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Introduction
Medical Laboratory Departments:
Laboratory medicine is generally divided into two sections, and each of which is further divided into a
number of units. These two sections are:

Histopathology Laboratory:
It is a medical specialty that Refers to the examination of a biopsy or surgical specimen.

Clinical Pathology Laboratory:

It is a medical specialty that is concerned with the diagnosis of disease based on laboratory analysis of body
fluids, (such as blood, urine, and tissue homogenates or extracts) Using Macroscopic examination,
Microscopic examination, Analyzers, Cultures, strips, and centrifugal machines.
Clinical pathology laboratory is divided into the following unites:

Clinical Chemistry Unit (also known as Chemical Pathology, Clinical Biochemistry or Medical
Biochemistry): is the study of chemical and biochemical mechanisms of the body in relation to disease.

Clinical Immunology Unit: is the study of immune systems in all organisms.

Clinical Microbiology Unit: is the study of microscopic organisms, such as bacteria, fungi and protozoa.

Clinical Hematology Unit: is the study of blood, the blood-forming organs, and blood diseases.

Cytogenetic Unit: is the study of cellular changes and everything related to cells.

Molecular Biology Unit: is the study of DNA and RNA sequencing, genes and genetics.

Serology: is a blood test to detect the presence of antibodies against a microorganism.

Laboratory Safety Rules

Laboratory should be designed in such a way that you can work safely:
1. It must be easily cleaned.
2. Contains a sink for washing.
3. Adequate Illumination for all laboratory activities.
Treat all body fluids as potentially infectious materials.
A lab coat, gloves and shoes should be worn during laboratory work.
Note: to remove gloves before using telephone or Other Personal Things.
Do not eat, drink, or chew gum in laboratory.
Do not use laboratory glassware as containers for food or drinks.
Work areas should be kept clean and tidy all time.
Do not place contaminated pipettes on the bench top.
Keep hands, pencils, loops etc. away from face, eyes, mouth, and body
while using chemicals or lab equipment.
Wash your hands with soap and water then alcohol after performing all experiments.
Never use mouth suction for chemicals or body fluids.
Perform adequate sterilization before washing or disposing waste.
Take care while using electricity and instrument such as centrifuge.
Good ventilation and lighting is recommended.

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Laboratory procedures
Laboratory procedures divided into three stages:

Pre-Analytical Stage:
Reading the request form correctly.
Recording full patient data and medical history.
Preparation of Labeled Test Tubes.
Collection and transport of the specimen.
Pre -analytical Laboratory Errors:

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Analytical Stage:
Check the test method, instruments, reagents, standards, and control materials.
Check the amount of reagent and sample, temperature, time of test.
Recording results correctly.
Analytical Laboratory Errors:

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(.)quality control
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Post-Analytical Stage:
Reporting the test result which must include:
1. Patient Data clearly.
2. Test name and type of specimen analyzed.
3. Test results clearly.

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4. The measurement unit and reference range (Review the range with age and sex).
5. The comment if found.
Interpretation of test results to follow if the result is seriously abnormal or unexpected.
Checking whole report after printing.
Post -analytical Laboratory Errors:

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Complete Urine Analysis

Urine Formation:
Urine is continuously formed by the kidneys. It is actually
an ultra filtrate of plasma from which glucose, amino
acids, water, and other substances essential to body
metabolism have been reabsorbed.
The kidney's ability to clear waste products selectively
from the blood while maintaining the essential water and
electrolyte balances in the body is controlled in nephrons.
The kidneys filter unwanted substances from the blood
and produce urine to excrete them.
There are three main steps of urine formation:
1. Glomerular Filtration:
Movement and filtration of blood plasma at the nephrons
by ultra filtration, leaving an ultra filtrate that resembles
plasma (except that the ultra filtrate has negligible plasma
proteins) to enter Bowman's space.
2. Tubular Reabsorption:
In the proximal tubule, 60% to 80% of the ultra filtrate is
reabsorbed.
Tubular reabsorption is the process by which solutes and
water are removed from the tubular fluid and transported
into the blood.
Note: It is called reabsorption (not absorption) because these substances have already been absorbed once
(in the intestines).

3. Tubular Secretion:
Transfer of materials from peritubular capillaries to renal tubular lumen and is caused mainly by active
transport.
In the distal tubule, secretion is the prominent activity.
Usually only a few substances are secreted which are present in great excess, or are natural poisons.
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Note: Certain substances appear in urine when their plasma levels are above certain set-point, or
"threshold," levels.
High-threshold substances, such as glucose and amino acids, are reabsorbed almost completely. The ap-
pearance of a high-threshold substance in urine is evidence that the filtered load of substance is exceeding
the maximal reabsorption rate of its transport system.

