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Y3 MOD clinical pathology > Effusions and Fluid Analysis > Flashcards

Effusions and Fluid Analysis Flashcards

1
Q

Peritoneal, pleural and pericardial cavities are lined by ?

A

Mesothelium

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2
Q

How is movement of the mesothelium facilitated?

A

Contain serous fluid

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3
Q

Describe the serous fluid

A

This fluid is an ultrafiltrate of blood

  • Low cellularity
  • Low total protein
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4
Q

Describe the pathophysiology of fluids in the body

A

Volume of fluid present depends upon equilibrium between:

  • Hydrostatic pressure of blood
  • Oncotic pressure of blood (proteins)
  • Permeability of vessels
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5
Q

Define effusion

A

Effusion: any accumulation of fluid in a body cavity

  • Indicative of a pathological process
  • Rate of fluid formation&raquo_space; Rate of fluid removal
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6
Q

What are the two classifications of effusions based on protein, cell count and cytology?

A

Transudate

Exudate

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7
Q

Define transudate

A

Effusion usually caused by imbalances of hydrostatic and/or oncotic pressure

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8
Q

Define exudate

A

Effusion usually caused by increased vascular permeability due to inflammation – higher protein much more cellular fluid

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9
Q

How are effusions classified based on aetiology and composition?

A

Haemorrhagic
Chylous
Pseudochylous
Neoplastic

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10
Q

Analysis of effusions is based on what characteristics?

A
  • Colour
  • Turbidity: clear or opaque
  • Odour
  • Cell counts and total protein
  • Microscopic examination
  • Biochemistry depending on the case
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11
Q

Describe haemorrhagic effusions and their causes

A 
- Heavily blood-stained 
Caused by:
- True cavity haemorrhage: vessel disruption
- Iatrogenic blood contamination
- Splenic tap
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12
Q

How will a sample appear if it has been Iatrogenically contaminated?

A
  • Initially clear then bloody or vice-versa
  • Swirling of blood
  • Should form clot
  • Supernatant clear
  • Can seen platelets
  • No erythrophagocytosis
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13
Q

What are the causes of true body cavity haemorrhage?

A

Bleeding tumour
Coagulopathy
Trauma

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14
Q

Describe the features and cytological appearance of a true body haemorrhage

A
  • Fluid does not clot
  • Supernatant often haemolysed due to RBC degradation in cavity
  • Microscopy:
    Erythrophagocytosis (RBC removed by macrophages)
    No platelets
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15
Q

How can abdominal haemorrhage be investigated?

A
  • Coagulation profile / haematology
  • Ultrasound abdomen to detect masses
  • Look for neoplastic cells on the cytology slide
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16
Q

What is chyle?

A

Chylomicron-rich lymph

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17
Q

What are chylomicrons and their functions?

A
  • TG-rich lipoproteins absorbed from the intestine
  • Transport of dietary lipid
  • Enter lymphatics, then the blood via thoracic duct
  • BIG so make fluid opaque (milky)
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18
Q

Describe the features of a chylous effusion

A
  • Milky fluid (white, opaque)
  • Protein often >25g/l*
  • Cell count very variable
  • Cytology mainly lymphocytes, but can be mixed
  • Neutrophils increase with chronicity
  • High [triglyceride] (> serum): over 1.13 mmol/L -> chyle
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19
Q

How does a chylous effusion form?

A

Formed due to lymphatic drainage impairment or lymphatic leakage
- Lymphatic drainage impairment or lymphatic leakage

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20
Q

What are the causes of a chylothorax?

A

Heart disease
Trauma/surgery
Neoplasia
Idiopathic

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21
Q

How is pseudochyle different to chyle?

A
  • Looks similar grossly
  • BUT not high in triglycerides
  • White colour due to cell debris, protein and cholesterol
  • Uncommon
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22
Q

Describe the features of (Low protein) Transudate

A
  • Clear, colourless
  • Protein < 25 g/l
  • Cell count < 1.5 x109/l
  • Few cells
  • Mainly monocytes and macrophages
  • Lymphocytes
  • Mesothelial cells
  • Few neutrophils
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23
Q

What is the pathophysiology of (Low protein) Transudate formation?

A

Decreased oncotic pressure due to low serum protein

Low protein fluid leaks out of vessels

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24
Q

What are the causes of transudates?

