TRANSUDATES AND EXUDATES Dr. K.

Doria February 12, 2014 TRANSUDATES Non-inflammatory Disorders that disrupt the balance in the regulation of fluid filtration and reabsorption EXUDATES Increase the permeability of the capillary endothelium Decrease the absorption of fluid by the lymphatic system DIFFERENTIATION OF TRANSUDATES FROM EXUDATES PARAMETER TRANSUDATES EXUDATES

Chemical Examination Glucose Total Protein Total Protein ration (fluid-to-serum) Lactate dehydrogenase activity Lactate dehydrogenase ration (fluid-to-serum) Pleural fluid cholesterol Pleural fluid: serum cholesterol ration Pleural fluid: serum total bilirubin ration equal to serum level < 3g/dL <0.5 <60% of serum 30mg/more <serum level >3g/dL >0.5 >60% of serum

<0.6

>0.6

<45-60mg/dL <0.3

>45-60mg/dL >0.3

Clarity Color

Physical Examination - Clear, pale yellow Cloudy; any abnormal color (brown etc) - Pale yellow - Any abnormal color (brown, cream) - Milky (less viscous) - No - Milky (more viscous) - Possible

- <0.6

- >0.6

Viscosity Clot spontaneously Specific gravity

Serum-ascites albumin gradient

- >1.1

- <1.1

- <1.018

- >1.018 CAUSES OF PLEURAL, PERICARDIAL, PERITONEAL EFFUSIONS PLEURAL EFFUSIONS PERICARDIAL PERITONEAL EFFUSIONS EFFUSIONS Transudates Infections (bacterial, - SAME AS PLEURAL viral, fungal, Decreased tuberculosis) hydrostatic pressure Eg. Congestive heart failure Decreased oncotic pressure Eg. Hepatic cirrhosis Nephrotic syndrome Cardiovascular diseases (myocardial infarction, aneurysms) Neoplasms (metastatic cancer) Hemorrhage (trauma,

Leukocyte count

Microscopic Examination <1000/mL > 1000/mL

Differential count

Few blood cells and mesothelial cells No crystals, if present

many, with predominant PMN

Crystals

many contain crystal like cholesterol, hematoidin

anticoagulant therapy) Exudates Increased capillary permeability - Infectious (bacterial, tuberculosis, fingal, viral) - Neoplasms (lung, metastatic cancer) - Systemic diseases (rheumatoid arthritis, systemic lupus erythematosus) Systemic disease (systemic lupus erythematous, rheumatoid arthritis) Increased capillary permeability -Infections (bacterial, tuberculosis) -Neoplasms (hepatic and metastatic cancers) -Pancreatitis -Metabolic disease (uremia)

MILKY EFFUSION CHYLOUS VERSUS PSEUDOCHYLOUS EFFUSION Pt. of difference CHYLOUS

CHYLOUS EFFUSION

PSEUDOCHYLOUS - Chronic inflammation - Chronic - Milky/green tinged metallic sheen - <50mg/dL - Decreased/absent - Odorless/fecaloid foul - Variable - No change

PLEURAL Gastrointestinal disease (pancreatitis) Decreased lymphatic absorption Neoplasms (lymphoma) Trauma surgery

PERITONEAL Decreased lymphatic absorption Neoplasms (lymphoma, metastasis) Trauma Tuberculosis

a. Cause b. Onset c. Appearance d. Triglycerides e. Chylomicrons f. Odor g. pH h. Extraction with ether after acidification with HCl i. Sudan III

- Thoracic duct leakage - Acute - Milky white/creamy yellow, bloody - >110mg/dL - Markedly increased - Odorless - Alkaline - it clears...

PHYSICAL EXAMINATION 1.) Cloudy Large numbers of leukocytes, chyle and lipid 2.) Milky Presence of chyle Due to lymphatic obstruction 3.) Chronic effusion Pseudochylous Due to breakdown of cellular components and high cholesterol content 4.) Bloody Traumatic tap Hemorrhagic effusion

- strongly (+)

- (-)/ weakly (+)

MICROSCOPIC EXAMINATION PERICARDIAL Total Cell Count > 1000 cells/L leukocytes = pericarditis PLEURAL >10,000 cells/L associated with neoplasms and trauma of the pleura PERITONEAL > 500 cells/L with a predominance of neutrophils (>50%) bacterial peritonitis MICROBIOLOGIC EXAMINATION 1) Gram stain 2) Acid fast stain 3) Culture

2. Differential cell count Pleural effusion o 90% neutrophil acute inflammation (exudates) o 90% lymphocytes tuberculosis, neoplasms, and systemic diseases Peritoneal fluid o 25% neutrophils bacterial infections (exudates) Cell types o Neutrophils o Eosinophils o Lymphocytes o Monocytes o Macrophages o Plasma cells o Mesothelial cells o Malignant cells CHEMICAL EXAMINATION 1.) Total protein 2.) Glucose < 60mg/dL difference between the serum and fluid is >30mg/dL 3.) Amylase 1.5 to 2 times the serum values 4.) Triglyceride 110 mg/dL indicate a chylous effusion 5.) CEA