WELCOME

STOOL EXAMINATIONPresented by

Dr.Vinutha.M.GIII PG Scholar,

Dept of Roga NidanaGAMC, Bangalore

CONTENTSINTRODUCTIONCOMPOSITIONCOLLECTIONPRECAUTIONPRESERVATIONMACROSCOPIC EXAMINATIONCHEMICAL COMPOSITIONMICROSCOPIC EXAMINATIONSTOOL CULTUREMALA/PURISHA

INTRODUCTION Human feces - STOOL.Faeces / Feces- Plural-latin term- faex-

RESIDUE.Waste residue of indigestible materials of an

animal digestive tract expelled through the anus during defecation.

Meconium

SCATOLOGY or CAPROLOGY -study of feces.

COMPOSITION• ¾ Water, ¼ Solid• Undigested and Unabsorbed food• Intestinal secretions, Mucous• Bile pigments and Salts• Bacteria and Inorganic material• Epithelial cells, Leukocytes

COLLECTION• Universal Precautions• Dry, sterilized, wide mouthed container

(50 ml).• Plastic/waxed cardboard box/match box• Uncontaminated with Urine or any other

body secretions.• Properly named• Always a fresh sample -tested • Morning specimen-5 to 6 ml

PRECAUCTION• Labeled specimen • Contamination • Specimen should not be left uncovered

(Prevent drying) • Examined within 1 hr of collection • Disposed properly after examination

PRESERVATIONVarious preservativesAq. 10% formalinMIF-merthiolate iodine formaldehydeLV-PVA-low viscocity polyvinyl alcoholSAF-sodium acetate acetic acid formalinSchaudinn’s fixativeModified PVA Cu and ZnOne vial fixative-ECOFIX,PARASAFE,UNIFIX

Contd..CONSISTENCY AND FORMNormal- Well formed-Semisolid

Abnormal: conditionPale, Bulky, Frothy

Hard

Flattened and Ribbon

Watery

Rice water-

Steatorrhea

Constipation

Obstruction in lumen- Bowel

Bacterial infection

Cholera

COLOUR Normal- Light to dark brown

Color Condition

• Yellow- • Black-

• Bright red/ Hematochezia-• Fresh Blood-• Pale/ Gray-

• White-

• Blue-

• Silver-Aluminium paint

• Violet/ Purple-

Giardiasis, GERD, Gilbert’s syndromeBleeding in the upper GIT, Iron administration, bismuth subsalicylate, BeetrootBleeding in the lower GITAmebic dysentry Cholecystitis, Gallstones, Hepatitis, Chronic pancreatitis, Cirrhosis. After barium meal, Biliary obstruction.RADIOTHERAPY, cesium & Thallium poisoning.Carcinoma of ampulla of vater

Symptom in porphyria.

Infant stages color

• Exclusively breast fed infants-

• Infants fed on cow’s milk preparations-

• Babies fed on newer modified cow’s milk-

• Some healthy children

loose and green or pasty and yellow stools.paler yellow colour and of a much firmer consistency. Clay coloured or greenish stools.

pass frequent, loose stools containing undigested vegetable matter called as Toddler’s diarrhoea.

Contd..ODOURDepends on- PH of stool Methyl sulfidesBenzopyrrole volatiles(indole and sketole)

& Hydrogen sulphidesubstances that produce normal odour-

Intestinal bacterial fermentation and putrefaction.

Odour Condition

• Foul odour-

• Sickly sweet odour-

• Increased odor-

Degradation of undigested protein and excessive carbohydrate intake.

Undigested Lactose.

Celiac disease, Crohn’s disease, Ulcerative colitis, Chronic Pancreatitis, Cystic fibrosis,.

PARTS OF PARASITE AND ADULT PARASITEWorms and their parts• Round worm• Hook worm• Tape worm• Pin worm• Whipworm

C H E M I C A L E X A M I N A T I O N

NORMAL

• Water –

• pH –

• Occult blood- • RS –

• Bile –

• Sodium –

• Chlorides –

• Potassium –

• Lipids / Fatty acids –

• Nitrogen -

Upto 75%

5.8 to 7.5

NegativeNegative

Negative in Adults

5.8 to 9.8 mEq/24hrs

2.5 to 3.9 mEq/24hrs

15.7 to 20.7 mEq/24hrs

0 to 6 gms/24hrs

<2.5g/24hrs

PHProcedure Increased pH-

ALKALINEDecreased pH-ACIDIC

• Atleast ½ ml of faeces -collected.

• Patient shouldn’t receive any antibiotics.

• Strip of nitrazine paper – dipped in sample.

• Colitis

• Antibiotic use

• Villous adenoma

• Excess Protein in diet.

• Carbohydrate Malabsorption- Lactose intolerance

• Fat Malabsorption

• Disaccharidase defficiency

• Contagoin- E.Coli, rotavirus.

OCCULT BLOOD:Principle Method Intpretation

Benzidine test-Perioxidase

+hemoglobin in blood converts

hydrogen peroxide

water and nascent oxygen

oxygen oxidises

benzidine in acidmedium

green to blue coloured complex.