A
  • Decreased oncotic pressure - Severe hypoalbuminaemia
  • Portal hypertension
  • Over hydration
  • Cardiac failure
  • Thrombi in major vessels (acute phase)
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25
What are the 3 causes of hypoalbuminaemia
- Protein losing enteropathy - Protein losing nephropathy - Reduced protein production in liver disease
26
How can transudates be further investigated?
- Biochemistry (plasma/serum): Albumin, Creatinine - Urinalysis (check for proteinuria) - Urine protein:creatinine ratio - Imaging - Look for GI or renal disease
27
Describe the features of High protein (modified) transudates
- ‘Modified’: more protein and cells than pure transudate but not as much exudate - Colourless to amber or pink - Clear (low cell count) - Protein > 25 g/l - Cell count < 5.0 x109/L
28
What is the pathophysiology of High protein (modified) transudates
Increased hydrostatic pressure | (Higher protein) fluid pushed out
29
How does a High protein (modified) transudates appear on cytology?
- Low cellularity (usually higher than pure transudates) - Mixed population of cells - More neutrophils than transudate
30
What are the causes of modified transudates?
Increased intravascular hydrostatic pressure in liver or lung (venous congestion): - Congestive heart failure - Thrombi or neoplasia Also: - Non-exfoliating neoplasia - Lung lobe/ splenic torsion - Occasionally feline infectious peritonitis
31
Describe the appearance and features of exudates
- Turbid (due to lots of cells) - Yellow/brown/bloody - High nucleated cell count - High protein - Mostly neutrophils: Inflammation (e.g. pleuritis, peritonitis, pericarditis)
32
Describe the pathophysiology of exudates
Increased vessel permeability | High protein, cellular fluid leaks out
33
Describe septic exudates and its cause
- Intracellular organisms - But not always visible - Absence of organisms does not rule out sepsis - Often degenerate neutrophils (karyolysis & karyorrhexis)
34
Describe non-septic exudates and its cause
- Non-degenerate neutrophils | - Lower numbers of hypersegmented neutrophils and pyknotic cells
35
What are the causes of septic exudates?
- Penetrating wound - Foreign body - GI perforation or ischaemia - Haematogenous route
36
Describe the effect of gut contamination on a sample
Smelly Brown Bits of plant material Free bacteria
37
What are the causes of non-septic exudates?
- Ruptured gall bladder - Ruptured urinary bladder - Necrotic tumour - Pancreatitis - FIP*
38
Describe the fluid sample that would be taken in the case of feline infectious peritonitis
- Yellow sticky fluid - High protein -> froths - Moderate cellularity - Globulin:albumin ratio A:G low in FIP A:G< 0.4 then FIP likely A:G> 0.8 NOT FIP
39
Describe how the cytology of an FIP case would look
- Abundant proteinaceous background - Cells mainly neutrophils - Fewer macrophages
40
What are some further tests used for FIP diagnosis?
- Immunohistochemistry of fluid pellet for coronavirus and/or PCR - Serology - Can measure alpha 1-acid glycoprotein = Acute phase protein - No single test definitively diagnostic (except for histology)
41
Describe bile peritonitis and how it occurs
- Ruptured gall bladder / bile duct - Trauma - Following obstruction - Chemical peritonitis +/- secondary infection
42
What colour is the fluid from bile peritonitis?
Green
43
Describe how the cytology from bile peritonitis would look
- Neutrophils - Macrophages with green pigment - [Bilirubin] fluid higher than [bilirubin] plasma
44
The concentration of which substance changes if there's a ruptured bladder?
[Creatinine] fluid > [Creatinine] plasma | Usually at least twice
45
How would fluid from a ruptured bladder case appear? How does it change?
- Urea equalises between fluid and plasma so may be similar (or higher) - Fluid starts as transudate (very low protein because diluted by urine) - Urine -> irritant -> changes to exudate
46
What are the effects of neoplastic effusions
- Compression of blood vessels and lymphatics -> increased hydrostatic pressure and/or abnormal vasculature - Increased vessel permeability - Inflammation - Necrosis - Haemorrhage - Cell exfoliation
47
Name 3 tumours that can cause neoplastic effusions
Lymphoma Adenocarcinoma Mesothelioma
48
What are some pitfalls in diagnosing neoplasias?
- Mesothelial cells found in all effusions - Shed off pleura / peritoneum - Can become reactive and look like tumour cells!
49
Describe the appearance of reactive mesothelial cells
- Eosinophilic fringe or brush-boarder - May be multinucleated - May contain prominent multiple nucleoli or variable shapes and sizes - May phagocytose cells and particulate matter
50
What are the indications for using arthrocentesis?
- Joint disease of unknown aetiology - Diseases in multiple joints - Suspected infective arthritis - Pyrexia of Unknown Origin - Monitoring therapeutic response
51
Describe the normal appearance of synovial fluid
Clear, pale yellow
52
Describe the appearance of synovial fluid during inflammation
Yellow turbid
53
What does uniformly bloody synovial fluid suggest?
Haemarthrosis
54
What does clear then bloody synovial fluid suggest?
Contamination
55
What are the main principles when handling a sample
- Make smear immediately - Note viscosity - Collect into EDTA and sterile plain tube - Always send fresh smear with sample
56
Describe all of the normal features of synovial fluid
Clear pale yellow Very viscous Hypocellular Protein background
57
How does synovial fluid appear grossly and on cytology when there has been trauma
Grossly red Low viscosity due to effusion Red cells Some neutrophils
58
How would the cytology of synovial fluid in the case of osteoarthritis appear?
- Cellularity normal or mildly increased - Predominantly mononuclear - Can see osteoclasts (rarely)
59
How would the cytology of synovial fluid in the case of inflammatory arthropathy appear?
- Viscosity reduced - Cellularity increased - Increased cell count - Mainly neutrophils - Degenerative change rarely evident if infective
60
How would the cytology of synovial fluid in the case of septic arthritis
- Usually monoarticular - Penetrating wound - Haematogenous spread (rare) - Often we do not see bacteria and culture is negative

Y3 MOD clinical pathology (10 decks)

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