diagnosis of steatorrhea
●​ Used to QUANTIFY the amounts of fat

Sample: 3-day stool

Principle: Titration with NaOH

●​ Separates fat from other debris

Process:
●​ Take out the fat from the solution
●​ Weigh / quantify the amount of fat using an automated instrument

Result:
●​ Normal value: 1–6 g fats/day
●​ Steatorrhea: >6 g fats/day or 18–21 g of entire sample
II. Acid Steatocrit ●​ An example of gravimetric method
●​ Screens for steatorrhea in pediatric populations
●​ Rapid test to estimate the amount of fat excretion
○​ only estimation as pediatric populations cannot be asked to
collect a 3-day stool sample

Process:
●​ Emulsify the fecal sample with water in a container
●​ The consistency should be creamy
●​ Add acid (e.g., NITRIC ACID)
●​ Place the capillary tube in the container
●​ Centrifuge
●​ Afterwards, there will be formation of layers: *bottom to top
○​ Solid bottom layer (non-fatty): undigested
○​ Liquid intermediate layer: water
○​ Top fatty layer: % of fat
●​ Determine the size of the FATTY LAYER

🟰
○​ % = (vol of fat layer / vol of solid layer) x 100
○​ Larger size of fatty layer More fats are present in the stool
III. Other Methods ●​ Near-infrared reflectance spectroscopy (NIRS)
●​ Nuclear magnetic resonance spectroscopy

❗ Fat has a specific wavelength which it can absorb light. Thus,

spectroscopic method is also used for fat determination
 TESTS, MATERIALS, AND INSTRUMENTATION FOR FECAL FAT ANALYSIS

Procedure Materials, Instrumentation

Sudan III Sudan stain

Microscopy

Van de Kamer Titration Fecal fat extraction and titration of long chain fatty acid by NaOH
Gold standard test for fecal fats

Steatocrit & Acid steatocrit Hct centrifuge, gravimetric assay

Fecal elastase I Immunoassay ELISA technique

For determination of exocrine dysfunction of pancreas

Near-infrared reflectance NIRS spectrophotometer with specialized computer software

spectroscopy (NIRS)

Nuclear magnetic Microwaved-dried specimen

resonance spectroscopy Hydrogen nuclear magnetic spectrophotometer
📌MUSCLE FIBERS
📍Creatorrhea — abnormal excretion of muscle fibers in the feces

●​ Used to determine: Maldigestion syndromes

●​ Determination: The patient should include red meat in the diet within 24 hours before
collection

1.​ Emulsify stool + 10% EOSIN (stain)

2.​ Apply a coverslip and let it stand for 3 minutes
3.​ Examine under high power for 5 minutes
4.​ Count the number of undigested fibers per HPF

●​ Check for: Undigested and Striations

○​ No striation: Completely digested
○​ Unidirectional striations: Partially digested
○​ Striations in both direction: Undigested
●​ Abnormal: 10 undigested muscle fibers ➡️ Creatorrhea / Maldigestion syndrome
○​ Undigested striated muscle fiber
■​ biliary obstruction
■​ gastrocolic fistulas
■​ pancreatic insufficiency (cystic fibrosis)
Partially Digested Muscle Fiber
📌FECAL LEUKOCYTES
Remember: WBCs are not normally seen in feces
●​ But not all types of infection can increase WBC in the stool
●​ Enterotoxin-producing bacteria — diarrhea without WBC or normal range of WBC

Invasive condition: >3 neutrophils/HPF

Diarrhea with WBC Diarrhea without WBC

●​ Campylobacter ●​ Toxin-producing bacteria

●​ Salmonella ○​ Staphylococcus aureus
●​ Shigella ○​ Vibrio cholerae
●​ Yersinia ●​ Viruses
●​ Enteroinvasive E. coli ●​ Parasites
Determination: All slide preparations must be performed on fresh specimens

Preparation Steps / Comments Advantages

Wet preparation: 1. Put the sample in a tube Loeffler’s Methylene Blue

Stool + Loeffler’s 2. Emulsify the sample with small ●​ More PREFERRED

Methylene Blue amount of water to make it soft ●​ Has the capability to stain

➡️
nucleus and granules of the
3. Add now the stain WBC easier identification of
WBC (esp. neutrophil)
4. Make a smear of the solution on
a slide

Dried preparation: 1. Put directly the sample on the ●​ Provides PERMANENT slides for
slide to make a smear evaluation
Stool + Wright’s /
Gram stain 2. Add now the stain Gram stain

