BLOOD,URINE,STOOL ANALYSIS

AND MCS
NORMAL VS ABNORMAL
 PRESENTERS

• LAYENI JUBRIL O
• MADU CHISOM I
 OUTLINE
• INTRODUCTION
• BLOOD ANALYSIS
• URINE ANALYSIS
• STOOL ANALYSIS
• CONCLUSION
• REFERENCE
 INTRODUCTION
• In recent years great advances have been made in the
area of laboratory medicine with the introduction of
automated machines and commercial kits.
• however laboratory technology still remains relevant
In the practice of medicine especially in the developing
world the main aims of using laboratory tech are to
assist in making a diagnosis of disease assess prognosis
and monitor response to treatment
• This involves analysis of body fluids and waste such as
blood, urine and stool
 BLOOD ANALYSIS
• Blood analysis involves laboratory
examination of a sample of blood.it is used to
obtain information about its physical and
chemical properties. Blood analysis is
commonly carried out on a sample of blood
drawn from the vein of the arm, the finger, or
the earlobe; in some cases, the blood cells of
the bone marrow may also be examined.
PROPERTIES OF BLOOD
 COLLECTION OF BLOOD SAMPLE
• To ensure quality blood sample are collected
patient must be appropriately prepared by
providing information about what is required
of the patient e.g.
• For fasting samples patient needs to be
informed that he/she should take nothing
after the last meal at 8pm for samples to be
taken at 9am the following morning
• In some cases patient might be advised to
avoid some type of food prior to the date of
blood collection so as not to influence results
• Correct technique must be applied for
example calcium collection does not require
tourniquet
• Request form must be properly filled
 TYPES OF BLOOD ANALYSIS
• BIOCHEMICAL ANALYSIS
• CELLULAR ANALYSIS
• MOLECULAR ANALYSIS
 BIOCHEMICAL ANALYSIS

• A basic metabolic panel measures sodium,

potassium, chloride, bicarbonate, urea
nitrogen , magnesium, creatinine, glucose,
and sometimes includes calcium.
 BIOCHEMICAL ANALYSIS
TEST NORMAL UNIT

UREA 10-50 Mg/dl

CALCIUM 2.15-2.55 Mg/dl

URIC ACID 2,4-7 Mg/dl

CHLORIDE 96-110 Mmol/L

MAGNESIUM 1.6-2.4 Mmol/l

PHOSPHORUS 2.7-4.5 Mg/dl

POTTASIUM 3.5-5 Mmol/l

SODIUM 133-150 Mg/dl

BICARBONATE 18-32 Mmol/l

 BIOCHEMICAL ANALYSIS CONTD
TEST NORMAL UNIT

CREATININE 0.5-1.1 g/dl

TOTAL PROTEIN 6.6-8.7 g/dl

ALBUMIN 3.5-5.0 Mg/dl

TOTAL BILIRUBIN 0-1.0 Mg/dl

CONJUGATED 0-0.25 MG/DL

BILIRUBIN
SGOT(AST) 0-37 IU/L

SGPT(ALT) 0-40 IU/L

ALP 98-279 IU/L

 BIOCHEMICAL ANALYSIS CONTD
TEST NORMAL UNIT

TOTAL CHOLESTEROL <170 Mg/dl

HDL CHOLESTEROL 130 Mg/dl

LDL CHOLESTEROL <110 Mg/dl

TRIGLYCERIDES <150 Mg/dl

FASTING BLOOD SUGAR 76-110 Mg/dl

RANDOM BLOOD 76-150 Mg/dl

SUGAR
OGTT 76-110 Mg/dl
 CELLULAR ANALYSIS
• This involves analysis for anomalies in the
quality and quantity of cellular content of
blood . cells such basophils, eosinophil's
neutrophils, monocyte and lymphocyte and
erythrocytes(RBC)
 CELLULAR ANALYSIS
CELL NORMAL COUNT