Complete Urinalysis:
A urinalysis is a group of tests that detect and semi-quantitatively measure various compounds that are
eliminated in urine, including the byproducts of normal and abnormal metabolism as well as cells, and
cellular fragments.

Why and When Urine Analysis Is Done?

1. As a general evaluation of health.
2. To screen for a disease or infection of the urinary tract.
3. Diagnosis of some metabolic and endocrine disturbances in the body such as diabetes.
4. Discolored or foul-smelling urine.
5. Pain during urination.
6. Blood in urine (hematuria).
7. Frequent urination.
8. Abdominal pain, back pain or Swelling in hands, feet, abdomen or face.
9. Pregnant women to chick the risk of pregnancy toxemia.

Collection Of Urine Sample:

The first voided morning specimen is preferred because it is usually more concentrated and therefore more
likely to reveal abnormalities.
This is usually hypertonic and reflects the ability of the kidney to concentrate urine during dehydration which
occurs overnight.
Collection Method (Midstream Urine Collection):
1. Clean the area around your genitals.
2. Begin urinating into the toilet.
3. After urine has flowed for several seconds, place the collection container into the stream and
collect this midstream urine without interrupting the flow.
4. Finish urinating into the toilet.
5. Carefully replace the lid on the container and return it to the lab.
Note: urine samples for bacteriological examination must be collected in clean sterilized container and
culture done from separate sample or before routine examination.

Precautions For Urine Analysis:

The ideal situation is when specimen is analyzed shortly after collection (within 1h).
If examination cannot be done directly after collection the sample must be refrigerated within 1 hour of
collection.
If specimen is not refrigerated within 1 hour of collection, the following changes in composition may
occur:
1. Increased pH from the breakdown of urea to ammonia by urease-producing bacteria.
2. Decreased glucose from glycolysis and bacterial utilization.
3. Decreased ketones because of volatilization.
4. Decreased bilirubin from exposure to light.
5. Increased bacteria from bacterial reproduction.
6. Increased nitrite from bacterial reduction of nitrate.
7. Precipitation of amorphous Crystals.
8. Changes in color caused by oxidation or reduction of metabolites.

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9. Increased turbidity caused by bacterial growth and precipitation of amorphous material.

10. Disintegration of red blood cells (RBCs) and casts, particularly in dilute alkaline urine.
Urine specimens should not remain un-refrigerated for longer than two hours. Refrigeration will slow
microbial growth and tends to stabilize most urine components for up to 12 hours.
Note: you must re-warm sample before analysis.

Urine Sample Rejection:

Generally specimens that could lead to false interpretation should be rejected such as:
1. Sample must be sufficient quantity.
2. Specimens that is contaminated from a woman's menstrual period or feces.
3. Not getting urine sample to lab in 2 hour.
4. Sample that is taken in dirty container.

A) Urine Physical Examination:

The first part of a urinalysis is direct visual observation.

1. Urine Volume:
Urine volume measurements are part of the assessment for fluid balance and kidney function. The
normal volume of urine voided by the average adult in 24-hour period ranges from 600 to 2500 ml
with a normal fluid intake of about 2 liters per day. The amount voided over any period is directly
related to the individual's fluid intake, temperature and climate.

Polyuria:
It means Production of abnormally large volumes of urine (at least 2.5 L over 24 hours in adults).
Note: Polyuria is sometimes used to refer to frequent urination, irrespective of passed volume.

What Are Causes Of Polyuria?

Physiological causes:
1. Cold climate.
2. Drinking large amounts of fluids.
3. During pregnancy (frequent urination).
4. High protein diet: end product is urea which cause osmotic diursis and decrease reabsorption
of water.
5. Diuretic foods (foods and beverages containing caffeine, such as chocolate, coffee, tea, and
soft drinks, hot spicy foods, juices high in acid, alcoholic beverages, etc.)
Pathological causes:
1. Diabetes mellitus (glucose in urine cause osmotic diuresis).
2. Diabetes inspidus (caused by a deficiency of antidiuretic hormone (ADH)).
3. Hypercalcaemia (leads to nephrogenic diabetes inspidus).
4. Hyperparathyroidism (causing excessive mobilization of Ca from bone so rise in plasma and its
filtration in kidney renal tubules increase causing Calcification leads to nephrogenic diabetes
inspiidus).
5. Renal diseases such as glomerulonephritis and cystitis.
6. Urinary tract infection although it more commonly causes frequent passage of small volumes
of urine rather than a large volume.
Oliguria
It means Production of abnormally small amounts of urine (less than 400 ml/day in adults).