➡️
●​ Observation of gram-positive
and gram-negative bacteria
aid in the initial treatment
Lactoferrin latex Special type of latex serves a ●​ Remains sensitive in
agglutination test carrier of Ab which is directed to refrigerated and frozen
lactoferrin specimens

Lactoferrin — 2° granules of
neutrophils; (+) invasive bacterial
pathogen

⬆️ lactoferrin 🟰 ⬆️ neutrophil
in the feces

(+) Result: Agglutination

🟰
●​ Presence of lactoferrin in the
sample neutrophils in the
sample
📍Diarrhea
⬆️
●​ Stool weight: >200 g/day
●​ Liquidity: liquidity
●​ Frequency of defecation: >3x a day

●​ Duration of illness:
○​ Acute: <4 weeks
○​ Chronic: >4 weeks

●​ 3 mechanisms: *Differences are based on the cause of diarrhea

○​ Secretory
○​ Osmotic
○​ Altered motility
 Laboratory Tests for Diarrhea

Fecal electrolytes Fecal Osmotic Gap = 290 – [2 (fecal sodium + fecal potassium)]
●​ normal fecal sodium: 30 mmol/L
●​ normal fecal potassium: 75 mmol/L

⬆️ fecal electrolyte
⬇️ fecal electrolyte
●​ Secretory diarrhea:
●​ Osmotic diarrhea:

Fecal osmolality Near 290 mOsm/serum Osm

●​ Normal total fecal osmolarity is close to the serum osmolality

⬇️ fecal osmolality 🟰 <50 mOsm/kg

⬆️ fecal osmolality 🟰 >75 mOsm/kg
●​ Secretory diarrhea:
●​ Osmotic diarrhea:

Stool pH ●​ Secretory diarrhea: >5.6 pH

➡️ osmotic diarrhea
●​ Osmotic diarrhea: <5.3 pH
○​ malabsorption of sugars
 Classification of Mechanism Cases
Diarrhea

Secretory ●​ ⬆️ solute secretion by the ●​ Enterotoxin-producing

intestine organisms

●​ ⬆️ amount of osmotically active

⬆️
Osmotic ●​ Maldigestion
solutes remain in the lumen ●​ CHO in stool
●​ Giardiasis
●​ Ingestion of osmotically active ●​ Strongyloidiasis
●​ Surgical procedures

Intestinal ●​ ⬆️ intestinal hypermotility ●​ Secretory and osmotic

Hypermotility diarrhea
●​ Laxatives (castor oil)
●​ Emotion / stress
●​ Cardiovascular drugs
🔹Secretory Diarrhea
●​ Large intestine is normal but there is an ⬆️secretion of solute 🟰 water will follow 🟰 ⬆️
⬆️
secretion of water which overrides reabsorptive capacity of large intestine

⬇️
●​ fecal electrolytes
●​ stool osmolality

Causes of Secretory Diarrhea

Enterotoxin-producing ●​ Vibrio cholerae

organisms ●​ Staphylococcus
●​ Escherichia coli
●​ Clostridium
●​ Salmonella
●​ Shigella
●​ Campylobacter
●​ Protozoa
●​ Cryptosporidium
Stimulant ●​ Laxatives — contribute to the watery of feces

Hormones
Inflammatory bowel ●​ Crohn’s disease
diseases ●​ Ulcerative colitis
●​ Lymphocytic colitis
●​ Diverticulitis

⬆️
Endocrine disorders ●​ Hyperthyroidism
●​ Zollinger-Ellison syndrome — secretion of gastrin
●​ Vipoma — a non-beta pancreatic islet cell tumor secreting vasoactive
intestinal peptide (VIP), resulting in a syndrome of watery diarrhea,
hypokalemia, and achlorhydria (WDHA syndrome)

Neoplasm

Collagen-vascular
disorders
🔹Osmotic Diarrhea
⬇️ fecal electrolytes
⬆️ stool osmolality
●​
●​

●​ Caused by:
○​ Poor absorption that exerts osmotic pressure across the intestinal mucosa
○​ Malabsorption — impaired nutrient absorption

⬆️
○​ Maldigestion — impaired food digestion
○​ Ingestion of large amount of active solutes

➡️ ➡️
🟰 ⬆️
●​ Incomplete breakdown / absorption of food increased fecal material in the large intestine

➡️
retention of water and electrolytes in the large intestine amount of osmotically active
solutes remain in the lumen of digestive tract excessively watery stool

➡️ ➡️ decreased electrolytes
➡️
●​ Presence of unabsorbable solute increases the stool osmolality
concentration increased osmotic gap
 Conditions Associated with Osmotic Diarrhea

