URINE BILE ACIDS Studies of urine bile acids in people have shown them to be a sensitive test for liver

dysfunction.
Advantages of Urine Bile Acids There are several advantages of urine bile acids over serum bile acids measurement:

no requirement for fasting. avoids shortcomings of randomly collected serum samples and spurious results caused by spontaneous gall bladder contraction, incomplete or delayed gastric emptying, and slow intestinal transit time. provides a time-averaged sample that dampens acute changes in serum bile acids concentration that can occur due to physiologic variables affecting the enterohepatic circulation. no need for multiple venipuntures. less costly to perform.

Recent studies have evaluated urine bile acids testing in dogs and cats with liver disease. Serum and urine bile acids concentrations were compared in 126 dogs and 79 cats. Of the dogs, 102 had liver disease diagnosed at biopsy, 9 had other diseases, and 15 were healthy. Of the cats, 54 had liver disease, 17 had other diseases, and 8 were healthy. The highest serum bile acids concentration from either fasting, post-prandial, or randomly taken samples was compared to the urine bile acids concentration, collected within 24 hours of the serum. Urine bile acids concentrations were reported as a ratio to urine creatinine to eliminate changes due to differences in urine flow and urine concentration. Results:

for dogs, the sensitivity and specificity of urine bile acids for diagnosis of liver dysfunction were 61% and 100%, respectively, whereas serum bile acids had a sensitivity of 78% and specificity of 67%. for cats, the sensitivity and specificity of urine bile acids were 85% and 88%, respectively, whereas serum bile acids had a sensitivity of 87%, and the same specificity of 88%. patients with porto-systemic shunts (PSS) tended to have lower urine bile acids: creatinine ratios than patients with hepatocellular disease.

Conclusions:

the sensitivity and specificity of urine bile acids measurement were similar to those of serum bile acids, but the urine bile acids test was more specific for canine liver dysfunction than was serum bile acids testing. a pattern of results showing very high serum bile acids but only slightly increased urine bile acids may be indicative of a shunting disease such as PSS or MVD. while bile acids testing can identify animals with hepatic dysfunction, it may fail to recognize animals with hepatic disease in the absence of hepatic dysfunction.

To Measure Urine Bile Acids, 1mL of urine is required. Test Code 85645. A randomly collected urine sample is acceptable, but blood contamination should be avoided.

********************************************************************* *********

SERUM BILE ACIDS As serum bile acids testing is now often used as a screening test rather than for confirming hepatic dysfunction in ill patients, questions have arisen about the interpretation of results.
Results from fasting and post-prandial bile acids can vary or give spurious values due to:

common presence of microvascular dysplasia (MVD). Bile acids can be intermittently high in these dogs, although they often are

clinically normal. Certain breeds, such as Cairn Terriers and toy breeds, are predisposed to MVD. not all bile acids are stored in the gall bladder. Only ~60-80% of resting bile acids are in the gall bladder at any given time. Some bile acids are continuously released into the small intestine. gall bladder has periodic, small spontaneous contractions. incomplete post-prandial gall bladder contraction. variation in timing of peak bile acids concentration after feeding. Most dogs show maximum bile acids 2-4 hours post-prandially, although some dogs peak at 6-8 hours. delayed gastric emptying. differences in intestinal transit time.

These physiologic variations in the enterohepatic cycle explain why fasting bile acids sometimes can be higher than post-prandial bile acids. Such differences can be quite large, and fasting bile acids 100 mol/L more than post-prandial concentrations can be seen. Hepatic dysfunction is considered to be present when resting or postprandial bile acids are greater than 25 mol/L (dog) and 20 mol/L (cat). Animals with vascular shunts but normal hepatocytes tend to have lower and often normal fasting bile acids than do animals with hepatocellular disease. Monitoring Serum Bile Acids in Patients with Liver Disease:

interpretation of changes in bile acids can be difficult. modest reduction in serum bile acids concentrations cannot be used to conclude there is improvement in liver function or reduction in liver disease. animals with chronic liver disease develop acquired vascular shunts that do not close, even if liver disease resolves. Thus, postprandial bile acids likely will always be increased, despite improvement in liver function. ursodiol (Actigal) cross-reacts with the bile acids test and so use of this drug can falsely elevate bile acids concentration. As ursodiol will saturate the bile acids pool with chronic use,

discontinuing it for a short time will not eliminate its effects on bile acids.

References: Trainor et.al., J Vet Int Med 17: 145-153, 2003; Center, Proc. N Am Vet Conf 2003; pp. 413-415.

Glucose
Also known as: Blood sugar; Fasting blood sugar; FBS; Fasting blood glucose; FBG; Fasting plasma glucose; FPG; Blood glucose; Oral Glucose Tolerance Test; OGTT; GTT; Urine glucose Formal name: Blood Glucose; Urine Glucose Related tests: Urinalysis; Insulin; C-Peptide; A1c; Microalbumin; CMP; BMP

At a Glance Test Sample The Test Common Questions Ask Us Related Pages

At a Glance
Why Get Tested?
To determine if your blood glucose level is within a healthy range; to screen for, diagnose, and monitor high blood glucose (hyperglycemia) or low blood glucose (hypoglycemia), diabetes, and pre-diabetes; to check for glucose in your urine

When to Get Tested?

Blood glucose: as part of a regular physical, when you have symptoms suggesting hyperglycemia or hypoglycemia, and during pregnancy; if you are diabetic, self-checks up to several times a day to monitor blood glucose levels Urine glucose: usually as part of a urinalysis

Sample Required?

A blood sample drawn from a vein in your arm or a drop of blood from a skin prick; sometimes a random urine sample is used. Some diabetic patients may use a continuous glucose monitor, which is a small sensor wire inserted beneath the skin of the abdomen that measures blood glucose every five minutes.

Test Preparation Needed?