What Are Causes Of Oliguria?

Physiological causes:
1. Reduced fluid intake.
2. Exercise that cause sweating and dehydration.
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Pathological causes(Related to kidney disorder):

1. Pre-renal causes (in response to hypoperfusion of the kidney): Dehydration caused by
prolonged vomiting, diarrhea, or burns, Cardiac insufficiency.
2. Renal causes (due to kidney damage): Nephritic syndrome, post-streptococcal
glomerulonephritis, and acute tubular necrosis.
3. Post-renal causes (as a consequence of obstruction of the urine flow): Enlarged prostate,
Tumor compression urinary outflow.
Anuria:
Also sometimes called anuresis and it means failure of the kidneys to produce urine. But it is practically
defined as passage of less than 50 ml of urine in a day.
What Are Causes Of Anuria?
1. Bilateral complete urinary tract obstruction (an enlarged prostate gland is a common cause of
obstructive anuria).
2. It may occur with end stage renal disease.
3. Some severe obstruction like kidney stones or tumours.

2. Urine Aspect:
Normally, fresh urine is clear to very slightly cloudy.
Note: Urine can become cloudy if it sits at room temperature or is
refrigerated. However, the degree of turbidity should correspond to
the amount of material observed under the microscope.

Observe the clarity of a fresh urine sample by visually examining a

well-mixed specimen in front of good light source.
Common terms used to report appearance include the
following: Clear, hazy, slightly cloudy, cloudy, turbid, and milky.
Elements that alter urine clarity and may be associated with
disease are: Bacteria, Epithelial cells, Erythrocytes, Leukocytes,
Mucus, Crystals, Amorphous, sperms, yeast, fungus, or parasites.
Note: vaginal discharges mixed with urine or fecal contamination
is common causes of turbidity.

Clearing of the specimen after addition of a small amount of acid indicates that precipitation of salts is
the probable cause of turbidity.
3. Urine Color:
The yellow color of urine is caused by the presence of the pigment urochrome, a product of hemoglobin
metabolism that under normal conditions is produced at a constant rate.
Normal urine color ranges from pale yellow to deep amber but the concentration of urine affects its color.
Highly concentrated urine is a darker and diluted urine is a lighter yellow so the more you drink, the clearer
your urine looks. When you drink less, the color becomes more concentrated.
The color of urine may be affected by diet, hydration, medications, and disease.
Note: Normal urine color darkens on standing because of the oxidation of urobilinogen to urobilin.
This decomposition process starts about 30 minutes after.

Fresh urine has a characteristic aromatic odor. Diet, drugs,

disease, and Microorganisms may alter the odor.
A fresh urine specimen that has a Foul odor usually indicates a urinary
tract infection.
Very pale yellow or colorless urine:
It May indicate Diabetes Militus, Diabetes Insipidus, Alcohol ingestion
(inhibit ADH release), caffeine ingestion (increase GFR by dilating
afferent arterioles), Diuretic therapy.

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Deep yellow urine:

Dehydration or drinking too few fluids can concentrate urochrome, making urine much deeper in color.
Also found in concentrated urine caused by fever, sweating, reduced fluid intake, or first morning specimen,
number of drugs can darken urine.
Red or pink urine:
The presence of red blood cells is the main reason that urine turns cloudy red (Smoky urine).
Greenish-yellow urine:
It May indicate bilirubin in urine (give greenish foam when shaken).

4. Urine Specific Gravity:

It is defined as the ratio of the density of a given solid or liquid substance to the density of water at a specific
temperature and pressure. So Substances with a specific gravity greater than 1 are denser than water, so will
sink in it, and those with a specific gravity of less than 1 are less dense than water, will float in it.
Urine specific gravity measures urine density, or the ability of the kidney to reabsorb water and essential
chemicals before they are excreted in the urine.
The USG is influenced by the number of molecules in urine, as well as their molecular weight and size.
Note: urine specific gravity is directly proportional to urine osmolality which measures solute
concentration so it is an indication of the concentration of substances dissolved in urine.

