FAECES EXAMINATION / OCCULT BLOOD IN FAECES

STOOL ANALYSIS CONSISTED OF

1.physical examination ( macros & microscopic ),
2.chemical examination, ( blood, pH, bile, electrolytes, fat etc)
3.other specific diagnostic tests.

INDICATION FOR STOOL ANALYSIS :

a) diarrhea or constipation
b) icterus
c) parasitic/ bac /viral infection
d) GI tract abnormality
E) Anemia
f) Other abnormalities.

STOOL SPECIMEN COLLECTION

a. Use clean and dry bed pan or glass jar
b. Patient may not pass urine when collecting stool , because urine has a harmful effect on
protozoa
c. Transfer small amount of stool ( soft , mucus/pus/blood containing specimen) into
screw cap container (leak proof , odor free, brown/black color and easy to transport)
d. If not possible , specimen from glove during rectal examination can be used , and
transferred to slide glass and filter paper
e. For collection 0f 24 hour stool ,, at least 3 days stool and calculated by using whole
specimen . The 24 h specimen correlates , very poorly with the amount of food ingest ed
f. Fresh specimen in preferred for most examination

EXAMINATION
1.PHYSICAL EXAMINATION
a) MACROSCOPIC EXAMINATION :
Color :
The brown color of the stool is caused by stercobillin, the result of reduction of bilirubin by bacteria. Stool darken
on standing and color of stool is influenced by diet, food dye, drugs and blood. It is important to relate it with
food /drug history of the patient.

Color Cause
white antacid, barium , acholic ( brocade of bile)

gray staetorrhoea ( pancreatic insufficiency )

yellow greenish bilirubin ( new born, no intestinal flora)

biliverdin

green chlorphyl rich diet, diarrhea, calomel

orange azo dye

red bleeding lower GI trac, beets

black iron, charcoal, bismuth cherries, bleeding upper GI tract

Volume : normal 100 -250 g/day depend on diet

ODOR:
Intestinal putrefaction and fermentation produces indole and scatole which gives the normal odor of stool.
High protein diet caused foul smelling odor,
In diarrhea there as sour smell undigested acid.

CONSISTENCY:
Normal formable, a bit soft .
Waterry stool is caused by diarrhea due to mal absorption, infection, laxatives.
Constipation and hard stool/skibala is associated with firm, spherical masses of stool; often result from irritable
colon syndrome or overuse of laxatives.
A narrow ribbon like stool is suggestive of spastic bowel or rectal stricture.
Large amount of mushy , foul smelling gray stool that floats on the water is characteristic of steatorrhoea.

MUCUS :
Presence of mucus is abnormal and should be reported .
Translucent gelatinous mucus slinging to surface suggest spastic constipation or colitis, due to excessive straining.
Mucus also associated with inflammation and infections .
Mucus incorporated in stool suggest small intestine abnormality, mucus on surface of stool is
usually cause by abnormality in colon.
Mucus with pus and blood is associated with bacillary dysentry , intestinal tuberculosis or ulcerating
colitis/ intussusception.
Adenoma of colon can produce 3 – 4 L mucus/day and cause dehydration and electrolyte
disturbance.

PUS:
Chronic ulcerative colitis, shigellosis, abscesses, fistulas and chronic bacillary dysentery passed large
quantities of pus and mucus with the stool. Amoebic colitis seldom produce a lot of pus.

b) MICROSCOPIC EXAMINATION.
The purpose of microscopic examination id to find undigested food particles ( starch/amylum, muscle, fibers,
elastic fibers, fat, etc), eggs and segment of parasites, yeast.

1.Prepare microscope and 2 piece Glass Object.

2.a) Drops 1 drop Lugol solution at the first object glass
b) Take a little bit of faeces with toot pick and mix carefully with Lugol solution at object glass.
c) Cover with deck glass
d) Examine with microscope with objective lens 10 X.
e) Looking for parasite and amylum.
3. a) Drops 1 drop Eosin at the first object glass
b) Take a little bit of faeces with toot pick and mix carefully with Eosin at object glass.
c) Cover with deck glass
d) Examine with microscope with objective lens 10 X .
e) Looking for erythrocyte, leukocyte, and egg worm
Parasites :
Protozoa/Worm
Eosin or Lugol 1 – 2 % solution is used for examination.
Usually protozoa is found as an inactive form, except in watery stool, active form can be found. Eggs or segment of
worms can be observed.

