Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Body Cavity and Joint Effusions: Why They Form and How to
Document related concepts
Transcript
Dr. Jennifer L. Brazzell, DVM, MRCVS, Dipl. ACVP (Clinical Pathology) Anatomic Pathology Resident and Graduate student Western College of Veterinary Medicine University of Saskatchewan, CANADA 1. 2. 3. Participants will learn proper effusion collection, transport, processing, and storage methods that optimize effusion analysis. Participants will understand the mechanisms by which body cavity and joint effusions form. Participants will learn to classify pathologic effusions by interpreting their physical, chemical, and cellular composition. 2 1. 2. 3. 4. 5. Sample Collection and Processing Components of Fluid Analysis Review of Normal Circulation Body Cavity Effusions Joint Effusions 3 Submit fluids from body cavities and joints (with known cellular and protein content) for full fluid analysis ◦ Total solids, WBC count, and RBC count Fluids from cystic masses or from washings (e.g. tracheal wash) should be submitted for cytologic evaluation 4 Lavender topped anticoagulated EDTA tube for cytological evaluation If culture or biochemical tests also submitted, aliquot separate portion into a sterile non-anticoagulated container/tube. Whenever possible, fresh direct smears, +/- sediment smears, +/- roll preparations should be submitted 5 Use the following techniques to make direct and sediment smears of your fluid sample ◦ Push smears ◦ Pull/slide-over-slide smears ◦ Roll/line preparations 6 Push smears ◦ Like making a blood smear ◦ Ideal for bloody/fluid samples 7 Pull/slide-over-slide smears: ◦ Good for samples containing fragile cells (e.g. neoplastic lymphocytes) 8 Roll/line preparations: ◦ Method of concentrating cells without sediment 450 9 Staining one slide for evaluation of sample quality is recommended Heat fixation/other fixation techniques are not required prior to staining Any Romanowski-type stain (e.g. DiffQuick) acceptable Slides stained with vital dyes (e.g. methylene blue, Sedi-Stain) cannot be reevaluated Keep away from formalin 10 1. 2. 3. 4. 5. Sample Collection and Processing Components of Fluid Analysis Review of Normal Circulation Body Cavity Effusions Joint Effusions 11 Physical characteristics ◦ Volume ◦ Color Supernatant: Yellow-orange-green—bilirubin Red, pink, brown—blood or hemoglobin containing White—contains chylomicrons Sediment: Red—RBCs Cream-tan—WBCs Greenish tinge---eosinophils 12 ◦ Transparency Opaque fluids--chylomicrons or cellular content ◦ Odor Foul smelling?, urine-like? ◦ Mucin quality: Normal=long string of mucin between needle and slide, will stay in a ball on slide Abnormal=thin, runny consistency N.B. EDTA degrades hyaluronic acid 13 Chemical characteristics ◦ Measurement of total protein by refractometry--not reliable if chylous ◦ Cholesterol and triglycerides—chylous/pseudochylous effusions ◦ Bilirubin—bile peritonitis ◦ Urea/creatinine—uroperitoneum ◦ Lipase--pancreatitis ◦ Miscellaneous others—lactate, glucose 14 Cellular characteristics ◦ Total RBC count/HCT Low in non-hemorrhagic fluids Approaches that of peripheral blood in acute hemorrhagic effusions ◦ Total nucleated cell count Varies depending on cause of effusion 15 1. 2. 3. 4. 5. Sample Collection and Processing Components of Fluid Analysis Review of Normal Circulation Causes and Types of Body Cavity Effusions Joint Effusions 16 Circulatory system consists of: ◦ Blood ◦ Central pump (heart) ◦ Blood distribution (arterial) and collection (venous) networks ◦ System for exchange of nutrients and waste products between blood and extravascular tissue (microcirculation) Effusion: escape of fluid into a part Caused by circulatory disturbance Journal of Investigative Dermatology. 2006. 126:2167-2177. 17 Remember portal circulation http://webanatomy.net/anatomy/hepatic_portal_system.jpg http://leavingbio.net/CIRCULATORY%20SYSTEM/CIR CULATORY%20SYSTEM.htm 18 Lymphatics parallel the veins and drain fluid from extravascular spaces into blood vascular system http://www.athletictapeinfo.com/kinesiology-tapehttp://medical2/161-microcirculatory-benefits-of-kinesiology-taping/ dictionary.thefreedictionary.com/_/viewer.aspx?pat h=vet&name=gr254.jpg 19 Normally balanced so no net loss or gain of fluid across capillary bed In health: plasma filtrate leaves capillariesenters interstitial spacediffuses into serous body cavitiesremoved by lymphatics and returned to plasma Very small amount in health Decreased plasma oncotic pressure