Electrolytes, Stool

Stool for Electrolytes or Osmolality

Specimen Collection Criteria

Collect: Random stool sample that is liquid in consistency. Solid stool will NOT be accepted.

Physician Office/Drawsite Specimen Preparation

Refrigerate (2-8C or 36-46F) specimen immediately. May be transported and stored refrigerated for 2 hours after collection. For longer storage, the specimen should be frozen (-20C/-4F or below).

Preparation for Courier Transport

Transport refrigerated (2-8C or 36-46F).

Rejection Criteria

Formed stool is not a suitable specimen and will not be accepted for this test.

Storage

The liquid stool should be refrigerated immediately following collection. If analysis cannot be performed within 2 hours after refrigeration, the sample should be frozen (-20C/-4F or below). For more information on this test please see procedures at InsideBeaumont Clinical Pathology, Automated Chemistry

Laboratory

Royal Oak Automated Chemistry Laboratory

Performed

Sunday - Saturday Routine results available the same day.

Reference Range

Na (sodium): 20-50 mmol/L K (potassium): 80-140 mmol/L Osmolality: 300-350 mosm/kg

Test Methodology

Electrolytes - Ion selective electrode Osmolality - Freezing point depression

Interpretation

The osmolal gap in secretory diarrhea is less than 50 mosm/kg and in osmotic diarrhea is greater than 50 mosm/kg. Osmolal gap is calculated as follows: Measured stool osmolality - 2 x [Na + K] in stool. A very low stool osmolality is suggestive of factitious diarrhea.

Clinical Utility

Stool osmolality is useful in cases of chronic diarrhea to differentiate secretory, osmotic and factitious diarrhea. It may be helpful to the physician to know whether the diarrhea is (i) a secretory type caused by either an organism or an abnormality of water or electrolyte transport

across the cell wall of the gut; (ii) an osmotic type caused by malabsorption of non-electrolyte substances, most commonly carbohydrates or certain laxatives (eg. magnesium).

Factitious diarrhea: If the stool osmolality is significantly lower than plasma osmolality, factitious diarrhea (i.e. addition of water or liquid to stool by patient) should be suspected. Secretory diarrhea: In secretory diarrhea the measured stool osmolality should be similar to 2 x [Na + K] of the stool specimen. The osmolal gap [measured- calculated osmolality] should be < 50 mosm/kg. If the stool sample was not refrigerated immediately after collection, and if necessary frozen, the measured osmolality may be inappropriately elevated. This change is due to bacterial metabolism which results in production of osmotically active substances. If inappropriate handling has occurred it is suggested that the stool osmolality is assumed to be 290 mosm/kg. However this may not be appropriate if osmotic diarrhea is suspected. Osmotic diarrhea: In osmotic diarrhea the osmolal gap should be > 50 mosm/kg. The values of sodium, potassium and osmolality in the stool fluid as well as their relationship to one another are useful in making this distinction and deciding on a course of treatment.

Stool osmotic gap

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Stool osmolal gap (or stool osmotic gap) is a calculation performed to distinguish among different causes of diarrhea. A low stool osmolal gap can imply secretory diarrhea, while a high gap can imply osmotic diarrhea.[1] It is calculated with the equation 290 2 * (stool Na + stool K).[2] The 290 is the value of the stool osmolality. The stool osmolality is usually not directly measured, and is often given a constant in the range of 290 to 300.[3] A normal gap is less than 50.[4] High osmolal gap causes of osmotic diarrhea include celiac sprue, chronic pancreatitis, lactase deficiency, and Whipple's disease. Low osmolol gap causes of secretory diarrhea include toxin-mediated causes (cholera, enterotoxigenic strains of E. coli) and secretagogues such as vasoactive intestinal peptide (from a VIPoma, for example). Uncommon causes include gastrinoma, medullary thyroid carcinoma (which produces excess calcitonin), and villous adenoma.

Clinical Significance
Fecal electrolytes are useful in assessing cases of watery diarrhea. Normal fecal fluid has an osmolality close to that of plasma, (about 290 mOsmol / kg H2O) , sodium about 30 mmol/ L, potassium about 75 mmol/L, and magnesium about 5 to 100 mmol/L depending upon diet, although it is usually < 45 mmol/L. The magnitude of the osmolar gap, the difference between the measured fecal osmolality and that contributed by sodium and potassium, calculated by 2*(Na++K+) in mOsm/ kg H2O, indicates the concentration of poorly absorbable solute(s). A fecal sodium of > 90 mmol/L and an osmotic gap of < 50 mOsm / kg suggests secretory diarrhea or osmotic diarrhea due to sodium containing laxatives. Fecal sodium of > 150 mmol/L and an osmolality of > 375 400 mOsmol/kg suggests contamination with concentrated urine, while a fecal osmolality of < 200 250 mOsmol/kg suggests contamination with dilute urine or water. Increased fecal magnesium suggests presence of magnesium containing laxatives.