Ancylostoma duodenale

White Blood Cells (WBC):

Acetic acid 10 % or Eosin is used for WBC examination.
Choose a small portion of mucus or liquid stool on a glass microscopic slide and add a drop of acetic acid or
Eosin .
WBC increases in bacillary disentry, ulcerative colitis and other inflammation /infection . Loeffler’s
methylene blue can be used for differential counting with high power.
Count 200 cells , identify as mono or polymorpho nuclear cells. Counting must be done on fresh specimen.
Red Blood Cells (RBC) :
RBC can only be found in lower GI trac bleeding ( rectum, anus). In proximal GIT bleeding the RBC will already be
hemolysed . Loos of more than 50 -75 ml blood in upper GIT gives a dark red to black color in stool ( tarry
appearance).
Persistence of black/tarr appearance for 2 – 3 days suggest the loos of 1000 ml blood may persist up to 5 – 12 days.

Epithels :
Normal shedding of GIT epithels can be found using NaCl 0,9% solution. Number of cells increased in
inflammation/infections

Macrophages :
Relatively big cells with phagocytic ability.

Food particles :
Fibers
Normal with 1 – 2 % .Eosin solution, muscle/vegetables. Fibers can be observed. Muscle fibers, showed as
reterangular fiber with cross striation . Increased numbers found in abnormal digestion.

Fat:
Normal fat in stool consists primary of fatty acid and fatty acid salts, neutral fat and small amount of carotenoid ,
sterol and paraffin.
Normal up to 100 of small ( 1 – 4 um) orange red particles/high power field of neutral fat can be observed using .
Sudan III/IV or Oil Red Solution. Fatty acid present in light flakes or needle like crystals. Increase/ large
number of fat globules (6-7 um) up to > 30 um can be found in steatorrhoeae, pancreas insuff, bile obstruction.
Carbohydrate:
Using Lugol Solution, blue black small particles of amylum can be obserb. Increased in malabsorption.

2.CHEMICAL EXAMINATION :
pH :

Normal is neutral or weakly alkaline. Chemical fermentation changes the pH to acid and protein breakdown
changes the pH to alkaline. pH less than 5,5 is suggestive for dissacharidase deficiency ( unless patient receive
antibiotic).

SUGAR:
Non specific test :
Screening test for dissacharicase deff , stool can be analyzed for sugars using non specific semi quantitative sugar
reduction method ( benendict, Clinitest) .Presence of > 0,5 g/dl reducing substance is considered abnormal . Can be
combined with oral loading /tolerance test.

Specific sugar test:

Identification the sugar using chromatography or specific enzymes for each sugar ( glucose oxidase, galactose
oxidase etc)

3.OTHER SPECIFIC DIAGNOSTIC TESTS.

TESTS FOR TRYPSIN :
Used as screening test in infants to detect pancreas insuff , especially cystic pancreas fibrosis. Small amount of
diluted stool is put on an unexposed /x Ray gelatin film and incubated. Complete digestion by trypsin is seen as a
slight clearing at the periphery of the drop.

BLOOD:
Occult Blood testing
The test employs a substance ( benzidine, guajac, o tolidine ) that are oxidiced to colored
compound by )2 liberated from H202 through the action of peroxidase activity og the heme
portion of Hb.
Interfering subst include iron salts, bromide, iodide, traces of heme in myoglobin ( meat, blood in
diet), plant peroxidase ( chrorophyll , radish, banana, other uncocked vegetables)

Cleaning chemical toilet , bacteria in bowel -- give false positive result.

Large dose of vitamin C interfere with oxidation react on and cause false negative result .
Incorrect sample specimen will also cause false negative.
Normal : Negative blood result.
Positive result : Patient receiving certain drugs ( aspirin, NSAID, has been shown to be associated
with blood loss through GIT) pectic ulcer, malignancy etc.

APT TEST:
To differentiate the origin of blood in melena neonatorum between neonatus or mothers blood .
Alkaline solution were added to the blood in stool. Neonatus blood is resistant to alkaline , the color will be red but
adult (mother) blood will be turn into hematin (brownish).
Colon albumin test :
To detect occult blood in stool by immunologist method using albumin antibody.