In general, it is recommended that you fast - nothing to eat or drink except water - 8 hours before having a blood glucose test. In persons with diabetes, glucose levels are often checked both while fasting and after meals to provide the best control of diabetes. For random, timed, and post-meal glucose tests, follow your doctor's instructions.

The Test Sample

What is being tested?
This test measures the amount of glucose in the blood or urine. Glucose is the primary energy source for the bodys cells and the only energy source for the brain and nervous system. A steady supply must be available for use, and a relatively constant level of glucose must be maintained in the blood. During digestion, fruits, vegetables, breads and other carbohydrates are broken down into glucose (and other nutrients); they are absorbed by the small intestine and circulated throughout the body. Using glucose for energy production depends on insulin, a hormone produced by the pancreas. Insulin facilitates transport of glucose into the body's cells and directs the liver to store excess energy as glycogen for short-term storage and/or as triglycerides in adipose (fat) cells. Normally, blood glucose rises slightly after a meal and insulin is released by the pancreas into the blood in response, with the amount corresponding to the size and content of the meal. As glucose moves into the cells and is metabolized, the level in the blood drops and the pancreas responds by slowing, then stopping the release of insulin. If the blood glucose level drops too low, such as might occur in between meals or after a strenuous workout, glucagon (another pancreatic hormone) is secreted to induce the liver to turn some glycogen back into glucose, raising the blood glucose level. If the glucose/insulin feedback mechanism is working properly, the amount of glucose in the blood remains fairly stable. If the balance is disrupted and the glucose level in the blood rises, then the body tries to restore the balance, both by increasing insulin production and by eliminating excess glucose in the urine. There are a few different conditions that may disrupt the balance between glucose and the pancreatic hormones, resulting in high or low blood glucose. The most common cause is diabetes. Diabetes is a group of disorders associated with insufficient insulin production and/or a resistance to insulin. People with untreated diabetes are not able to process and use glucose normally. Those who are not able to produce enough insulin to process glucose are diagnosed as having type1 diabetes while people who are resistant to insulin have type 2. Either type of diabetic may have acute and/or chronically increased blood glucose levels.

Severe, acute high blood glucose (hyperglycemia) or low blood glucose (hypoglycemia) can be life-threatening, causing organ failure, brain damage, coma, and, in extreme cases, death. Chronically high blood glucose levels can cause progressive damage to body organs such as the kidneys, eyes, heart and blood vessels, and nerves. Chronic hypoglycemia can lead to brain and nerve damage. Some women may develop hyperglycemia during pregnancy, which is termed gestational diabetes. If untreated, this can cause these mothers to give birth to large babies who may have low glucose levels. Women who have had gestational diabetes may or may not go on to develop diabetes.

How is the sample collected for testing?

A blood sample is obtained by inserting a needle into a vein in the arm or a drop of blood is taken by pricking the skin, typically on a finger, with a small, pointed lancet (fingerstick). Sometimes, a random urine sample is collected. Some diabetics may use a continuous glucose monitor, which is a small sensor wire inserted beneath the skin of the abdomen and held in place with an adhesive patch. The sensor measures blood glucose levels every five minutes and sends the results to a device that is attached to the person's clothing. A digital readout on the device lets the person know the blood glucose level in real time. NOTE: If undergoing medical tests makes you or someone you care for anxious, embarrassed, or even difficult to manage, you might consider reading one or more of the following articles: Coping with Test Pain, Discomfort, and Anxiety, Tips on Blood Testing, Tips to Help Children through Their Medical Tests, and Tips to Help the Elderly through Their Medical Tests. Another article, Follow That Sample, provides a glimpse at the collection and processing of a blood sample and throat culture.

Is any test preparation needed to ensure the quality of the sample?

For screening purposes, fasting is generally recommended - nothing to eat or drink except water at least 8 hours before a blood glucose test. Those who have been diagnosed with diabetes and are monitoring glucose levels are often tested both while fasting and after meals. For random and timed tests, follow the doctor's instructions. A glucose tolerance test requires that you fast for the first blood sample and then drink a liquid containing a specified amount of glucose. Subsequent blood samples are drawn at specified times.

The Test
1. 2. 3. 4. How is it used? When is it ordered? What does the test result mean? Is there anything else I should know?

How is it used?
The blood glucose test may be used to:

Screen for both high blood glucose (hyperglycemia) and low blood glucose (hypoglycemia) Help diagnose diabetes Monitor glucose levels in persons with diabetes

Depending on the purpose of testing, glucose may be measured on a fasting basis (collected after an 8- to 10-hour fast), randomly (anytime), post prandial (after a meal), and/or as part of an oral glucose challenge or tolerance test (OGTT / GTT). Screening Blood glucose is often measured as part of a group of tests, such as a CMP (Comprehensive Metabolic Panel), during routine physicals. This is done to screen for diabetes, which often causes no symptoms early in its course, and for pre-diabetes moderately increased blood glucose levels that indicate an increased risk of developing type 2 diabetes. For screening purposes, a CMP or blood glucose test is performed on a fasting basis (fasting blood glucose, FBG). Many pregnant women are screened for gestational diabetes, a temporary form of hyperglycemia, between their 24th and 28th week of pregnancy using a version of the OGTT, a 1-hour glucose challenge (GCT). For this test, a woman is given a standard amount of a glucose solution to drink. After one hour, her glucose level is measured and if the level is higher than a defined value, then a longer OGTT (usually 2 or 3 hours) is performed to clarify the woman's status. This is the recommendation of the American Congress of Obstetricians and Gynecologists. In 2011, the American Diabetes Association adopted guidelines that recommend changes in the way women are tested for gestational diabetes. Instead of the GCT described above, a 2-hour OGTT, using a 75-gram glucose drink, is performed. If one or more of her glucose levels at fasting, 1 hour, or 2 hours are above a certain level, then she is diagnosed as having gestational diabetes. The ADAs new recommendations follow those proposed in 2010 by the International Association of Diabetes and Pregnancy Study Group (IADPSG). This group based their recommendations on results of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) trial. This large study found that risk to babies increases with the gradual increase of maternal glucose levels; it determined that there is an increased risk of adverse outcomes for a baby even when only one of the mothers glucose levels is below the cutpoints used to diagnose gestational diabetes, and slightly lowered some of the cutpoints from those used in older guidelines. (For more on this, read the article Panel Suggests New Criteria for Gestational Diabetes.) Diagnosis The American Diabetes Association recommends a fasting glucose or a different test, the