Benzidine – Glacial acetic acid – Hydrogen peroxide – Over stool in slide – Colour change.

Ulcers,Diverticullitis,Ulcerative Collitis,Diaphragmatic Hernia,Adenoma,CA Colon, Gastrium

FATMicroscopic examination:

Quantitative fecal fat test:

Interpretation

•Random faeces stained with Sudan staining ( Sudan III or IV)•Visible amounts of fat

•Done over a period of 3 days•In a container all faeces collected•Thoroughly mixed to homogenize•Small sample is obtained•Fat content extracted with solvents•Measured by saponification

• Malabsorption Syndrome

• Obstructive Jaundice

• Non tropical sprue/Coeliac Sprue

• Crohn’s disease• Cystic Fibrosis• Whipple’s disease• Enteritis and

Pancreatic diseases

Contd..REDUCING SUBSTANCESScreening test -carbohydrate

malabsorbtion disorders -lactose intolerance or disaccharidase deficiency,

Stool - positive for RS -Rota viral Infection in Infants.

Materials: Reagents: Procedure:

•Wooden applicator sticks•Plastic transfer pipette, 6 inches16 x 125 mm test tubes•Clinitest color reaction chart•Vortex mixer

•Clinitest tablets •Type I water•MAS Urinalysis Abnormal Level 1 control•Normal Urinalysis Control

•1 volume of stool (approximately “pea” size) to a 16 x 125 mm test tube. •Add 2 volumes of type I water. •Mix thoroughly using a vortex mixer • centrifuge for 5 minutes at 2000 rpm (full speed).•Using a plastic (uniform drop) pipette, transfer 15 drops of this suspension to a clear test tube (16 x 125). •Add one Clinitest tablet.•end of this 15 second waiting period•Compare the color of the liquid

Contd.. Warning: This is an exothermic reaction

and the test tube will become very hot. Keep hands and face away from the test tube opening.

Note: Ignore sediment that may form in the bottom of the test tube and changes after the 15 second waiting period.

ResultsCLINITEST % REPORTING

SYSTEMCOLOUR

0.0 N -Normal BLUE

0.25 T-Nomal Blue to green

0.5 1+ Suspicious Shades of green

0.75 2+ To Brown

1.0 3+ to

2.0 4+ Orange

>2 >4+ greenish-brown

M I C R O S C O P I C E X A M I N AT I O N O F T E M P O R A R Y M E T H O D

RequirementsMicroscope slidesCover slipsSodium chloride solutionLugol’s Iodine SolutionWooden applicatorFresh stoolGloves

Method:A drop of warm Saline or Lugol’s Iodine is placed

over a clean microscopic slide.• About 2mg of stool sample should be taken and

mixed with soln placed over the slide.• Coverslip is placed avoiding air bubbles.• Examined under Microscope.

STOOL EXAMINATIONTemporary

Scanty infectionConcentration techniques

Saline sedimentation

Formol Ether Sed. Conc.

Baermann’s technique

Permanent Stained smearsIron haematoxylin stainTrichrome stain Modified Ziehl Neelsen stain (Crypto.)

Iron haematoxylin stainFecal smear- fixed in Schaudinn’s solution-15minImmersed 2-5 min 70%alcohol70%alcohol having trace of iodine50% alcohol for 2-5minWashed in H2o-5-10minImmersed in 2%aqeous ferric ammonium sulphateWashed in H2o 3-5 min & stained by 0.5% aqueous hematoxylin

5-15minWashed 2-5 min & differentiated in saturated aq. Picric acid 10-

15minWashed 10-15min & dehydrated by passing through increasing of

alcoholCleared in toulene /xylol and mounted

Trichrome stain

Quicker & simplerSmear is fixed in Schaudinn’s solutionTaken up by alcohol Trichrome stain- applied-5-10minDifferentiated in acid-alcohol Dehydrated ClearedMounted

Normal

• Undigested food materials – None to small amount

• Starch – None• Eggs, Cysts, Parasitic fragments – None• Yeasts – None• Leukocytes – None

ABNORMALABNORMAL IMPLICATION

Large amounts of leukocytes Chronic Ulceratice Collitis, Chronic Bacillary Dysentry, Localised Abscess, Fistulas.

Mononuclear Leukocytes Typhoid

Polymorphonuclear Leukocytes

Shigellosis, Salmonellosis, Invasice E. coli diarrhoea, Ulceratice Collitis.

EGG COUNTING METHODSSemi quantitative assessmentStandard Wet mountModified Kato thick smear techniqueMc. Master’s methodStoll’s dilution techScotch tape method- Enterobius vermicularisBell’s dilution-filtration count- schistosome eggs

STANDARD WET MOUNT

Thick smear-Kato technique

MC. MASTER’S METHODChamber

Eggs in 20mg

Salt floatation

Concentration

Square grid on the roof of

chamber

Stoll’s technique

Scotch tape methodApp. 4inch cellophane

tape

Sticky side of tape pressed against

the skin across the anus

Sticky side of tape placed

on glass slide

Drop of toulene/xylol

betW. Tape & slide

3 consecutive days @ early

morning

STOOL CULTURE

Gram –ve - E. coli, Enterobacter, Proteus, Pseudomonas aeruginosa, Bacteroides.