Increased hydrostatic presssure Arterial end Capillary bed Venous end 20 The Starling equation reads as follows: Where: ◦ ([Pc − Pi] − σ[πc − πi]) is the net driving force, ◦ Kf is the proportionality constant, and ◦ Jv is the net fluid movement between compartments. According to Starling's equation, the movement of fluid depends on six variables: ◦ ◦ ◦ ◦ ◦ ◦ Capillary hydrostatic pressure ( Pc ) Interstitial hydrostatic pressure ( Pi ) Capillary oncotic pressure ( πc ) Interstitial oncotic pressure ( πi ) Filtration coefficient ( Kf ) Reflection coefficient ( σ ) 21 The Starling equation is an equation that illustrates the role of hydrostatic and oncotic forces (the so-called Starling forces) in the movement of fluid across capillary membranes 22 Arteriole 30 17 Blood Pressure 8 8 Tissue hydrostatic pressure 25 10 25 Blood oncotic pressure Tissue oncotic pressure 7 Venule 10 6 NET ABSORPTION PRESSURE NET FILTRATION PRESSURE (17 - 8) – (25 –10) = -6 mm Hg (30 - 8) – (25 –10) = +7 mm Hg 7 - 6= 1 Lymph vessels 23 1. 2. 3. 4. 5. Sample Collection and Processing Components of Fluid Analysis Review of Normal Circulation Body Cavity Effusions Joint Effusions 24 Effusion: accumulation of fluid in a body space or cavity Effusions accumulate when pathology disturbs the balance between fluid entry and fluid removal 25 Five basic pathologic processes are responsible for most effusions: ◦ 1) Transudation Protein-poor Protein-rich ◦ 2) Exudation ◦ 3) Hemorrhage ◦ 4) Lymphorrhage ◦ 5) Rupture of a hollow organ/tissue 26 Some have suggested that the term ―modified transudate‖ is descriptive and does not infer any cause for the effusion Suggest the use of ―protein-poor‖ and ―protein-rich‖ transudate offer more clinically relevant information 27 Increased hydrostatic pressure ◦ Portal hypertension (right-side heart failure, hepatic fibrosis) ◦ Pulmonary hypertension (left side heart failure) ◦ Decreased lymphatic drainage due to obstruction or compression Decreased oncotic pressure ◦ Albumin loss due to protein losing enteropathy or nephropathy ◦ Lack of production due to liver failure (particularly due to cirrhosis) 28 Protein-poor transudates: ◦ Usually found in hypoproteinemic patients (<1.5 g/dL) but hypoproteinemia alone often will not cause effusion unless it developed rapidly ◦ Usually multifactorial (e.g. hypoproteinemia and liver fibrosis resulting in portal hypertension) Protein-rich transudates: ◦ Occur when there is increased pressure in the liver or lungs due to venous congestionheart failure 29 Type of Effusion Opacity/Color Total Protein (g/dL) Nucleated cells (x 103/uL) Cell Content Protein-poor transudate Clear/colorless <2.0 <1.5 Mostly macrophages, rare lymphocytes and neutrophils Protein-rich transudate Clear to mildly opaque/Yellow >2.0 <5.0 Mixed macrophages and neutrophils 30 31 32 33 Occur due to increased vascular permeability caused by inflammation Proteins and plasma ooze out of blood May be septic/infectious (degenerate neutrophils) or non-septic/noninfectious (non-degenerate neutrophils) 34 Characterized by cellular content: ◦ Neutrophilic—more acute ◦ Mixed neutrophilic-macrophagic—more chronic (think atypical bacteria, fungi, foreign body long-standing inflammation) ◦ Macrophagic—rare in veterinary medicine ◦ Eosinophilic—parasites, paraneoplastic, hypersensitivity 35 Type of Effusion Opacity/Color Total Protein (g/dL) Nucleated cells (x 103/uL) Cell Content Protein-poor transudate Clear/colorless <2.0 <1.5 Mostly macrophages, rare lymphocytes and neutrophils Protein-rich transudate Clear to mildly opaque/Yellow >2.0 <5.0 Mixed macrophages and neutrophils Exudate Cloudy/cream colored >2.0 >5.0 Predominantly neutrophils with lesser numbers of macrophages, few lymphocytes Rarely eosinophil rich 36 Septic—bacteria, fungi, protozoa, parasites. virus Non-septic—neoplasia, sterile foreign body or fluid (bile, urine), inflammation of an organ (pancreatitis, torsion causing necrosis) 37 38 39 Trauma, bleeding neoplasms, coagulopathies Must distinguish from blood contamination Most pericardial effusions Recent hemorrhage—looks like peripheral blood smear, may have platelets Longer standing—erythrophagia, hemosiderin, other heme breakdown products, mesothelial reactivity 40 Type of Effusion Opacity/Color Total Protein (g/dL) Nucleated cells (x 103/uL) Cell Content Protein-poor transudate Clear/colorless <2.0 <1.5 Mostly macrophages, rare lymphocytes and neutrophils Protein-rich transudate Clear to mildly opaque/Yellow >2.0 <5.0 Mixed macrophages and