hemoglobin A1c (A1c), to diagnose diabetes but says that testing should be done twice, at different times, preferably with the same test in order to confirm a diagnosis of diabetes. Another way to diagnose diabetes, especially if the screening test is not diagnostic, is the OGTT test. This test is a series of blood glucose tests. A fasting glucose is collected; then the person being tested drinks a standard amount of a glucose solution to "challenge" their system. This is followed by one or more additional glucose tests performed at specific intervals to track glucose levels over time. In those with suspected hypoglycemia in which an initial FBG result is low, the glucose test is used as part of the "Whipple triad" to confirm a diagnosis. (See Common Questions #5). Monitoring Diabetics must monitor their own blood glucose levels, often several times a day, to determine how far above or below normal their glucose is and to determine what oral medications or insulin(s) they may need. This is usually done by placing a drop of blood from a skin prick onto a glucose strip and then inserting the strip into a glucose meter, a small machine that provides a digital readout of the blood glucose level. Urine Urine glucose is one of the substances tested when a urinalysis is performed. A urinalysis may be done routinely as part of a physical or prenatal checkup, when a doctor suspects that a person may have a urinary tract infection or for a variety of other reasons. The doctor may follow up an elevated urine glucose test with blood glucose testing. ^ Back to top

When is it ordered?
Blood glucose testing can be used to screen healthy, asymptomatic individuals for diabetes and pre-diabetes because diabetes is a common disease that begins with few symptoms. Screening with a glucose test may occur during public health fairs or as part of workplace health programs. It may also be ordered when someone has a routine physical exam. Screening is especially important for people at high risk of developing diabetes, such as those with a family history of diabetes, those who are overweight, and those who are more than 40 to 45 years old. The glucose test may also be ordered to help diagnose diabetes when someone has symptoms of high blood glucose (hyperglycemia), such as:

Increased thirst, usually with frequent urination Fatigue Blurred vision Slow-healing infections

or symptoms of low blood glucose (hypoglycemia), such as:

Sweating Hunger Trembling Anxiety Confusion Blurred Vision

Blood glucose testing is also done in emergency settings to determine if low or high glucose is contributing to symptoms such as fainting and unconsciousness. Pre-diabetes is characterized by fasting or OGTT levels that are higher than normal but lower than those defined as diabetic. The doctor may order a glucose test at regular intervals to monitor the person's status. With known diabetics, doctors will order glucose levels periodically in conjunction with other tests such as A1c to monitor glucose control over time. Occasionally, a blood glucose level may be ordered along with insulin and C-peptide to evaluate insulin production. Diabetics are often required to self-check their glucose, up to several times a day, to monitor glucose levels and to determine treatment options as prescribed by their doctor. Pregnant women are usually screened for gestational diabetes late in their pregnancies, unless they have early symptoms or have had gestational diabetes with a previous pregnancy. When a woman has gestational diabetes, her doctor will usually order glucose levels throughout the rest of her pregnancy and after delivery to monitor her condition. ^ Back to top

What does the test result mean?

Blood Glucose High levels of glucose most frequently indicate diabetes, but many other diseases and conditions can also cause an elevated blood glucose. The following information summarizes the meaning of the test results. These are based on the clinical practice recommendations of the American Diabetes Association.

Fasting Blood Glucose

Glucose Level From 70 to 99 mg/dL (3.9 to 5.5 mmol/L) From 100 to 125 mg/dL (5.6 to 6.9 mmol/L) Indication Normal fasting glucose Impaired fasting glucose (prediabetes)

126 mg/dL (7.0 mmol/L) and above on more than one testing Diabetes occasion

Oral Glucose Tolerance Test (OGTT)

Levels applicable except during pregnancy. Sample drawn 2 hours after a 75-gram glucose drink. Glucose Level Indication Less than 140 mg/dL (7.8 mmol/L) Normal glucose tolerance Impaired glucose tolerance (preFrom 140 to 200 mg/dL (7.8 to 11.1 mmol/L) diabetes) Over 200 mg/dL (11.1 mmol/L) on more than one testing Diabetes occasion

Gestational Diabetes Screening: Glucose Challenge Test (as currently recommended by the American Congress of Obstetricians and Gynecologists)
Sample drawn 1 hour after a 50-gram glucose drink. Glucose Level Indication Less than 140* mg/dL (7.8 mmol/L) Normal screen 140* mg/dL (7.8 mmol/L) and over Abnormal, needs OGTT (see below) * Some use a cutoff of 130 mg/dL (7.2 mmol/L) because that identifies 90% of women with gestational diabetes, compared to 80% identified using the threshold of 140 mg/dL (7.8 mmol/L).

Gestational Diabetes Diagnostic: OGTT

In 2011, the American Diabetes Association adopted new guidelines that recommend a 2-hour glucose tolerance test rather than a 3-hour OGTT as still recommended by the American Congress of Obstetricians and Gynecologists. Details from both are included below. Time of Sample Current ACOG Target LEVEL ADA Target Level Collection Glucose load: Samples drawn after Glucose load: Samples drawn after 100-gram glucose drink 75-gram glucose drink Fasting (prior to 95 mg/dL (5.3 mmol/L) 92 mg/dL (5.1 mmol/L) glucose load) 1 hour after glucose 180 mg/dL (10.0 mmol/L) 180 mg/dL (10.0 mmol/L) load 2 hours after 155 mg/dL (8.6 mmol/L) 153 mg/dL (8.5 mmol/L) glucose load 3 hours after 140 mg/dL (7.8 mmol/L) Not applicable glucose load If TWO or more values meet or If ONE or more values meet or Results exceed the target level, gestational exceed the target level, gestational interpretation diabetes is diagnosed. diabetes is diagnosed.