Clinical Information
The concentration of sodium in fecal water and the rate of excretion are dependent upon 3 factors: -Five% to 10% of the normal daily dietary load of sodium passes into the gastrointestinal (GI) tract -Sodium is passively transported from serum and other vascular spaces to equilibrate fecal osmotic pressure with vascular osmotic pressure -Certain rare toxins (cholera toxin) cause sodium transport into fecal water

Interpretation
Typically, stool sodium is similar to serum since the gastrointestinal (GI) tract does not secrete water. A useful formula is 2x (stool sodium + stool potassium) = stool osmolality + or - 30 mOsm.

Increased fecal sodium content or daily excretion rate with normal fecal potassium and no osmotic gap indicates secretory diarrhea.

Normal fecal sodium and potassium in the presence of an osmotic gap (>30 mOsm/kg) suggests osmotic diarrhea.

Normal or low fecal sodium in association with high fecal potassium suggests deterioration of the epithelial membrane or a bleeding lesion.

High sodium and potassium in the absence of an osmotic gap indicate active electrolyte transport in the GI tract that might be induced by agents such as cholera toxin or hypersecretion of vasointestinal peptide.

If sodium concentration or 24-hour sodium excretion rate is 2 to 3 times normal and osmotic gap >30 mOsm/kg, secretory diarrhea may be the cause. Agents such as phenolphthalein, bisacodyl, or cholera toxin should be suspected.

For very low stool osmolality, consider factitial diarrhea.

Cautions
This test will be performed on watery feces (diarrhea) only.

In the event a formed stool is submitted, the test will not be performed and the report will indicate: "A formed stool specimen was submitted for analysis. This test was not performed because it only has clinical value if performed on a naturally occurring watery stool specimen."

Clinical Information
Potassium is an intracellular cation normally present in fecal water at a concentration approximately 20 times higher than the serum concentration.

The fecal water potassium content is comprised of 2 fractions-approximately 15% of the normal dietary intake of potassium (80 mEq/day) passes through the gastrointestinal (GI) tract to be deposited directly in fecal water, and a small fraction of potassium crosses the epithelial barrier of the GI tract from extra cellular fluids based on osmotic pressure.

In adults, the median daily excretion of potassium is 9 mEq/day, ranging from 0 mEq/day to 30 mEq/day. The median concentration of potassium in fecal water is 40 mEq/kg, ranging from 0

mEq/day to 200 mEq/kg. Potassium excretion is race-related; excretion in blacks is less than in Caucasians, usually by a factor of 2.

The fecal water potassium concentration and daily excretion rate will be normal if the cause of diarrhea is bacteria or due to ingestion of osmotic agents such as magnesium, phenolphthalein, and sulfate. The fecal water potassium daily excretion rate will be normal, but the measured concentration will be increased in patients with contracted colon volume.

Both the daily excretion rate of potassium and potassium concentration will be elevated in ulcerative colitis or other diseases where there is bleeding into the GI tract, exposure to cholera toxin, and in patients with islet cell tumors, increased secretion of vasointestinal peptide (vipoma syndrome), primary aldosteronism, ingestion of mineralocorticoids, and due to bacterial metabolism of unabsorbed carbohydrates passing through the GI tract.

Reference Values
0-15 years: not established > or =16 years: 0-199 mEq/kg

Interpretation
Typically, stool potassium is 20 times serum potassium. A useful formula is 2x (stool sodium + stool potassium) = stool osmolality + or - 30 mOsm.

Fecal potassium concentration and daily excretion rate are usually below the median level in patients with osmotic diarrhea. Normal fecal sodium and potassium in the presence of an osmotic gap (>30 mOsm/kg) suggests osmotic diarrhea.

Increased fecal sodium content or daily excretion rate with normal fecal potassium and no osmotic gap indicates secretory diarrhea.

High fecal potassium in association with normal or low fecal sodium suggests deterioration of the epithelial membrane or a bleeding lesion.

High sodium and potassium (3 times normal) in the absence of an osmotic gap indicate active electrolyte transport in the gastrointestinal (GI) tract that might be induced by agents such as cholera toxin, hypersecretion of vasointestinal peptide, or islet cell tumor.

For very low stool osmolality, consider factitial diarrhea.

The fecal potassium concentration and excretion rate are increased 2-fold to 3-fold with ulcerative colitis, or bleeding into the GI tract, when exposed to cholera toxin, with ingestion of mineralocorticoids, in primary aldosteronism, and due to bacterial metabolism of unabsorbed carbohydrates.

The fecal water potassium concentration and daily excretion rate exceeds 3 times normal in association with islet cell tumors and increased secretion of vasointestinal peptide.

Cautions
This test will be performed on watery stools (diarrhea) only.

In the event a formed stool is submitted, the test will not be performed, and the report will indicate: "A formed stool specimen was submitted for analysis. This test was not performed because it only has clinical value if performed on a naturally occurring watery stool specimen."

High concentrations of gadolinium and iodine are known to interfere with most metals tests. If either gadolinium- or iodine-containing contrast media has been administered, a specimen must not be collected for 96 hours.