CLINICAL CHEMISTRY-STOOL
Introduction
Stool (feces) analysis is a non-invasive and vital diagnostic tool in clinical chemistry and
parasitology. It helps detect intestinal infections, digestive disorders, the presence of ova, cysts,
trophozoites, and helminths, and offers valuable clues to conditions like malabsorption,
gastrointestinal bleeding, or inflammation.
Stool Chemistry Parameters
pH: Normally ranges between 6.5 and 7.5. Acidic stool (lower pH) suggests carbohydrate
malabsorption such as lactose intolerance.
Occult Blood (FOBT): Normally negative. A positive test indicates gastrointestinal bleeding,
possibly from colorectal cancer, ulcers, or polyps.
Reducing Substances: Normally absent. Their presence suggests sugar malabsorption,
common in conditions like lactase deficiency.
Fat (Sudan Stain): Normally fewer than 7 fat droplets per high power field. An increased number
indicates steatorrhea, suggesting fat malabsorption.
Leukocytes: Should be absent. If present, they point toward inflammatory diarrhea, for example
due to Shigella or inflammatory bowel disease.
Elastase: Present in normal amounts. Decreased levels suggest pancreatic insufficiency.
Chymotrypsin: Normal levels indicate proper pancreatic enzyme function. Low levels suggest
exocrine pancreatic insufficiency.
Alpha-1 Antitrypsin: Normally low. Elevated levels are associated with protein-losing
enteropathies.
Parasitological Stool Examination
Diagnostic methods include:
Direct wet mount using saline and iodine to detect motile trophozoites and cysts.
Concentration techniques, such as formol-ether sedimentation and zinc sulfate flotation,
increase detection of ova and cysts.
Staining methods like trichrome (for protozoa) and acid-fast (for coccidia: Cryptosporidium,
Cyclospora, Isospora).
Antigen detection techniques such as ELISA and immunochromatographic tests provide
sensitive results.
Molecular methods (PCR) help confirm parasitic infections by detecting specific DNA.
Parasites in Stool – With Distinguishing Features
Protozoa
Entamoeba histolytica appears as both cysts and trophozoites. Cysts have 1–4 nuclei and
chromatoid bars. Trophozoites have a central karyosome and may contain ingested red blood
cells.
Giardia lamblia presents as oval cysts with 4 nuclei and trophozoites that are pear-shaped,
bilaterally symmetrical, and resemble a “face” or “monkey face.”
Cryptosporidium spp. appear as small spherical oocysts, 4–6 microns in size, and stain acid-fast
positive.
Cyclospora cayetanensis produces larger oocysts (8–10 microns) that are refractile,
autofluorescent, and acid-fast positive.
Isospora belli oocysts are oval and measure 20–30 microns. They stain acid-fast positive.
Balantidium coli has large ciliated trophozoites with a visible macronucleus. Also exists in a
cystic form.
Blastocystis hominis shows a vacuolar form with a central body and peripheral nuclei.
Helminths (Worms)
▪ Nematodes (Roundworms)
Ascaris lumbricoides produces fertilized eggs that are round with thick shells and unfertilized
eggs that are oval with thin shells and disorganized content.
Enterobius vermicularis eggs are oval, flattened on one side, and embryonated. Commonly
detected using a perianal swab (Scotch tape test).
Trichuris trichiura eggs are barrel-shaped with bipolar plugs.
Hookworms (Ancylostoma and Necator) have thin-shelled, oval eggs that contain segmented
embryos (4–8 blastomeres).
Strongyloides stercoralis is usually detected in its rhabditiform larval stage, characterized by a
short buccal cavity and prominent genital primordium.
▪ Cestodes (Tapeworms)
Taenia spp. eggs are spherical with a thick wall and radially striated shell.
Hymenolepis nana eggs are oval with distinct polar filaments.
Diphyllobothrium latum eggs are oval, operculated, and have a terminal knob.
▪ Trematodes (Flukes)
Schistosoma mansoni eggs are large with a lateral spine.
Schistosoma haematobium eggs have a terminal spine and are usually found in urine.
Fasciolopsis buski produces large, operculated eggs that are oval.
Clonorchis sinensis eggs are small, operculated, and possess a shoulder-like structure and
terminal knob.
Special Stains & Techniques for Parasites
Modified Ziehl–Neelsen stain: Used for Cryptosporidium, Cyclospora, and Isospora.
Trichrome stain: Best for visualizing trophozoites such as Giardia and Entamoeba.
Iodine wet mount: Enhances visualization of cysts, their nuclei, and glycogen content.
Formalin–ethyl acetate concentration: Concentrates parasites like ova and cysts.
Scotch tape test: Specific method for detecting Enterobius eggs.
Kato-Katz technique: Used to quantify helminth eggs, especially Schistosoma species.
Summary of Key Parasites and Forms
Entamoeba histolytica: Cysts and trophozoites, the latter often showing ingested RBCs.
Giardia lamblia: Cysts and trophozoites with characteristic “monkey face” appearance.
Cryptosporidium: Acid-fast oocysts approximately 5 microns in diameter.
Ascaris lumbricoides: Ova with thick, mammillated outer coat.
Trichuris trichiura: Ova are barrel-shaped with bipolar plugs.
Hookworm: Ova are oval and segmented.
Strongyloides: Detected via larvae with a short buccal cavity.
Taenia spp.: Eggs have thick, striated walls.
Schistosoma mansoni: Eggs exhibit a lateral spine.
Clinical Notes
Always collect multiple stool samples (at least three) on alternate days for increased sensitivity.
Diarrheic stools must be examined within 30 minutes to detect active trophozoites.
If examination is delayed, preserve the sample using formalin or polyvinyl alcohol (PVA).
Parasitic infections may present with eosinophilia, weight loss, anemia, and gastrointestinal
symptoms.
Dr LëK.