Moderately increased blood glucose levels may be seen in those with pre-diabetes. Left unaddressed, pre-diabetes increases the risk of developing type 2 diabetes. Some other diseases and conditions that can result in an elevated blood glucose level include:

Acromegaly Acute stress (response to trauma, heart attack, and stroke for instance) Chronic kidney failure Cushing syndrome Excessive food intake Hyperthyroidism Pancreatic cancer Pancreatitis

A low level of glucose may indicate hypoglycemia, a condition characterized by a drop in blood glucose to a level where first it causes nervous system symptoms (sweating, palpitations, hunger, trembling, and anxiety), then begins to affect the brain (causing confusion, hallucinations, blurred vision, and sometimes even coma and death). A diagnosis of hypoglycemia uses three criteria known as the Whipple triad. (See the common questions section.). A low blood glucose level (hypoglycemia) may be seen with:

Adrenal insufficiency Drinking excessive alcohol Severe liver disease Hypopituitarism Hypothyroidism Insulin overdose Insulinomas Starvation

Urine Glucose Low to undetectable urine glucose results are considered normal. Any condition that raises blood glucose such as diabetes or the other conditions listed above also has the potential to elevate the concentration of glucose in the urine. Increased urine glucose may be seen with medications, such as estrogens and chloral hydrate, and with some forms of kidney disease. ^ Back to top

Is there anything else I should know?

Extreme stress can cause a temporary rise in blood glucose. This can be a result of trauma, surgery, heart attack or stroke, for example.

Drugs, including corticosteroids, tricyclic antidepressants, diuretics, epinephrine, estrogens (birth control pills and hormone replacement), lithium, phenytoin, and salicylates, can increase glucose levels, while drugs such as acetaminophen and anabolic steroids can decrease levels.

Microalbumin Urine Test

A microalbumin test checks urine for the presence of a protein called albumin. Albumin is normally found in the blood and filtered by the kidneys. When the kidneys are working properly, albumin is not present in the urine. But when the kidneys are damaged, small amounts of albumin leak into the urine. This condition is called microalbuminuria. Microalbuminuria is most often caused by kidney damage from diabetes. But many other conditions can lead to kidney damage, such as high blood pressure, heart failure, cirrhosis, or systemic lupus erythematosus (SLE). If early kidney damage is not treated, larger amounts of albumin and protein may leak into the urine. This condition is called macroalbuminuria or proteinuria. When the kidneys spill protein, it can mean serious kidney damage is present. This can lead to chronic kidney disease. A microalbumin urine test can be done on a sample of urine collected randomly (usually after the first time you urinate in the morning), a sample collected over a 24-hour period, or a sample collected over a specific period of time, such as 4 hours or overnight.

Why It Is Done
A microalbumin urine test is done to check for protein (albumin) in the urine. Early detection may change treatment in an effort to preserve as much kidney function as possible.

How To Prepare
You do not need to do anything before having this test.

How It Is Done
For a random urine test, you will provide a clean-catch midstream urine sample. A morning urine sample gives the best information about microalbumin levels.
Clean-catch midstream one-time urine collection

This collection method prevents contamination of the sample.

Wash your hands to make sure they are clean before collecting the urine. If the collection cup has a lid, remove it carefully and set it down with the inner surface up. Do not touch the inside of the cup with your fingers. Clean the area around your genitals. o A man should pull back the foreskin, if present, and clean the head of his penis thoroughly with medicated towelettes or swabs.

A woman should spread open the folds of skin around her vagina with one hand, then use her other hand to clean the area around her vagina and urethra thoroughly with medicated towelettes or swabs. She should wipe the area from front to back to avoid contaminating the urethra with bacteria from the anus. Begin urinating into the toilet or urinal. A woman should continue to hold apart the folds of skin around the vagina while she urinates. After the urine has flowed for several seconds, place the collection cup into the stream and collect about 2 fl oz (60 mL) of this "midstream" urine without interrupting the flow. Do not touch the rim of the cup to your genital area, and do not get toilet paper, pubic hair, stool (feces), menstrual blood, or other foreign matter in the urine sample. Finish urinating into the toilet or urinal. Carefully replace the lid on the cup and return it to the lab. If you are collecting the urine at home and cannot get it to the lab in an hour, refrigerate it.

A urine sample collected over time, such as over 4 or 24 hours, gives the most accurate results so you may be asked to collect your urine over a specific time period.
Timed urine collection (24 hours)

You start collecting your urine in the morning. When you first get up, empty your bladder but do not save this urine. Write down the time that you urinated to mark the beginning of your 24hour collection period. For the next 24 hours, collect all your urine. Your doctor or lab will usually provide you with a large container that holds about 1 gal (4 L). The container has a small amount of preservative in it. Urinate into a small, clean container and then pour the urine into the large container. Do not touch the inside of either container with your fingers. Keep the large container in the refrigerator for the 24 hours. Empty your bladder for the final time at or just before the end of the 24-hour period. Add this urine to the large container and record the time. Do not get toilet paper, pubic hair, stool (feces), menstrual blood, or other foreign matter in the urine sample.

Microalbumin Urine Test

(continued)

How It Feels
There is no discomfort while collecting a urine sample.

Risks
There is no chance of problems while collecting a urine sample.

Results

A microalbumin test checks urine for the presence of a protein called albumin. Microalbuminuria is most often caused by kidney damage from diabetes. The normal values listed here-called a reference range-are just a guide. These ranges vary from lab to lab, and your lab may have a different range for whats normal. Your lab report should contain the range your lab uses. Also, your doctor will evaluate your results based on your health and other factors. This means that a value that falls outside the normal values listed here may still be normal for you or your lab. Normal results may vary depending on:

The laboratory. The type (random versus timed) of urine sample collected. The time of day of the sample. Whether you are male or female. Whether you are on bed rest or able to move about normally. Albumin in urine

Less than 30 milligrams (mg) of albumin in 24 hours

Normal:

Less than 20 milligrams per liter (mg/L) for 10-hour (overnight) collection

Higher-than-normal values

You may need more than one test to find out how well your kidneys are working.