Crystals :
Normal : Triple phosphate, /Ca oxalate, acid crystals.
Abnormal : Charcoat Leyden, Hematoidin crystals

Stool culture
Culture for Salmonella ,Shigella , Pathogen Coli, viral etc

Common causes of blood in the stool include:

 Anal fissure
 Colorectal cancer
 Crohns disease
 Ulcerative colitis
 Internal hemorrhoids
 Inflammatory enteritis - inflammation of the small intestine, which may be caused by various
forms of food poisoning as well as by other conditions:
 E. coli enteritis, the most common cause of travelers' diarrhea
 Campylobacter enteritis
 Shigellosis
 Salmonellosis (salmonella enteritis/samonella enterocolitis)
 Bacterial gastroenteritis
 Dysentery
 Staphylococcus aureus
 Radiation enteritis
 Diverticulosis
 Upper gastrointestinal bleeding
 Peptic ulcer disease
 Esophageal varices
 Gastric cancer
 Constipation
STOOL TESTS MAY INCLUDE:
 Fecal occult blood test (FOBT) – to detect blood in the stool
 O&P (Ova and Parasite) – to detect parasites
 Fecal white blood cells – to detect white blood cells in the stool

 Fecal elastase – a protein-cleaving enzyme produced and secreted by the pancreas; it is

resistant to degradation by other enzymes and so is excreted and can be measured in the stool.
The amount of this enzyme is reduced in pancreatic insufficiency.
 Fecal fat, qualitative – usually a suspension of stool placed on a glass slide that is treated with
a special stain and examined under the microscope to detect the presence of fat droplets

If the qualitative fecal fat is negative, then a 72-hour quantitative fecal fat test may be ordered. This
is a better evaluation of fat digestion and absorption. There are two reasons for this:
 For the quantitative test, the person being tested is required to ingest a moderately high
amount of fat per day prior to and during sample collection so their absorption ability is being
"challenged."

 Fat is not released into the stool at a constant rate so the combination and mixing of the stool
from a 72-hour collection gives a more accurate picture of average absorption and elimination
than a single sample.

A fecal fat test is primarily ordered when a person

has signs and symptoms of malabsorption such as:
 Fatty stools that are loose and foul-smelling (steatorrhea)

 Persistent diarrhea
 Abdominal pain, cramps, bloating, and gas

 Weight loss

 Failure to thrive (in children)

These symptoms may or may not be accompanied by other indicators such as fatigue, anemia
and/or specific nutritional deficiencies in, for example, iron or vitamin B12.
A qualitative fecal fat may be ordered as a screening test. If it is positive for excess fecal fat, then
a quantitative test is generally not necessary.

If the qualitative test is negative and the healthcare provider still suspects excess fecal fat, then a
quantitative 72-hour fecal fat may be ordered.

What does the test result mean?

A POSITIVE QUALITATIVE FECAL FAT TEST OR AN INCREASED AMOUNT OF FAT IN A 72-
HOUR QUANTITATIVE FECAL FAT TEST INDICATES THAT FAT IS LIKELY NOT BEING ABSORBED
NORMALLY AND THAT THE PERSON MAY HAVE IMPAIRED DIGESTION OR MALABSORPTION.

MALABSORPTION IS SEEN WITH A WIDE VARIETY OF DISEASES AND CONDITIONS. SOME

CAUSES OF MALABSORPTION INCLUDE:
 Diseases affecting the intestines such as:

o Infections, including parasitic, bacterial or viral
o Celiac disease
o Inflammatory bowel disease (Crohn disease, ulcerative colitis)
 Pancreatic insufficiency caused by:
o Chronic pancreatitis
o Pancreatic cancer
o Cystic fibrosis (affects the function of the pancreas)
o Shwachman-Diamond Syndrome
 Diseases and conditions of the bile ducts and/or gallbladder

o Cancer

o Narrowing or blockage of the common bile duct, the main tube that carries bile from the
liver and gallbladder to the intestines

Other laboratory tests used in conjunction with the fecal fat test are usually required to determine
the underlying cause of fat malabsorption.

A negative qualitative fecal fat test does not necessarily rule out malabsorption so it may be
followed up with a quantitative test.

In a 72-hour fecal fat test, a low level of fecal fat generally indicates that the person tested is
digesting and absorbing fats normally and suggests that the symptoms being experienced are likely
due to another cause.

Is there anything else ?

Laxatives, enemas, barium, mineral oil, fat-blocking supplements, psyllium fiber, and fat substitutes
may affect test results.

Children cannot ingest as much daily fat as adults. Their test preparation will be adjusted and their
72-hour fecal fat test results will typically be reported as a percentage. This result is a "coefficient"
that compares the amount of fat eaten to the amount excreted in order to evaluate the quantity of fat
absorbed.

Although 72 hours is the typical sample collected for a quantitative fecal fat, a healthcare provider
may sometimes ask for a 24- or 48-hour stool sample instead. 