The range of USG depends on the state of hydration and usually between (1000 and 1030),Specific gravity
between 1.000 and 1.035 on a random sample should be considered normal if kidney function is normal.
Reduced specific gravity (Hyposthenuria) (1000 -1010):
1. Diabetes insipidus.
2. Excess fluid intake.
3. Pyelonephritis.
4. Glomerulonephritis.
5. Treatment with diuretics.
6. Renal failure.
Raised specific gravity (Hypersthenuria) (1025 -1035):
1. Diabetes mellitus.
2. Adrenal insufficiency.
3. Congestive cardiac failure (related to decreased blood flow to the kidneys).
4. Excessive sweating.
5. Excessive water loss (dehydration, fever, vomiting, diarrhea).
6. Toxemia of pregnancy.
7. Cystitis - products of inflammatory reaction are added to the urine.

B) Urine Chemical Examination:

The most cost-effective device used to screen urine is a paper or plastic dipstick. This microchemistry system
has been available for many years and allows qualitative and semi-quantitative analysis within one minute
by simple but careful observation. The color change occurring on each segment of the strip is compared to a
color chart to obtain results.
The findings of reagent testing are often confirmed by additional chemical tests called confirmatory
tests.
1. Dip the test areas of the strip in urine specimen (fresh, well mixed and un-centrifuged).
2. Remove excess of urine by tapping the edge of the strip against the container.
3. Compare the test areas closely with corresponding color charts on the bottle at times specified.
If the dipstick is kept in the urine sample too long, the impregnated chemicals in the strip might be
dissolved and could produce inaccurate readings and values.
If the reagents absorb moisture from the air before they are used, they will not produce accurate results.

1. Urine Reaction (PH):

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PH is a measure of the acidity or basicity of a solution.

Urine changes from a weak acid in the morning to a weak base by evening in healthy people because no food
or beverages are consumed while sleeping, pH may range from low as 4.5 to high as 8.
The pH is an indicator of the renal tubules ability to maintain normal hydrogen ion concentration in the
plasma and extracellular fluid.
The kidneys maintain normal acid-base balance primarily through re-absorption of sodium and tubular
secretion of hydrogen and ammonium ions.
Precipitation of urine crystals in supersaturated urine is highly dependent on urine pH.
Some medications are more effective in acidic or alkaline environments so Control of urinary pH is
important in management of several diseases:
Urine should be kept acid during treatment of UTI or persistent bacteriuria.
Urine should be kept acid during management of urinary calculi that develop in alkaline urine.
With prolonged standing, the pH of a urine specimen becomes alkaline because bacteria split
urea and produce ammonia.
High urine pH (Alkaline) may be due to:
1. Kidneys that do not properly remove acids (kidney tubular acidosis, also known as renal
tubular acidosis)
2. Kidney failure.
3. Stomach pumping (gastric suction).
4. Urinary tract infection.
5. Vomiting.
Low urine pH (Acidic) may be due to:
1. Diabetic ketoacidosis.
2. Diarrhea.
3. Too much acid in the body fluids (metabolic acidosis), such as diabetic ketoacidosis.
4. Starvation.
Note: The pH of urine never reaches 9, either in normal or abnormal conditions. Therefore, a pH
finding of 9 indicates that a fresh specimen should be obtained to ensure the validity of analysis.

2. Urine Protein:
In healthy renal and urinary tract system, urine contains no protein or only traces amounts which
consist of albumin (one-third of normal urine protein is albumin) and globulins from plasma.
Presence of increased amounts of protein in urine is called proteinuria and is an indication of renal or
systemic diseases.
Proteinuria can also be a result of overproduction of proteins by the body.
When protein escape through urine, you may notice the following symptoms:
1. Foamy or bubbly-looking urine when you use the toilet.
2. Swelling in your hands, feet, abdomen or face.
Note:
1. If more than a trace of protein is found persistently in the urine, a quantitative 24-hour
evaluation of protein excretion is necessary.
2. If positive urine strips test must be followed by other confirmatory test.