If your results are higher than normal, your doctor may check your urine more often to watch for kidney damage. If you have 2 or 3 high results in a 3- to 6-month period and you have diabetes, your doctor may find kidney damage (diabetic nephropathy). Even though diabetes is the most common reason for high results, there are many other kidney problems that can cause high results.

Pregnant women with diabetes may have their urine checked to watch for high amounts of albumin.

What Affects the Test

Reasons you may not be able to have the test or why the results may not be helpful include:

Having high blood sugar levels, urinary tract infections, high blood pressure, heart failure, or a high fever during an infection.

Exercising just before the test. Taking medicines, such as aspirin, corticosteroids, or some antibiotics, such as amoxicillin. Having menstrual bleeding or vaginal discharge, which may temporarily affect the urine sample.

What To Think About

The American Diabetes Association recommends a microalbumin urine test for people with: o Type 2 diabetes: First at diagnosis, and then yearly for diabetic nephropathy. o Type 1 diabetes: Yearly screening for diabetic nephropathy should begin 5 years after diagnosis. If a microalbumin urine test shows that kidney damage may be present, a test to check creatinine levels may be done. A blood test for creatinine is done along with a 24-hour creatinine clearance urine test to check kidney function. For more information, see the topic Creatinine and Creatinine Clearance. A less precise test, the urine dipstick test, can be used to check for microalbuminuria in a single sample of urine. But the dipstick test does not accurately detect microalbuminuria and is not recommended in place of a microalbumin urine test.

Ketones - urine
To use the sharing features on this page, please enable JavaScript. Ketones build up when the body needs to break down fats and fatty acids to use as fuel. This is most likely to occur when the body does not get enough sugar or carbohydrates. A urine test can be done to check the level of ketones in your body.

How the Test is Performed

The test requires a clean catch urine sample. To obtain a clean catch sample, men or boys should clean the head of the penis. Women or girls need to wash the area between the lips of the vagina with soapy water and rinse well. As you start to urinate, allow a small amount to fall into the toilet bowl to clear the urethra of contaminants. Then, put a clean container under your urine stream and catch 1 to 2 ounces of urine. Remove the container from the urine stream. Cap and mark the container and give it to the health care provider or assistant. For infants, thoroughly wash the area around the urethra. Open a urine collection bag (a plastic bag with an adhesive paper on one end), and place it on the infant. For boys, the entire penis can be placed in the bag and the adhesive attached to the skin. For girls, the bag is placed over the labia. Diaper as usual over the secured bag.

This procedure may take a couple of attempts -- lively infants can displace the bag. The infant should be checked frequently and the bag changed after the infant has urinated into the bag. The urine is drained into the container for transport to the laboratory. Urine ketones are usually measured as a "spot test" using a dipstick coated with chemicals that react with ketone bodies. The dipstick is dipped in the urine sample, and a color change indicates the presence of ketones.

How to Prepare for the Test

You may have to eat a special diet, and you should stop taking any drugs that may affect the test. If the collection is being taken from an infant, you may need extra collection bags.

How the Test Will Feel

The test involves only normal urination, and there is no discomfort.

Why the Test is Performed

Ketone testing is most often done if you have type 1 diabetes and:

Your blood sugar is higher than 240 mg/dL You have an illness such as pneumonia, heart attack, or stroke Nausea or vomiting occur You are pregnant

Normal Results
A negative test result is normal. Normal value ranges may vary slightly among different laboratories. Some labs use different measurements or test different samples. Talk to your doctor about the meaning of your specific test results.

What Abnormal Results Mean

An abnormal result means you have ketones in your urine. The results are usually listed as small, moderate, or large as follows:

Small: < 20 mg/dL Moderate: 30 - 40 mg/dL Large: > 80 mg/dL

This may be due to diabetic ketoacidosis, a problem that occurs in people with Type 1 diabetes. It occurs when the body cannot use sugar (glucose) as a fuel source because there is little or no insulin. Fat is used for fuel instead. An abnormal result may also be due to:

Abnormal food or nutrition intake due to: o Anorexia o Fasting o High protein or low carbohydrate diets o Starvation o Vomiting over a long period of time Disorders of increased metabolism Acute or severe illness Burns Fever Hyperthyroidism Nursing a baby (lactation) Pregnancy

Risks
There are no risks.

Considerations
Special diets can change test results. For example, a diet low in carbohydrates and high in protein and fat can raise ketone levels in the blood, which can then enter the urine. Some drugs, including glucocorticoids, can cause false positive measurements.

Strawberry Naevus
This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful. Synonym: infantile haemangioma Strawberry naevus is the name given to an haemangioma which occurs in infancy, usually on the face.

On this page

Natural history

Epidemiology Presentation Differential diagnosis Investigations Associated diseases Management Complications Prognosis Document references Internet and further reading Acknowledgements

Natural history

The lesions may be present at birth, or may develop in the first few weeks after birth. They may begin as a small flat red area, but usually develop into a raised dimpled (strawberry-like) lesion. The lesions typically grow in size as the child grows, until the age of approximately 3-4 years, when they start to regress spontaneously. This process can take up to 10 years.1

Epidemiology
There are currently no recent published prospective studies examining the incidence of haemangiomas. Older studies were performed before the discrimination of 'haemangiomas' from other vascular birthmarks was well-established.2

Strawberry naevi are very common, occurring in about 3-5% of babies. They are rather less common in children of Afro-Caribbean origin and even more uncommon in those of Asian extraction. There is a 3:1 female preponderance.3 In children with a birthweight of less than 1 kg, there is a 1 in 4 chance that they will develop a haemangioma.4 In this group, the sex ratio is equal.3

Presentation

One third of strawberry naevi will be evident at birth, the remainder developing in the first 4 weeks after birth. In the initial stages, the lesions may be bluish or red spots or patches, and the superficial lesions may remain flat. Deeper lesions have a bluish appearance. Compound lesions may occur, having both superficial and deep areas. The vast majority of strawberry naevi occur on the head and neck but, occasionally, these lesions may occur at other sites throughout the body. The vast majority of strawberry naevi cause no symptoms at all, but visceral haemangiomas, or large superficial haemangiomas may cause problems.