WBC ADULT 4-11X109/L

NEWBORN 10- 25X109/L
4-7YRS 6-15X109/L
8-12YRS 4.5-13.5X109/L
NEUTROPHIL 40-75%
EOSINOPHIL 1-6%
MONOCYTE 2-8%
LYMPHOCTE 20-45%
BASOPHIL 0-1%
RBC MALE 4.5-6.5 X1012/L
FEMALE 3.8-5.8 X 1012/L
NEWBORN 4.0-6.0 X 1012/L

PCV MALE 40-50 %

FEMALE 37-47%
NEWBORN 44-64%
 MOLECULAR ANALYSIS
• This series of test analyses blood constituent
at molecular level they include:
• Protein electrophoresis
• Western blot
• Polymerase chain reaction
 URINE ANALYSIS
• MICROSCOPIC EXAMINATION
• CHEMICAL ANALYSIS(URINE DIPSTICK)
• MACROSCOPIC EXAMINATION
Macroscopic Examination
Odor:
− Ammonia-like: (Urea-splitting bacteria)
− Foul, offensive: Old specimen, pus or inflammation
− Sweet: Glucose
− Fruity: Ketones
− Maple syrup-like: Maple Syrup Urine Disease

Color:
− Colorless Diluted urine
− Deep Yellow Concentrated Urine, Riboflavin
− Yellow-Green Bilirubin / Biliverdin
− Red Blood / Hemoglobin
− Brownish-red Acidified Blood (Actute GN)
− Brownish-black Homogentisic acid (Melanin)
Macroscopic Examination

Turbidity:
− Typically cells or crystals.
− Cellular elements and bacteria will clear by centrifugation.
− Crystals dissolved by a variety of methods (acid or base).
− Microscopic examination will determine which is present.
CHEMICAL ANAYSIS (The Urine Dipstick)
Glucose

Significance
– Diabetes mellitus. Negative
– Renal glycosuria.
Trace (100 mg/dL)

Limitations + (250 mg/dL)

– Interference: reducing agents, ketones.
– Only measures glucose and not other sugars. ++ (500 mg/dL)
– Renal threshold must be passed in order for glucose
to spill into the urine. +++ (1000 mg/dL)

++++ (2000+ mg/dL)

Other Tests
– CuSO4 test for reducing sugars.
Detection of Reducing Sugars* by CuSO4

Sugar Disease(s)
- Galactose Galactosemias
- Fructose Fructosuria, Fructose Intolerance,
etc.
- Lactose Lactase Deficiency
- Pentoses Essential Pentosuria
- Maltose Non-pathogenic

* NOT Sucrose because it is not a reducing sugar

 Bilirrubin

Significance
- Increased direct bilirubin (correlates with
urobilinogen and serum bilirubin)

Limitations Negative
- Interference: prolonged exposure of sample to
light + (weak)
- Only measures direct bilirubin--will not pick up
indirect bilirubin
++ (moderate)
Other Tests
- Ictotest (more sensitive tablet version of same +++ (strong)
assay)
- Serum test for total and direct bilirubin is more
informative
 Ketone

Significance
- Diabetic ketoacidosis
Negative
- Prolonged fasting
Trace (5 mg/dL)
Limitations
- Interference: expired reagents (degradation + (15 mg/dL)
with exposure to moisture in air)
- Only measures acetoacetate not other
ketone bodies (such as in rebound ketosis). ++ (40 mg/dL)

Other Tests +++ (80 mg/dL)

- Ketostix (more sensitive tablet version of
same assay) ++++ (160+ mg/dL)
- Serum glucose measurement to confirm
DKA
 Urine Specific Gravity

Significance
- Diabetes insipidus 1.000

1.005
Limitations
- Interference: alkaline urine 1.010
- Does not measure non-ionized solutes (e.g. glucose)
1.015

Other Tests 1.020

- Refractometry
- Hydrometer 1.025
- Osmolality measurement (typically used with water
1.030
deprivation test)
 Urine Blood Detection

Significance
- Hematuria (nephritis, trauma, etc)
- Hemoglobinuria (hemolysis, etc) Negative
- Myoglobinuria (rhabdomyolysis, etc)
Trace (non-hemolyzed)
Limitations
- Interference: reducing agents, microbial
peroxidases
- Cannot distinguish between the above disease Trace (hemolyzed)
processes
+ (weak)
Other Tests
- Urine microscopic examination ++ (moderate)
- Urine cytology
+++ (strong)
The Urine Dipstick:
pH