DIAG HEPATITIS IN LAB RESULT

What are liver function tests?
Liver function test (LFT)
- a blood test that gives an indication of whether the liver is functioning properly.
- detect inflammation and damage to the liver
Useful to see if there is
1. active damage in the liver cells
2. sluggish bile flow (cholestasis).
3. function synthetic of the liver
Diagnosis of liver disease depends on
1. patient history
2. physical examination
3. laboratory testing, biopsy and sometimes imaging studies such as ultrasound scans.

The most indication of LFT

- have / suspect liver disease
- taking a medication that can harm the liver
- have symptoms of liver or bile system disease. ( abdominal pain, nausea, vomiting or yellow skin )
- monitor the activity and severity of liver disorders.
- drink alcohol excessively

LIVER FUNCTION TESTS

1.Integrity liver cells test
Enzyme liver consist in cytoplasm and mitochondria.
a . At increasing permeability cells wall enzyme cytoplasm will bee increase ( AST, ALT, LDH 5)
b. If damage involve mitochondria enzyme will bee increase too (AST, GLDH).
The activity of AST in the serum is less than that of ALT because only 20 % of AST is localized in cytoplasm and 80 %
is in the mitochondria.
Mitochondria enz only appear in the blood following complete cell destruction and necrosis leading to an increase
in enzyme

If ALT and AST are found together in elevated amounts in the blood, liver damage is most likely present.
AST then increase above ALT/ complete cell destruction
The ratio AST : ALT : the Ritis ratio , rises above 1
AST = Aspartate Aminotransferase = SGOT
AST enzyme is also found in muscles and many other tissues besides the liver.

2.Test for cholestases :

Cholestatic enzymes ( Alkali Phosphatase/ ALP, GGT, 5 NT) activities increase ( especially in extra hepatic
blockage), but only mild increase in hepato cellular destruction .
The basic test may indicate cholestasis if the GGT is raised more than ALT /SGPT
The most sensitive for cholestasis : ALP but less specific , because ALP elevation also seen in normal childhood,
pregnancy and bone disease.

3.Syntetic function tests

a) Albumin concentrations :
Impaired of synthesis function ----hypo albuminemia; more prominent in chronic than in acute phase. This
test is less sensitive but good for make prognosis
b) Protein Electrophoresis (Protein separate into fragment Alfa 1 glob, Alfa 2 Glob, Beta glob, Gamma glob).
Protein profiles are useful as additional information to make differential diagnosis eq polyclonal gammopathy
type.
c) Cholinesterase enzyme activity
In hepatocellular destruction (chronic hepatitis , liver cirrhosis and drug related liver disease,
organophosphate intoxication ): serum or plasma cholinesterase is reduced . Cholinesterase enzyme activity good
for estimate prognosis.
 d) Coagulation factor : Prothrombin time.
e) Flocculation test: base on stabilization colloid. Now is rarely use

4.Excretory function tests.

a. Bilirubin concentration ( total, direct, indirect) . Urinary bilirubin, urinary and fecal urobilinogen, urinary urobilin
and fecal sterkobilin.
b. Gamma GT & Alkali Phosphatase
c. Ichterus index : (Now is rarely use )
It is an absolute test, it only estimates serum bilirubin concentration by comparing serum color to potassium
bichromat solution color.
5.Detoxifying function test
Blood amonia level
amonia absorb in gut ---- chance to ureum by liver cells, ---- excreted by kidney.
In Hepatic failure blood amonia level increases and could cause hepatic coma.

6.Tests for etiologic factors :

Auto antibodies ;
AMA /Anti Mitochondrial Antibody ---- in primary biliary cirrhosis
SMA /Smooth Muscle Antibody ---------- in chronic active hepatitis,
ANA /Anti Nuclear Antibody -------------- in lupoid , type chronic active
hepatitis.
Sero marker Virus hepatitis
Hepatitis A : anti HAV IgM
Hepatitis B : HBsAg, HBeAg, anti HBs, antiHBe
anti HBc (IgG/IgM), HBV DNA
Hepatitis C : anti HCV (total, IgM) HCV RNA
Hepatitis D : HDAg, anti HD(Ig G, IgM)
Hepatitis E : anti VHE (IgG, IgM)

7.Coagulation test
1.PT (Prothrombin Time ):
Test for production of coagulation factors
2.INR (international normalized ratio) :
Can monitor how much medicine (commonly warfarin) to take.  Increased levels of INR means blood is taking more
time than usual to clot.
The INR increases only if the liver is so damaged that synthesis of vitamin K-dependent coagulation factors has
been impaired;.
It is very important to normalize the INR before operating on people with liver problems.