Differential diagnosis

Angiosarcoma. Arteriovenous (AV) malformation. Congenital haemangioma (that does not involute). Teratoma. Venous malformation. Diffuse neonatal haemangiomatosis.

Investigations

Usually, no investigations will be required but, if an infant has 3 or more visible strawberry naevi, a whole body MRI scan should be performed to rule out internal lesions If there is uncertainty about the lesion, MRI and Doppler ultrasound may be used. Doppler may be useful to assess the persistence, increase or resolution of AV fistulae as this can influence the decision to observe or to treat.5 Biopsy, if required, should be undertaken with caution, as these lesions are very vascular.

Associated diseases

Periorbital haemangiomas, particularly with involvement of the upper eyelid, require refraction with retinoscopy to check for visual disturbances, especially astigmatism, and to prevent visual deprivation amblyopia. Rapidly growing haemangiomas can impinge on vital structures of the head and neck, particularly the airway or auditory canals. Large haemangiomas of the beard area have a higher incidence of upper airway haemangiomas. This may present as noisy breathing or stridor. An infantile haemangioma over the midline of the back may be a sign of an underlying occult spinal dysraphism, such as a tethered cord. MRI is indicated, or ultrasound, if the infant is younger than 5 months.

Management

The majority of these lesions will involute spontaneously over time and will require no treatment. This is especially true of those in premature babies.4 Occasionally, plastic surgery will be required following involution of the lesion, in order to remove redundant folds of floppy skin. Pulsed dye laser may be valuable if they are not resolving well, or are in places that cause particular embarrassment: o It is used to treat ulcerating haemangiomas. 3 o Laser treatment gives a better outcome than observation. Sometimes treatment causes pain. 6 o Not all children need active treatment. A number of drugs have been used to treat proliferation of these tumours: o Intralesional corticosteroids slow proliferation. o Those who fail to respond to steroids may respond to interferon-alfa 2a, but it can have toxic effects in some and spastic diplegia has been described.7,8 o Imiquimod, an immune response modifier, has also been used. Such treatment is generally reserved for dangerous and proliferating lesions.9 It has been shown to be more efficacious in superficial lesions.10 Surgical excision of proliferating haemangiomas needs care as they are very vascular.

Larger, visceral or life-threatening lesions may be treated with a combination of surgery and embolisation therapy.

Complications

Large facial haemangiomas may cause problems with sight, hearing, breathing, swallowing and speaking. They should be treated immediately to prevent further problems. Bleeding or ulceration may occur. Visceral haemangiomas may produce symptoms due to bleeding or mass effect. The symptoms will vary according to site. Occasionally, they may impinge on vital structures, ulcerate, bleed, induce consumptive coagulopathy, or cause high-output cardiac failure or significant structural abnormalities. Those on the face are of greatest concern.

Prognosis
They are the most common tumours in infancy and usually resolve without problem.

Examination of the Newborn

J D Matthews
(Minimal amendments RNH, JEH 1990, IMRW 1996) Examination Importance When

Introduction

History

The Examination Itself

Conclusion

Introduction
The whole key to the management of the newborn infant lies in a proper assessment of the baby at birth. This necessitates obtaining certain basic information in relation to two different individuals, the mother and the baby, and obtained in two completely different ways, by the history and by the physical examination.

History
Certain detailed and accurate information is essential in order to evaluate the results of the physical examination of the baby. This is required both for the mother and the infant, and is recorded on a form such as the blue infant record card. Know the relevance of each item on this card to the examination of the baby. a. The mother: This includes social and family history, personal and reproductive medical histories and especially knowledge of the current pregnancy, labour and delivery. Important are the parent's blood groups, date of last menstrual period, estimated date of delivery, duration of labour, state of fetal heart during labour, length of second stage, duration of rupture of membranes, presentation of fetus, whether or not there was an

operative delivery, drugs and anaesthetics given with their dosage and time of administration, characteristics and quantity of amniotic fluid, and abnormalities of the placenta. This information will have determined whether the baby is at risk in terms of the mother having a 'high risk' pregnancy or labour. b. The baby: Condition at birth and Apgar scores at 1 and 5 minutes after birth and details of any resuscitative measures used.

Examination
This information can be easily recorded by filling in the appropriate part of page 2 of the Blue Infant Record Card.

Importance
1. Earliest possible detection of deviations both from usual and from normal. Especially important in relation to serious correctable congenital malformations, where in some cases (e.g. oesophageal atresia, imperforate anus, and diaphragmatic hernia) the early diagnosis enables treatment which may make the difference between life and death, and in some cases (e.g. congenital dislocation of the hips and club feet) the earlier the diagnosis and initiation of treatment the less the incidence of permanent and severe disability. 2. Establishes a baseline for subsequent examinations. 3. Enables the doctor to give parents a true account of the baby's physical state, and where present to explain and reassure about minor deviations from usual which if not explained are likely to cause concern. Best pointed out by doctor rather than discovered by mother.

When
1. Immediately after birth 2. Before discharge from maternity unit 3. Whenever there is any concern about the infant's progress These examinations should where possible be carried out in the presence of the mother.

The Examination Itself

General Abdomen Overall Inspection Femoral Pulses Head Genitalia Chest Imperforate Anus Auscultation of the Heart Congenital Dislocation of the Hips

Feet

Nervous System

Myelocoele and Meningomyelocoele

Oesophageal Atresia

General
Requires a knowledge of limits of both the usual and the normal.