Coagulation Test (heating):

A tube filled with urine is heated using flame and take care to prevent
effervescence:
1. If no ppt. is formed so no protein in this sample.
2. If white ppt. is formed add few drops of Acetic Acid:
If ppt. is removed so this is amorphous phosphate ppt.
If ppt. is remaining so it will be albumin (due to protein denaturation
by heat).
Positive Protein test may indicate:

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1. Medication, vigorous exercise, diet, cold exposure, emotional or physical stress, Trauma,
Toxins, Obesity, Age over 65.
2. Proteinuria may also be associated with other diseases and conditions:
Diabetes, High blood pressure (hypertension), Family history of kidney disease, Immune system
disorders, multiple myeloma, amyloidosis, Preeclampsia (high blood pressure and proteinuria in
pregnancy).
3. Urine Sugar:
The presence of glucose in urine is called glycosuria or glucosuria.
The most common cause of glycosuria is untreated diabetes mellitus which raises plasma glucose
levels above normal, and beyond a certain threshold, the threshold varies from one individual to
another, with values around (160 - 180 mg/dl).
Positive glucose test may indicate:
1. Diabetes: Small increases in urine glucose levels after a large meal are not always cause
for concern.
2. Pregnancy: Up to half of women has glucose in their urine at some time during
pregnancy, May mean that a woman has gestational diabetes.
3. Renal glycosuria: A rare condition in which glucose is released from the kidneys into
urine, even when blood glucose levels are normal.
4. Cushing's syndrome, a pituitary gland disorder.
Note: These tests are specific for glucose only.

False positive reactions due to:

Stress, excitement, vitamin C excess, testing after a heavy meal, testing soon after the administration
of intravenous glucose, certain fruits and other foods, and drugs.

4. Urine ketone:
It's normal to have a small amount of ketones in your body. But high ketone levels could result in
serious illness or death. Ketone in urine is a sign that your body is using fat for energy instead of
glucose because not enough insulin is available to use glucose for energy.
Ketone bodies are three water-soluble compounds that are produced as by-products when fatty
acids are broken down for energy in liver and kidney. They are used as a source of energy in the
heart and brain. In the brain, they are a vital source of energy as an alternative to glucose during
fasting. The three ketone bodies are acetone, acetoacetic acid, and beta-hydroxybutyric acid.

ketonemia (Ketosis):
A state characterised by elevated levels of ketone bodies in the blood, occurring when the liver
converts fat into fatty acids and ketone bodies.

Ketonuria:
ketone bodies are present in urine when ketones in blood go above a certain level.
Ketonuria is seen in a variety of conditions: uncontrolled diabetes, anorexia, diets low in carbohydrates
and high in fats, starvation, fasting, excessive vomiting, Pregnancy and fever.

What Is The Indication For Urine Ketone Test?

Screening for ketonuria in pregnant women: During pregnancy, the early detection of ketones is
essential because ketoacidosis is a prominent factor that contributes to intrauterine death.
When your breath smells "fruity".
Screening for ketonuria in persons with diabetes:
1. Testing for ketones is indicated in any patient showing elevated urine and blood sugars
(blood sugar levels of 300 mg/dl or higher)

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2. When treatment is being switched from insulin to oral hypoglycemic agents, the
development of ketonuria within 24 hours after withdrawal of insulin usually indicates a
poor response to the oral hypoglycemic agents.
3. Ketone testing is done to differentiate between diabetic coma positive ketones and
insulin shock negative ketones.
Urine testing only detects acetoacetic acid, not the other ketones, acetone or beta-hydroxybuteric
acid.
False-positive results: may caused by drugs such as Penicillin or aspirin and depakene.
False-negative results: occur if urine stands too long, owing to loss of ketones into the air.
Moderate or large amounts are a danger sign. They upset the chemical balance of your blood and
can poison the body.
Positive Ketone test may indicate:
1. Metabolic disease such as: Diabetes mellitus (diabetic acidosis), Hyperthyroidism.
2. Dietary conditions such as: Starvation, fasting, High-fat diets, Prolonged vomiting,
diarrhea (cause dehydration).
3. Conditions in which metabolism is increased such as: prolonged Fever, Pregnancy or
lactation, strenuous exercise, severe stress, during acute illness, Post-surgical condition
(Ketonuria occurs after anesthesia (ether or chloroform))