5.0

6.0 Chemical Principle

H+ interacts with:
6.5
Methyl Red (at high concentration; low pH) and
Bromthymol Blue (at low concentration; high
7.0
pH), to form a colored complexes
(dual indicator system)
7.5

8.0 Read up to 2 minutes

R.R.: 4.5-8.0
8.5
Uses and Limitations of Urine pH Detection

Significance
- Acidic (less than 4.5): metabolic acidosis, high-protein diet
- Alkaline (greater than 8.0): renal tubular acidosis (>5.5)

Limitations
- Interference: bacterial overgrowth (alkaline or acidic),
“run over effect” effect of protein pad on pH indicator pad

Other Tests
- Titrable acidity
- Blood gases to determine acid-base status
pH Run Over Effect

Glucose
Bilirubin
Ketones
Specific Gravity Buffers from the protein area of
the strip (pH 3.0) spill over to the
Blood pH area of the strip and make the
pH pH of the sample appear more
acidic than it really is.
Protein
Urobilinogen
Nitrite
Leukocyte Esterase
The Urine Dipstick:
Protein

Chemical Principle
“Protein Error of Indicators Method”
Negative Pr
H Pr
H Pr
Trace H
Pr Pr
+ (30 mg/dL) H H
H Pr
++ (100 mg/dL) Tetrabromphenol Blue +
H+ H H
+
(buffered to pH 3.0)
H + +
+++ (300 mg/dL) Pr Pr H+ H
Pr
Pr Pr
++++ (2000 mg/dL) Pr
Read at 60 seconds
RR: Negative
Causes of Proteinuria

Functional Renal
- Severe muscular exertion - Glomerulonephritis
- Pregnancy - Nephrotic syndrome
- Orthostatic proteinuria - Renal tumor or infection

Pre-Renal Post-Renal
- Fever - Cystitis
- Renal hypoxia - Urethritis or prostatitis
- Hypertension - Contamination with vaginal
secretions
Uses and Limitations of Urine Protein Detection

Significance
- Proteinuria and the nephrotic syndrome.

Limitations
- Interference: highly alkaline urine.
- Much more sensitive to albumin than other proteins
(e.g., immunoglobulin light chains).

Other Tests
- Sulfosalicylic acid (SSA) turbidity test.
- Urine protein electrophoresis (UPEP)
- Bence Jones protein
 Proteins in “Normal” Urine

Protein % of Total Daily Maximum

Albumin 40% 60 mg
Tamm-Horsfall 40% 60 mg
Immunoglobulins 12% 24 mg
Secretory IgA 3% 6 mg
Other 5% 10 mg

TOTAL 100% 150 mg

The Urine Dipstick:
Urobilinogen

0.2 mg/dL Chemical Principle

1 mg/dL Urobilinogen + Diethylaminobenzaldehyde

(Ehrlich’s Reagent)
2 mg/dL -------> Colored Complex

4 mg/dL
Read at 60 seconds
8 mg/dL RR: 0.02-1.0 mg/dL
Uses and Limitations of Urobilinogen Detection

Significance
- High: increased hepatic processing of bilirubin
- Low: bile obstruction

Limitations
- Interference: prolonged exposure of specimen to oxygen
(urobilinogen ---> urobilin)
- Cannot detect low levels of urobilinogen

Other Tests
- Serum total and direct bilirubin
The Urine Dipstick:
Nitrite

Chemical Principle

Acidic
Negative Nitrite + p-arsenilic acid -------> Diazo compound
Diazo compound + Tetrahydrobenzoquinolinol
Positive
----------> Colored Complex

Read at 60 seconds
RR: Negative
Uses and Limitations of Nitrite Detection

Significance
- Gram negative bacteriuria

Limitations
- Interference: bacterial overgrowth
- Only able to detect bacteria that reduce nitrate to nitrite

Other Tests
- Correlate with leukocyte esterase and
- Urine microscopic examination (bacteria)
- Urine culture
The Urine Dipstick:
Leukocyte Esterase