Remember that although the range of normal is wide, the range of usual is much narrower. Therefore, regard with suspicion any findings outside the range of usual. It is important that a few exact measurements be made and recorded namely:- weight, crown-heel length, head circumference. These should be plotted on the appropriate centile chart as all parameters of growth need to be related to gestational age for sensible interpretation. Record the dimensions of any visible or palpable structural abnormality. Record respiratory rate and heart rate with infant quiet. While having a routine order of procedure in the examination of the infant makes less likely the omission of any essential part of the examination, your routine should be flexible. If the infant is quiet and relaxed when first approached, auscultation of heart and palpation of abdomen should precede more disturbing examinations such as those of the mouth and hips. If the infant is struggling and crying during auscultation of the heart, then temporary shunt reversal may prevent hearing of a murmur present when the baby is at rest.

Overall Inspection

In general does he look ill or well? Is he normally active? Is the cry normal? Are there any obvious malformations? (In particular, is the baby funny-looking, e.g. with Down Syndrome?) What of his colour? Pallor? Pallid cyanosis of shock? Cyanosis? Plethora? Jaundice? If pallor of skin, what of mucus membranes and nail beds? Is the cyanosis generalised or localised? Does the upper surface of the tongue look blue? What is the response of the cyanosis to oxygen and on crying? Is the cord yellow? What of respiration? Chest movements? Is there a grunt? Is there dyspnoea? The apex beat is frequently visible on inspection. What of the shape of the head? Do the bones move freely against each other along the suture lines? If the infant is small for dates or unusually skinny, suspect fetal malnutrition. Check on weight for length and look for other evidence of fetal malnutrition, such as dry scaly skin on abdomen and extremities and/or abdominal skin creases and lack of normal subcutaneous fat. (These babies need to be watched for hypoglycaemia and fed early.)

More Detailed Examination

Head

Palpate the anterior fontanelle, sagittal, coronal and lambdoid sutures and posterior fontanelle. Exclude presence of a third fontanelle, craniotabes and premature

synostosis of skull bones. The eyes are most easily examined if opened by the baby itself. This often occurs spontaneously if the eyes shaded from light with hands. Shine a light from the side to detect cataracts. Note presence of flattened bridge of nose or epicanthic folds. Is there a coloboma (defect of iris)? Are there any Brushfield's spots in the iris? Choanal atresia is checked for by seeing if the infant can breathe with mouth closed and then with left and right nostril occluded alternately. If in any doubt check nasal airways with a catheter, and if this is too large, try a feeding tube, and finally if necessary a probe. The nasal airway is the vital one in the neonate. Sternomastoid muscles should be palpated and the range of rotation of head to each side checked. A short neck is often significant and webbing should be looked for. Ears which are unusual in size or shape, are floppy and lacking in normal cartilage, and especially if low placed, are of significance and may be associated with urinary tract abnormalities. The mouth should be fully inspected with a good light and spatula and the palate inspected right back to the uvula to exclude minor degrees of cleft palate. Asymmetry, thoracic cage defects and spinal scoliosis should be noted. Apex beat position should be confirmed or determined if not visible in order to help determine heart size and possible presence of mediastinal shift. Auscultation of the chest may help give additional information, but apparent presence of normal findings on percussion and auscultation does not exclude gross intrathoracic abnormality. Even the slightest suspicion about the state of heart and lungs makes chest x-ray mandatory. If there is definite displacement, or any doubt as to the position of the apex beat, even in the absence of other signs of possible abnormality, such as cyanosis, differences in the two sides of the chest with regard to movement on respiration, air entry, breath sounds, and/or in percussion note, then early x-ray of the chest is essential. The presence of a 'scaphoid' abdomen would favour the diagnosis of gross diaphragmatic hernia with abdominal viscera largely in the thorax. Radiological findings even suggestive of diaphragmatic

Chest

hernia or any other space occupying lesion, be it solid or cystic, or pneumothorax, are an urgent indication for immediate transfer to a base hospital equipped and staffed to make the definitive diagnosis and then to proceed without delay to carry out corrective surgery. Before transfer, where the infant's condition is so bad it is unlikely to survive transport, certain immediate life saving measures may be indicated. For example, in the infant with a large proven pneumothorax air should be aspirated from the pleural cavity, and in the baby with so large an intra-thoracic space occupying lesion that it causes severe cyanosis not relieved by oxygen, carry out intra-tracheal intubation and give intermittent positive pressure oxygen. Presence of a significant murmur in itself in the absence of associated evidence of cardiac failure (i.e. increased respiratory rate, unexplained pallor, cyanosis, sweating, enlarged liver and gallop rhythm), would only be an indication for checking on femoral and peripheral pulses, x-ray of heart, doing an electrocardiograph and watching carefully. If facilities for these special investigations are not available, then immediate transfer to a unit with such facilities is called for. Evidence of significant systemic cyanosis or of early heart failure, or any deterioration in baby's condition, e.g. not as energetic as previously, or no longer taking feeds as well, is an indication for transferring to a specialised cardiological unit. Scaphoid abdomen suggests the presence of a gross diaphragmatic hernia. Distended abdomen calls for more detailed examination and frequently additional investigations to determine cause, which may vary from distension of stomach and intestines as a result of resuscitation, to gross pathology such as that associated with intrauterine peritonitis, or gross neoplastic disease. The liver and spleen should be felt for, and where palpable, their size, shape and consistency determined and recorded. Routine palpation of kidneys should be carried out to determine whether they are present and if so their position, size, shape and consistency. Careful inspection of umbilicus should include checking on adequacy of cord, tie, or clamp. A yellow cord at birth suggests intrauterine anoxia or haemolytic disease. If on examination of the severed cord at the infant's end,