Disaccharidase deficiency Lactose intolerance

❌ 🟰 ⬆️ 🟰 lactose
●​ Normal: Lactose —lactase—> glucose + galactose

🟰 ⬆️
●​ Abnormal: lactase lactose in intestine
fermentation by E.coli acid (<5.3 pH)
●​ Remember: E. coli is a lactose fermenter

Poorly absorbed sugars Lactose, sorbitol, mannitol

Malabsorption Celiac sprue

Laxatives

Magnesium-containing
antacids

Amebiasis Amoeba destroys the lining of intestine ➡️ problems with absorption

Antibiotic administration
🔹Altered Motility
●​ Peristalsis

➡️ ➡️ altered motility
○​ automatic wave-like movement of muscles that lines the GIT
○​ alteration in peristalsis disruption on the nerve or muscle of GIT
(improper contraction or relaxation)

●​ Problems in the muscle movement of GIT, either:

➡️ ❌ normal
○​ Enhanced motility (hypermotility)

➡️
■​ excessive movement of intestinal contents through the GIT
absorption of intestinal contents and nutrients diarrhea

➡️ ➡️ hard stool
○​ Slow motility (constipation)
■​ slow motility excessive absorption of water

●​ Most common cause: Irritable Bowel Syndrome

 Irritable Bowel Syndrome (IBS)
a functional disorder in which the nerves and muscles of the bowel are extra sensitive

Triggers ●​ food
●​ chemicals
●​ emotional stress — constipation
●​ exercise

Results ●​ cramping
●​ bloating
●​ flatus — prolong flatulence; gas is improperly excreted

➡️ ➡️ hard stool
●​ diarrhea
●​ constipation — slow motility excessive absorption of water
 Disturbances in Gastric Reservoir or Transporting Function
“Dumping Syndrome”

Early Dumping Syndrome (EDS) Late Dumping Syndrome

10–30 mins after meal 2–3 hrs after meal

➡️
●​ Immediate bowel movement after a meal
shortened gastric emptying half time

●​ Nausea ●​ Weakness
●​ Vomiting ●​ Sweating
●​ Bloating ●​ Dizziness
●​ Cramping ●​ Hypoglycemia
●​ Diarrhea
●​ Dizziness
●​ Fatigue
Normal gastric emptying half time: 35–100 mins

Causes of dumping syndrome:

●​ Gastrectomy

➡️ ➡️
●​ Gastric bypass surgery

➡️
●​ Post-vagotomy status — cutting vagus nerve will not feel hunger late dumping syndrome
●​ Zollinger-Ellison syndrome — excessive acidity in stomach faster digestion
●​ Duodenal ulcer disease
●​ Diabetes mellitus
📌OTHER FORMED ELEMENTS
CHEMICAL EXAMINATION

●​ Fecal occult blood test

●​ APT test (Fetal hemoglobin)

●​ Fecal enzymes
○​ X-ray film
○​ ELISA kits

●​ Fecal carbohydrates
○​ Clinitest
○​ pH
○​ D-xylose test
📌FECAL OCCULT BLOOD TEST (FOBT)
Etymology ●​ Occult = Hidden
●​ Small amount in the blood is not seen

Screening ●​ GI bleeding
test for ●​ Colorectal cancer — small amount of blood in the stool may be an indication that the patient
has carcinoma

Significant ●​ >2.5 mL blood per 150 g of stool

Sample ●​ Center portion of the stool

Principle ●​ Pseudoperoxidase activity of hemoglobin (Oxidation)

Hemoglobin + H2O2 + guaiac —pseudoperoxidase—> oxidized guaiac + H2O

(colorless) (blue color)

Chromogen ●​ Benzidine — most sensitive but carcinogenic (aplastic anemia)

●​ Guaiac — most preferred and cheaper
●​ O-toluidine
(➕) FOBT ●​ ANY blue discoloration

(➖) FOBT ●​ NO discoloration

False (➕) 😋Dietary pseudoperoxidases: *AVOID AT LEAST 3 CONSECUTIVE DAYS

○​ Red meat 🥩
●​

○​ Melon 🍈
FOBT

○​ Broccoli 🥦
○​ Cauliflower
○​ Horseradish

●​ 💊Medications: *AVOID FOR 7 DAYS

○​ Aspirin
○​ NSAIDs

➡️ ➡️ blood in the sample

○​ Other antiinflammatory drugs
*causes irritation to the GUT induces damage

●​ 🩸Contaminations:
○​ Menstruation
○​ Hemorrhage
 ➖)
➡️
False ( ●​ Reducing agents:
FOBT ○​ Ascorbic acid / Vitamin C >250 mg/day
○​ Iron therapy / supplements containing vitamin C