neutrophils Exudate Cloudy/cream colored >2.0 >5.0 Predominantly neutrophils with lesser numbers of macrophages, few lymphocytes Rarely eosinophil rich Hemorrhagic Opaque/red >2.0 >2.0 Acute: blood-associated leukocytes Chronic: macropahges, mesothelial cells 41 42 Mesothelial reactivity can be deceiving, don’t mistake for neoplasia!!! Common in long-standing canine effusions, particularly prominent in pericardial hemorrhagic effusions 43 Leakage of fluid from lymphatic vessels Lymphocyte predominant Chylous—contains chylomicrons, white and opaque ◦ NOTE: Inappetent animals may not have significant triglyceride content and thus will not have characteristic white color of chylous effusion Nonchylous—does not contain chylomicrons ◦ Not in drainage path from intestine to thoracic duct 44 Fluid triglyceride > serum triglyceride Fluid cholesterol:triglyceride <1 in chylous Cardiomyopathy is by far most common cause in cats Often idiopathic in dogs Rule out mediastinal lesions, hernias/torsions, trauma http://www.gallowayvet.com/Templa tes/ContentPages/Articles/ViewArtic leContent.aspx?Id=855 45 Type of Effusion Opacity/Color Total Protein (g/dL) Nucleated cells (x 103/uL) Cell Content Protein-poor transudate Clear/colorless <2.0 <1.5 Mostly macrophages, rare lymphocytes and neutrophils Protein-rich transudate Clear to mildly opaque/Yellow >2.0 <5.0 Mixed macrophages and neutrophils Exudate Cloudy/cream colored >2.0 >5.0 Predominantly neutrophils with lesser numbers of macrophages, few lymphocytes Rarely eosinophil rich Hemorrhagic Opaque/red >2.0 >2.0 Acute: blood-associated leukocytes Chronic: macrophages, mesothelial cells Lymphorrhage Opaque/white3.0-6.0 Usually pink (typical) Artifactually 5.0-10.0 Hazy/yellow-pink high (nonchylous) Lymphocyte predominant More chronic effusions may become inflamed with neutrophils/macrophages 46 47 48 Uroperitoneum—acutely abdominal fluid is just urine but inflammation will ensue if fluid persists ◦ Look for urine crystals, spermatozoa, urine odor ◦ Fluid creatinine should be > serum creatinine Bile peritonitis ◦ Fluid bilirubin > serum bilirubin ◦ Crystals, mucinous bile ◦ Green colored Stomach or intestinal perforation ◦ Look for enteric bacteria/stomach/GI contents 49 Highly variable in cellular and protein content Usually cellular and protein contents are within exudate limits 50 Carcinoma vs. mesothelial reactivity? 51 52 53 54 Lymphorrhage or lymphoma? 55 1. 2. 3. 4. 5. Sample Collection and Processing Components of Fluid Analysis Review of Normal Circulation Body Cavity Effusions Joint Effusions 56 Plasma ultrafiltrate with added mucopolysaccharides Normally colorless, clear, mucinous ◦ Cell counts: RBC: normal = 0 but often get few due to iatrogenic blood contamination Nucleated cells = <1,000-3,000/uL, small, quiescent mononuclear cells 57 http://www.vetmed.wsu.edu/resources/T echniques/arthro.aspx 58 59 1. 2. 3. Joint fluids only have a few patterns Hemorrhage—must differentiate iatrogenic from true Mononuclear reactivity Inflammation Infectious Non-infectious 60 Hemorrhage ◦ Blood contaminationstreaks of blood in the tube, see platelets ◦ Minimize by releasing suction before removing needle ◦ True hemorrhageuniformly red, often less viscous >6 hours old erythrophagia and/or hemosiderin-containing macrophages Olderxanthochromia ◦ Rule out trauma, coagulopathies 61 Mononuclear reactivity ◦ Due to degenerative arthropathies caused by joint instability, OCD 62 Mononuclear reactivity: ◦ Increased number of mononuclear cells; sometimes aggregated ◦ Increased cytoplasmic basophilic, volume, and/or vacuolation Normal Increased cytoplasmic basophilia Increased cytoplasmic vacuolation and volume Aggregates 63 Inflammatory ◦ Neutrophil predominant ◦ Infectious Bacterial: usually acute presentation, monoarticular (large joint), heat/pain, history of penetrating/surgical wound, neutrophils usually degenerate appearing 64 Rickettsial (Anaplasma phagocytophilum) and spirochetal (Borrelia burgdorferi): history of tick exposure in endemic area, polyarticular, organisms rarely identified, neutrophils often non-degenerate Other: fungal, Mycoplasmal, protozoal, viral 65 May not see bacteria, may be culture negative but antibiotic therapy responsive 66 ◦ Non-infectious/Immunemediated Also neutrophil predominant, primarily polyarthritis, smaller joints Non-erosive Idiopathic polyarthritis SLE Secondary to some stimulus: distant focus of infection, IBD, malignancy, drugs, vaccination Erosive Rheumatoid arthritis 67 [email protected] 68