Auscultation of the heart

Abdomen

only two instead of the usual three umbilical vessels are found, then be alerted to the greater chance of the baby having other more serious congenital abnormalities not necessarily revealed on initial clinical examination. If exomphalos (omphalocele) is present, this is an indication for applying a protective sterile plastic covering and transferring urgently to a surgical unit experienced in neonatal surgery. Prior to transfer give antibiotics capable of coping with both gram positive cocci and gram negative bacilli. Routine palpation of femoral pulses themselves and then simultaneously with the brachial or radial pulses may be the first indication of the presence of coarctation or of interruption of the thoracic aorta. This would warrant careful examination of the cardiovascular system including x-ray, chest, ECG and taking arm and leg blood pressures. Absence of a higher blood pressure in the legs than that of the arms would strongly support the diagnosis and indicate the need for urgent cardiological assessment. Presence of normal femoral pulses does not exclude coarctation of the aorta at this stage, and at each subsequent examination femoral pulses should continue to be checked. Abnormality suggestive of hermaphroditism should always be checked carefully and where present, the infant referred early for specialist assessment and possible biochemical, hormonal, cytological and chromosomal study. One of the causes of pseudohermaphroditism is congenital adrenal cortical hyperplasia (adreno-genital syndrome), which generally presents in the first few days of weeks of life with a 'salt losing syndrome' of sudden onset. Unless treated promptly and adequately for what it is, such an infant will rapidly die - a death which could have been prevented, had the diagnosis been thought of, confirmed and electrolyte and steroid therapy been promptly initiated. Presenting symptoms include anorexia, vomiting, diarrhoea, weight loss and extreme dehydration. Restriction of fluid and salt intake results in sudden collapse and death. In boys the presence of the 'hooded foreskin' strongly suggests the presence of hypospadias which strongly contra-indicates carrying out circumcision. Inguinal hernias should be looked for and other things

Femoral Pulses

Genitalia

being equal, be excised as soon as possible, preferably before the infant goes home. In girls an attempt should be made to separate the vulva. In this way, presence of vaginal cysts and vulval fusion will not be missed. This can be excluded by routine careful examination of the anus. Any unusual appearance in this warrants careful investigation. It has to be remembered that passage of normal meconium does not preclude the need for careful examination, e.g. imperforate anus with associated rectovaginal fistula. While routine digital examination of anus is not regarded as necessary, insertion of thermometer in taking temperature is advocated. Recognition in the early neonatal period is essential for proper treatment to be started early enough to result in the most satisfactory end results. The chances of early diagnosis by demonstration of positive Ortolani's sign are greatest when the examination is carried out immediately after birth. The standard method is Barlow's test. This must be repeated at all subsequent examinations until the infant is walking normally as the first examination may fail to demonstrate an abnormal hip. It is important that the baby should be properly relaxed during the examination. All feet should be examined at birth and where club feet (talipes, equino varus or talipes varus) or calcaneo valgus deformities are present, referral to an orthopaedic surgeon is indicated. Inability to dorsiflex and externally rotate foot so that the little toe can be brought in contact with the exterior aspect of the leg makes the diagnosis of 'club foot'. Inability to plantar flex foot properly, i.e. to at least 45 degrees beyond the right angle, makes the diagnosis of calcaneus deformity. The presence of normal activity and limb movements and normal limb tone should be checked. In addition attempts should be made to elicit normal grasp and Moro 'startle' reflex. Inability to do this strongly suggests significant abnormality of central nervous system. Remember that when the infant is crying it is sometimes not possible to elicit a normal Moro reflex. In this case the infant should

Imperforate Anus

Congenital Dislocation of Hips

Feet

Nervous System

be quietened when failure to elicit normal response would be significant.

Myelocoele & Meningomyelocoele

This is to be regarded as an indication for urgent referral to a neurosurgeon, especially where the membrane is thin or defective, as early closing of the defect may be called for where this is possible. Early surgery facilitates nursing care and frequently makes it possible to return the infant to the mother within a few days of birth. It also enables early treatment of any associated congenital dislocation of the hips. In some cases the degree of permanent neurological disability may be lessened by early operation. The ultimate prognosis of many of these infants has been radically altered now that the associated hydrocephalus frequently developing is amenable to shunt operation in the early neonatal period. Here, even more than with most atresias of the gastrointestinal tract, early diagnosis, preferably before the giving of the first feed with the associated dangers of aspiration and pneumonia is essential, and proper management in the time elapsing between diagnosis and surgical correction can be vital. Thought of and looked for, most cases can be diagnosed before the first feed is given. The classical picture is of spluttering, choking, coughing, sometimes going blue and returning to food. Every infant born to a mother with hydramnios and/or mucousy after birth should have a large soft plastic catheter (English size 6 or 8) passed through the mouth into the stomach. Failure to pass the catheter into the stomach, or where there is any doubt as to whether the catheter has entered the stomach should lead to immediate radiological examination, initially with a radio-opaque catheter in the oesophagus. The presence of the catheter in the stomach can be suspected if it goes in far enough to reach below the costal margin and confirmed by viewing the end of the catheter or by palpating it through the abdominal wall. The large soft rubber or plastic catheter is less traumatic than the smaller one which can be passed through the nose and unlike it, is not able to bend back on itself, giving a misleading impression that it has passed into the stomach.

Oesophageal Atresia

Conclusion

Routine physical examination takes only a few minutes and should be carried out in all infants at the earliest possible moment after birth, and again just before discharge from the maternity hospital. Routine physical examination excludes obvious abnormalities and helps make possible an earlier diagnosis of many not quite so obvious conditions. Many of the serious correctable congenital malformations can be detected at birth or within a few days, provided they are thought of and looked for. Early diagnosis of certain of these abnormalities, e.g. oesophageal atresia, greatly increases the chances of successful surgery and frequently makes the difference between survival and death. In other cases e.g. congenital dislocation of the hips, early detection and commencement of treatment prevents or greatly reduces permanent residual disability.