●​ Technical: Failure to wait the specified time after sample is applied to add
the developer reagent

Steps 1.​ Open the front flap of the guaiac-impregnated filter paper slide.
2.​ Using an applicator stick, take a sample from the center of the stool specimen.
3.​ Apply a thin smear of stool on the filter paper inside the box marked “A” on the slide.
4.​ Using the same applicator stick, take a second sample from a different part of the center of the
stool.
5.​ Apply a thin smear of the second sample inside the box marked “B.”
6.​ Close the cover of the filter paper slide.
7.​ Allow the stool samples to soak into the filter paper slide for 3–5 minutes.
8.​ Open the back of the slide.
9.​ Add 2 drops of hydrogen peroxidase developer to the boxes marked “A” and “B.”
10.​ Read results within 60 seconds. Any trace of blue on or at the edge of the smear is positive for
occult blood.
11.​ Add 1 drop of hydrogen peroxidase developer between the positive and negative internal
control.
12.​ Read quality control results within 10 seconds. The positive control will appear blue, and no color
will be present in the negative control.
📌APT TEST / APT DOWNEY TEST (FETAL
HEMOGLOBIN)

Used to ●​ Differentiate fetal blood and maternal blood based on the hgb present

Hb F (2a + 2y) Hb A1 (2a + 2b)

●​ Predominant hgb in infants ●​ Predominant hgb in adults

●​ Alkali resistant ●​ Denatured by alcohol
●​ Resists lysis when exposed to alkaline ●​ Lysed when exposed to alkaline
sol’n sol’n

Rationale ●​ Grossly bloody stools and vomitus are seen sometimes in neonates as the result
of swallowing maternal blood during delivery.
●​ Should it be necessary to distinguish between the presence of fetal blood or
maternal blood in an infant’s stool or vomitus, the APT test may be requested.

Specimen ●​ Infant stool

●​ Infant vomitus
Procedure ●​ Emulsified stool ➡️ centrifuge➡️ add 1% NaOH to supernatant
1.​ Emulsify specimens in water.
2.​ Centrifuge.
3.​ Divide pink supernatant into 2 tubes.
4.​ Add 1% NaOH to 1 tube.
5.​ Wait 2 minutes.
6.​ Compare color with that in the control tube.
7.​ Prepare controls using cord blood and adult blood.

Results ●​ (+) Fetal blood: Pink solution

●​ (+) Maternal blood: Yellow brown supernatant

Interference ●​ Thalassemia major — excessive hgb F

○​ Effect on the maternal blood under APT test: Pink solution
📌FECAL ENZYME
●​ Supplied to the GIT by pancreas

●​ Essential for digesting dietary CHONs, CHOs, and fats

●​ Chronic pancreatitis / cystic fibrosis ➡️ pancreatic enzyme insufficiency ➡️ steatorrhea &

appearance of undigested food in feces

●​ Used to:
○​ Assess the function of the pancreas in producing fecal enzymes
○​ Determine if there is insufficiency in the fecal enzymes

●​ Primary focus of fecalysis: Proteolytic enzymes

○​ Trypsin
○​ Chymotrypsin
○​ Elastase I
📍Trypsin
●​ MAJOR enzyme necessary for the degradation of PROTEIN
●​ Protein digesting enzymes

🔹X-ray Film
●​ Detects trypsin enzyme
●​ Procedures:
○​ Centrifuge the sample
○​ Use the supernatant
○​ Expose x-ray film to stool emulsified in water
■​ X-ray film — contains gelatin
■​ Trypsin — capable of digesting gelatin
○​ Wait if there will be clearing

➕ ✔️
●​ Results:

➖ ❌
○​ ( ) for trypsin: Clearing of the x-ray film
○​ ( ) for trypsin: No clearing of the x-ray film

➡️
■​ cystic fibrosis

➕
■​ problems in the exocrine glands cannot produce enzymes

➖
○​ False ( ): Proteolytic activity of bacterial enzyme
○​ False ( ): Intestinal degradation of trypsin; possible presence of trypsin inhibitors
📍Chymotrypsin
●​ MORE RESISTANT to intestinal degradation than trypsin