Chemical Principle
Derivatized pyrrole amino acid ester
Negative
Esterases
------------> 3-hydroxy-5-phenyl pyrrole
Trace

+ (weak) 3-hydroxy-5-phenyl pyrrole + diazo salt

-------------> Colored Complex
++ (moderate)
Read at 2 minutes
+++ (strong) RR: Negative
Analytic Sensitivity: 3-5 WBCs
Uses and Limitations of Leukocyte Esterase Detection

Significance
- Pyuria
- Acute inflammation
- Renal calculus

Limitations
- Interference: oxidizing agents, menstrual contamination

Other Tests
- Urine microscopic examination (WBCs and bacteria)
- Urine culture
Microscopic Examination
Abnormal Findings

Per High Power Field (HPF) (400x)

– > 3 erythrocytes
– > 5 leukocytes
– > 2 renal tubular cells
– > 10 bacteria
Per Low Power Field (LPF) (200x)
– > 3 hyaline casts or > 1 granular cast
– > 10 squamous cells (indicative of contaminated specimen)
– Any other cast (RBCs, WBCs)
Presence of:
– Fungal hyphae or yeast, parasite, viral inclusions
– Pathological crystals (cystine, leucine, tyrosine)
– Large number of uric acid or calcium oxalate crystals
Microscopic Examination
Cells

Erythrocytes
- “Dysmorphic” vs. “normal” (> 10 per HPF)

Leukocytes
- Neutrophils (glitter cells) More than 1 per 3 HPF
- Eosinophils Hansel test (special stain)

Epithelial Cells
- Squamous cells Indicate level of contamination
- Renal tubular epithelial cells Few are normal
- Transitional epithelial cells Few are normal

- Oval fat bodies Abnormal, indicate Nephrosis

 Microscopic Examination

RBCs Squamous Cells Tubular Epithelial

Cells

Transitional Oval Fat Body

Cells Yeasts
Microscopic Examination
Casts

Erythrocyte Casts: Glomerular diseases

Leukocyte Casts: Pyuria, glomerular disease

Degenerating Casts:
- Granular casts Nonspecific (Tamm-Horsfall protein)
- Hyaline casts Nonspecific (Tamm-Horsfall protein)
- Waxy casts Nonspecific
- Fatty casts Nephrotic syndrome
(oval fat body casts)
 Stool Analysis
What is the stool or feces?

1. Waste residue of indigestible material

(cellulose during the previous 4 days)
2. Bile pigments and salts

3. Intestinal secretions, including mucus

4. Leukocytes that migrate from the bloodstream

5. Epithelial cells that have been shade

6. Bacteria and Inorganic material(10-20%) chiefly calcium and

phosphates. Undigested and unabsorbed food.
 Random Collection
1. Universal precaution
2. Collect stool in a dry,clean container
3. uncontaminated with urine or other
body secretions, such as menstrual
blood
4. Collect the stool with a clean tongue
blade or similar object.
5. Deliver immediately after collection
 Ova and parasites
collection
1. Warm stools are best for detecting ova
or parasites.
Do not refrigerate specimen for ova or
parasites.
2. If the stool should be collect in 10 %
formalin or PVA
fixative, storage temperature is not
critical.
 Enteric pathogen
1.
collection
Some coliform bacilli produce antibiotic
substances that
destroy enteric pathogen.Refrigerate specimen
immediately.
2. A diarrheal stool will usually give accurate
results.
3. A freshly passed stool is the specimen of
choice.
4. Stool specimen should be collected before
antibiotic therapy, or
 Interfering factors
1. Patients receiving tetracyclines, anti-diarrheal
drugs, barium, bismuth, oil, iron , or
magnesium may not yield accurate results.
2. Bismuth found in toilet tissue interferes with
the results.
3. Do not collect stool from the toilet bowl.A
clean, dry bedpan is the best.
4. Lifestyle, personal habbits, environments may
interfere with proper sample procurement.
 Normal values in stool
Analysis
Macroscopic examination Normal value

Amount 100-200 g / day

Colour Brown
Odour Varies with pH of stool
and depend on bact-
erial fermentation
Consistency Plastic, not unusual to
see fiber, vegetable skins.
Size and shape Formed
Gross blood,Mucous,Pus, Parasites None
 Normal values in stool
analysis
Microscopic examination Normal values