Gram +ve - Clostridia, Lactobacilli, Enterococci, Anaerobic streptococci.

Contd..Culture media -

AGAR and is done aerobically.

XLD Agar media – Salmonella,

Shigella.

TCBS Agar media– Cholera.

MacConkey media – Yersinia

enterocolitica

Campylobacter culture media - Campylobacter

species.

Hanging drop test:

Drop stool -centre of a coverslip.

Drop of water / vaseline- each corner of the coverslip.

Invert a slide -central depression over the coverslip.

The coverslip -stick to the slide

Inverted the drop of bacterial culture-suspended in the central depression

of the slide.

Examine microscopically (X100) -motile organisms.

Cultures

Harada mori filter paper strip culture

S.StercoralisTrichostrongylus

Agar plate cultureS.Stercoralis

sensitive Charcoal culture

Contd..HARADA MORI FILTER PAPER STRIP

CULTURE:

AGAR PLATE CULTURE

App. 2g• Inoculated• Agar plates

SealedRoom

temperature

2 daysLarva crawl over

agar

CHARCOAL CULTURE

Softened faeces

Mixed 5-10 parts of moistened charcoal granules

Covered, stored-7-10 days, larvae

Contd..Wet film- microscopyCulture on selective media- salmonella, shigella &

Camphylo bacter spp.,etcMolecular genetics-PCR probes- detect Shiga toxin-

E.coliEIA- detection of rotavirus & adeno virus-

childrenDiarrhoel outbreaks- Norovirus-PCR/electron

microscopyOutbreaks of viral meningitis/encephalitis-

viral culture

INTESTINAL PARASITESEntamoeba histolytica- Pathogenic

Entameoba coli-Non pathogenic

Endolimax nana- Non pathogenic

Iodamoeba buetschlii –Non pathogenic

Balantidium coli-Pathogenic

Giardia lamblia-Pathogenic

Trichomonas vaginalis- Pathogenic

Cryptosporidium parvum-Pathogenic

Ascaris lumbricoides- Large round worm

Contd..

Enterobius vermicularis-pin worm

Contd..

Trichuris trichura- Whipworm

Necator americanus and Ancylostoma duodenale- Hookworm

Necator americanus and Ancylostoma duodenale

Strongyloides stercoralis-Threadworm

Taenia solium- Tape worm

Taenia solium- Tape worm

M A L A / P U R I S H A

Dosha dhathu mala moolam hi ….Synonyms:- Shakrit, Upveshana, Vit,

Gutha,Varcha

Formation of purisha“Pakwashya Tu Prapatasya

ShoshyemanasyeVahinna Paripinditpakavasye VayuSyat Katubhavata” [Charak Chikitsa

Sthana15/11]“Kittam Annasye Vinmutram”. [CharakChikitsa Sthana 15/18]

Panchbhautika constitution of purishaPurisha predominantly consists of agni andvayu mahabhuta.“Purisham parthivam” (Bhanumati onSushruta sutrasthan15/8)

Site of formation“Purishvahanam srotsam pakvashyo

mulamsthulgudam” (Charak vimansthana5/8)“Tatra vatvaschonirasnam

sthulantrapratibaddamgudam naam marmamch”(Sushruta

sharirsthana 6/25)

Purishadhara kala“Panchmi purishdharanam,ya Ante

kosthemalam Abhivibhajyte pakvashyastha”

[SushrutaShareer Sthana 4/16] “Yakrit samantat koshte ch tathaantrani

Samashrita Undukastham vibhajte Malam Maladharakala” [Sushruta shareer Sthana 4/17]

Quantity- Functions of purisha“Sapta Anjali purishasye” [Charak

shareerSthana 7/15]“Avshtambh purishasye” [Ashtang HridyaSutrasthana Sthana 11/5]

ASHTA STHANA PARIKSHA

•Mala swaroopaArishta

•Ati krishna, atishubra•Atipeeta, Aruna

Mruthyu karaka

•Excess ushnaAvashya mruthyu karaka

Mala pareeksha Contd..Condition Lakshana

Saama mala Guru, Durgandhi, Apsu nimajjathi

Nirama mala Laghu, Na Apsu nimajjathi

Kamala Tila pista Nibha

Atisara Bahu drava

Pravahika Kapha yukta mala

Grahani Muhur baddam, muhur dravam

PURISHAJA KRIMI

Sthana• Pakvashaya

Akruty• Sookshma

(minute),Vritha (round), Deergha (long)

• Sthoola(big), Prithavapucksa (flat tail) and Tanu(thin)

Varna• Shweta(white),

Shyava (pale), Neela (blue),

• Harita (green), Peeta (yellow).

Kakeruka –highly motile Makeruka – shape of MudrikaSausrada- shelters on fermented materialsLeliha- continuously licks/feeds and consume

Dhatus (seven tissue elements of the body)Sashoolika -causing pain in the host.21

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