●​ MORE SENSITIVE indicator of less severe cases of pancreatic insufficiency

●​ Remains STABLE in fecal specimens for up to 10 days at RT

●​ Capable of gelatin hydrolysis

●​ Measured most frequently by: Spectrophotometric methods

📍Elastase I
●​ An isoenzyme of elastase

✔️
●​ SPECIFIC or only produced in pancreas

❌
○​ elastase I = pancreas has the ability to produce substances
○​ elastase I = possible problems in the function of pancreas
●​ Provides a VERY SENSITIVE indicator of exocrine pancreatic insufficiency
●​ High concentrations in pancreatic secretions — account for ~6% of all secreted pancreatic
enzymes
●​ STRONGLY RESISTANT to degradation
●​ Not affected by motility disorders or mucosal defects

🔹ELISA Kits
●​ Measures elastase I
●​ Easy to perform
●​ Requires only a single stool specimen
●​ Uses monoclonal antibodies against human pancreatic elastase-1; therefore, the result is
specific for human enzyme and not affected by pancreatic enzyme replacement therapy
●​ Specific in differentiating pancreatic from non-pancreatic causes in patients with steatorrhea
📌FECAL CARBOHYDRATE
●​ Sugar is not digested but has to be absorbed to be present in the urine

●​ MOST VALUABLE in assessing cases of INFANT diarrhea (e.g., lactose intolerance)

➡️ osmotic pressure of the unabsorbed sugar

➡️ ➡️ osmotic diarrhea
●​ Presence of increased carbohydrates in the stool
in the intestine drawing in fluid and electrolytes

➡️
●​ Causes of the presence of CHOs in the feces:

➡️
○​ intestinal inability to absorb carbohydrates celiac disease
○​ lack of digestive enzymes (lactase) lactose intolerance

●​ Determination:
○​ Clinitest
○​ pH
○​ D-xylose test
Clinitest Principle: Copper reduction
Uses:
●​ General test for the presence of reducing sugars
○​ useful for determining lactose intolerance
○​ sucrose is not detected as it is not a reducing sugar
●​ Distinguishes between diarrhea caused by abnormal excretion of reducing
sugars and those caused by various viruses and parasites

Process: 1 part stool emulsified in 2 parts water

Carbohydrate intolerance: >0.5 g/dL
●​ positive result would be followed by more specific serum carbohydrate tolerance
tests

pH Normal stool pH: 7.0–8.0 pH

⬆️ ⬇️
CHO disorders: <5.5 stool pH

⬆️ 🟰 ⬆️ lactic acid
●​ CHO = pH (more acidic)

🟰 ⬇️
●​ use of carbohydrates by intestinal bacterial fermentation
level pH
D-xylose Uses: Differentiates PANCREATITIS or MALABSORPTION
Test Patient preparation: Fasting (8–12 hrs)
Sample baseline: Urine & Blood
Reagent: D-xylose (*applied in both urine and blood)

🟰 ✔️ maldigestion 🟰 ❌ malabsorption
➡️
Normal urine & blood D-xylose: Pancreatitis
D-xylose excreted in the urine

🟰
🟰
Low urine & blood D-xylose: Malabsorption D-xylose was not able to go back to
the blood D-xylose will not be excreted in the urine
●​ bacterial overgrowth
●​ intestinal resection
●​ celiac disease
●​ tropical sprue
●​ lymphoma
●​ Whipple disease
SUMMARY OF FECAL SCREENING TESTS

Test Methodology / Principle Interpretation

Examination for Microscopic count of neutrophils in smear 3/HPF

Neutrophils stained with: indicates condition affecting
●​ Methylene blue (wet stain) intestinal wall / invasive
●​ Gram stain (dried prep)
●​ Wright’s stain (dried prep)

Qualitative fecal Microscopic examination of direct smear 60 large red-orange droplets

fat stained with: indicates maldigestion
●​ Sudan III

Microscopic examination of smear heated 100 orange-red droplets

with: measuring 6–75um
●​ Acetic acid indicates malabsorption
●​ Sudan III
Occult blood Pseudoperoxidase activity of hgb liberates Blue color
oxygen from H2O2 to oxidize guaiac reagent indicates GI bleeding

APT test Addition of NaOH to hgb containing Pink color

emulsion determines presence of maternal indicates presence of fetal blood
or fetal blood

Trypsin Emulsified specimen placed on x-ray paper Inability to digest gelatin

determines ability to digest gelatin indicates lack of trypsin

Clinitest Addition of Clinitest tablet to emulsified Reaction of 0.5 g/dL reducing

stool defects presence of reducing substances
substance suggests CHO intolerance