Fat (Colorless, neutral fat (18%)and fatty acid crystals and soaps)
Undigested food None to small amount
Meat fibers, Starch, Trypsin None
Eggs and segments of parasites None
Yeasts None
Leukocytes None
 Normal values in stool
analysis
Chemical examination Normal values

Water Up to 75 %
pH 6.5-7.5
Occult blood Negative
Urobilinogen 50-300 g/24hr
Porphyrins Coporphyrins:400-1200g/24hr
Uroporphyrins:10-40 mg/24hr
Nitrogen <2.5 g/24hr
 Normal values in stool
analysis
Chemical examination Normal values

Bile Negative in adults:positive in children

Trypsin 20-950 units/g( positive in small amounts
in adults; present in greater amounts in
normal children.
Osmolarity used 200-250 mOsm with serum osmol-
arity to calculate osmotic gap
Sodium 5.8-9.8 mEq / 24hr
 Normal values in stool
analysis
Chemical examination Normal values

Chloride 2.5-3.9 mEq / 24 hr

Potassium 15.7-20.7 mEq /24 hr
Lipids ( fatty acid) 0-6 g / 24 hr
 Clinical Implications
1. Fecal consistency may be altered in various disease states

a. Diarrhea mixed with mucous and red blood

cells is associated with
1. Typhus 2. Typhoid 3.
Cholera

4. Amebiasis 5. Large bowel cancer

 Clinical Implications
b. Diarrhea mixed with mucus and white
blood cells is associated with
1. Ulcerative colitis 2. Regional enteritis

3. Shigellosis 4. Salmonellosis

5. Intestinal tuberculosis
 Clinical Implications
C. ”Pasty” stool is associated with a high fat content in the
stool:

1. A significant increase of fat is usually detected on gross examination

2. With common bile duct obstruction, the fat gives the stool a putty- like
appearance.
3. In cystic fibrosis, the increase of neutral fat gives a greasy, “butter stool”
appearance.
 Stool Odor
Normal value Varies with pH of stool and
diet. Indole and sketole are the substances
that produce normal odor formed by
intestinal bacteria putrefaction and
fermentation.
Clinical implication.
1. A foul odor is caused by degradation of
undigested protein.
2. A foul odor is produced by excessive
carbohydrate ingestion.
3. A sickly sweet odor is produced by volatile
fatty acids and undigested lactose
 Stool pH
Normal value : Neutral to acid or alkaline
Clinical implication
1. Increased pH ( alkaline)
a. protein break down b. Villous adenoma
c.Colitis d.Antibiotic use
2. Decreased pH ( acid)
a. Carbohydrate malabsorption
b. Fat malabsorption
c. Disaccharidase deficiency
Normal value : Brown
Stool color
Clinical implication:
1. Yellow to yellow-green : severe diarrhea
2. Green : severe diarrhea bile
Black: resulting from bleeding into the upper gastrointestinal tract (>100
ml blood)
3. Tan or Clay colored : blockage of the common bile duct.
4. Pale greasy alcoholic (no bile secretion) stool found in pancreatic
insufficiency.
 Stool color(con)
4. Maroon-to-red-to-pink : possible result of bleeding from the lower
gastrointestinal tract (eg. Tumors, hemorrhoids, fissures,inflammatory process)
5. Blood streak on the outer surface of usually indicates hemorrhoids or anal
abnormalities.
6. Blood in stool can arise from abnormalities higher in the colon. In some
case the transit time is rapid blood from stomach or duodenum can appear as
bright or dark red or maroon in stool.
 Blood in Stool
Normal value : Negative
Clinical Implication :
1. Dark red to tarry black indicates a loss of 0.50 to 0.75 ml of blood from the
upper GI tract.
2. Positive for occult blood may be caused by
a. Carcinoma of colon b. Ulcerative colitis
c. Adenoma d. Diaphramatic hernia
e. Gastric carcinoma f. Diverticulitis
g. Ulcers
 Mucous in Stool
Normal value : Negative for mucous
Clinical Implication:
1. Translucent gelatinous mucous clinging to the surface of formed stool occurs
in
a. Spastic constipation b. Mucous colitis
c. Emotionally disturbed patients
d. Excessive straining at stool
2. Bloody mucous clinging to the surface suggests
a. Neoplasm b. Inflammation of the rectal canal
 Mucous in Stool (con)
3. Mucous with pus and blood is associated with
a. Ulcerative colitis b. Bacilliary
dysentery

c. Ulcerating cancer of colon d. Acute

diverticulitis

e. Intestinal tuberculosis
 Fat in Stool
Normal value : fat in stool will account for up to 20 % of total solids. Lipids are
measured as fatty acids (0-6.0 g/24hr)
Clinical Implication :
1. Increased fat or fatty acids is associated with the malabsorption syndromes
a. Nontropical sprue b. Crohn’s disease
c. Whipple’s disease d. Cystic fibrosis
e. Enteritis and pancreatic diseases
f. Surgical removal of a section of the intestine
 Urobilinogen in Stool
Normal value :25-400 Ehrlich units / 24 hr
75-350 Ehrlich units/100 g
Clinical Implication:
1. Increased values are associated with Hemolytic
anemias
2. Decreased values are associated with
a. Complete biliary obstruction
b. Severe liver disease, infectious hepatitis
c. Oral antibiotic therapy that alters intestinal
bacteria flora
 Bile in Stool
Normal value : Adults –negative
: Children may be positive
Clinical Implication:
1. Bile may be present in diarrheal stools.
2. Increased bile levels occur in Hemolytic anemia
 Trypsin in Stool
Normal value : Positive in small amounts in 95 %
of normal persons.
Clinical Implication : Decreased amounts occur in
a. Pancreatic deficiency
b. Malabsorption syndromes
c. Screen for cystic fibrosis
 Leukocytes in Stool
Normal value : Negative Clinical Implication
1. Large amounts of leukocytes
a. Chronic ulcerative colitis b. Chronic
bacilliary dysentery
c. Localized abscess
d. Fistulas of sigmoid rectum or anus

2. Mononuclear leukocytes appear in Typhoid

 Leukocytes in Stool (con)
3. Polymorphonuclear leukocytes appear in
a. Shigellosis b. Salmonellosis
c. Yersinia d. Invasive Escherichia
coli diarrhea
e. Ulcerative colitis
4. Absence of leukocytes is associated with
a. Cholera b. Non specific diarrhea
c. Viral diarrhea d. Amebic colitis
e. Noninvasive E.coli diarrhea
f. Toxigenic bacteria Staphylococci spp.,
 Porphyrins in Stool
Normal value : Coproporphyrin 400-1200 g / 24hr
Urophorphyrin 10-40 g / 24 hr.
These values vary from Lab to Lab.

Clinical Implication:
1. Increased fecal coproporphyrin is associated
with
a. Coproporphyria (hereditary) b. Porphyria
variegata
c. Protoporphyria d. Hemolytic
anemia
2. Increased fecal protoporphyrin is associated
 Stool Electrolytes
Normal values : Sodium 5.8-9.8
mEq / 24 hr
Chloride 2.5-3.9 mEq / 24
hr
Potassium 15.7-20.7 mEq /24 hr
Clinical Implication :
1. Idiopathic proctocolitis Sodium and Chloride
Normal Potassium
2. Cholera Sodium and Chloride
 MICROSCOPY CULTURE AND
SENSITIVITY(MCS)
• When there is an infection .it's critical to
know the causative organism and antibiotics
which will be effective against the particular
pathogen . This means that (1) the species
(and strain) of bacteria (or other pathogen)
must be identified and (2) the drugs most
effective at inhibiting their growth must be
determined. The only reliable way this can be
done is by microscopy culture and sensitivity
test.
 REFERENCES
• NELSON TEXT BOOK OF PEDIATRICS 19TH EDITION

• PAEDIATRICS AND CHILD HEALTH IN THE TROPICS

• LASUCOM DEPARTMENT OF HEMATOLOGY

PRACTICAL MANUAL

• www.wikipedia.com

• www.britanica.com
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