5. Urine Nitrite:
Nitrates are normal in urine (mainly coming from food additives and food protein), but presence of
Nitrites is not normal.
Positive Nitrite test may indicate that the cause of the UTI is a gram negative organism, most
commonly Escherichia coli. Due to a bacterial conversion of endogenous nitrates to nitrites.
A positive reagent test result should be verified by microscopic examination, or urine culture and
sensitivity tests.
Negative nitrite urine test may not indicate the absence of a UTI since some bacteria do not
convert nitrates to nitrites.
The sensitivity of the urine dipstick test for nitrites has been found to be low (45 %- 60% in most
situations) with higher levels of specificity (85 %- 98%).
Note: Color intensity is not significant, and is not proportional to the number of bacteria present
in urine.
False negative results:
1. High doses of vitamin C.
2. Urine has not incubated in patient's bladder for 4 hours.
3. Some important bacteria that do not reduce dye (Gram-positive as staphylococci,
streptococci don't contain the enzyme reductase).
4. The bacterial enzymes that reduce nitrate to nitrite can convert nitrite to nitrogen.
5. Sensitivity decreases if sufficient dietary nitrate are not be present for the nitrate-to-
nitrite reaction to occur.
False positive results:
1. Bilirubin.
2. If urine sits too long at room temperature, allowing contaminant bacteria to multiply.

6. Urine Bilirubin:
Bilirubin is the yellow breakdown product of normal heme catabolism. So normally, tiny amount of bilirubin
is excreted in urine accounting for the light yellow color.
Bilirubin fractions present in blood and urine:
1. Unconjugated:
Albumin-bound in serum, measured as indirect-reacting bilirubin, never present in urine.
2. Conjugated:
Unbound in serum, measured as direct-reacting bilirubin, present in urine.

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Note: Examine urine within 1 hour of collection because bilirubin is unstable, especially when
exposed to light.
If urine is yellow-green to brown, shake the urine. If yellow-green foam develops, bilirubin is
probably present.

High concentrations of ascorbic acid cause decreased sensitivity.

Iodine test: Add drops of iodine carefully on the tube wall if green colored ring
developed gradually between iodine and urine this indicate that bilirubin is present.
Concentration of bilirubin in the plasma must exceed 1.5 mg/dl, for the coloration to
be easily visible.
Positive Billirubin test may indicate liver or gallbladder problems:
1. Biliary tract disease.
2. Cirrhosis.
3. Gallstones in the biliary tract.
4. Hepatitis.
5. Liver disease.
6. Tumors of the liver or gallbladder.

7. Urine Urobilinogen:
Urobilinogen is a colourless product of bilirubin reduction in the intestines by bacterial action.
Some urobilinogen is reabsorbed, taken up into the circulation and excreted by the kidney. This
constitutes the normal "intrahepatic urobilinogen cycle". So normally urine has trace amounts of
urobilinogen.
Urobilinogen is converted to the yellow pigmented urobilin apparent in urine.
Urobilinogen in the intestine is directly reduced to brown stercobilin, which gives the feces their
characteristic color.
False positive urobilinogen reaction may occur when substances known to react with Ehrlich's
reagent such as sulfonamides are present in urine.
False Negative result may be due to the instability of urobilinogen, if urine specimen has remained
at room temperature for an extended period of time in the light.
Positive Urobilinogen test may indicate: urobilinogen is increased by any condition that causes an
increase in the production of bilirubin such as: cirrhosis of the liver, acute hepatitis, pernicious and
hemolytic anemia, and hemorrhage.
Low or absence of urobilinogen May be caused by: Post-hepatic Jaundice, Impaired intestinal
absorption (i.e., diarrhea), during broad-spectrum antibiotic therapy, suppression of normal gut
flora may prevent the breakdown of bilirubin to urobilinogen.

C) Urine Microscopic Examination:

The sediment should be examined for Type and Amount and should always be made shortly after
collection so that:
1. Degeneration and lyses of cellular elements will not occur.
2. Bacteria will not proliferate.
Procedure:
Centrifugation:
1. Shake the urine sample to make the sample homogenous.
2. Put (5 -10) ml of urine sample into test tube.
3. The recommended parameter for the urine centrifugation is 5 minutes at 2000 RPM.
Re-suspension:
Pour the sample tube except few drops and mix to provide the better homogeneous distribution
possible.
Examination:
1. Place a drop of unstained suspension in a glass slide on the microscope stage.

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2. The sediment is first examined under low power field (LPF) magnification to identify most
crystals, casts, squamous cells, and other large objects.
3. Switch to high power field (HPF) magnification and examine for other elements, i.e.,
WBCs, RBCs, Epithelial cells, yeast, bacteria, Sperm cells, mucous filaments and crystals.

1. Urine Pus cells:

Leucocytes usually enter tubular lumen through and between tubular epithelial cells, it have lobed
nuclei and retractile cytoplasmic granules, typically appear as round, granular cells which are 1.5 - 2
times the diameter of RBCs.
An increase in urinary Pus is called pyuria and indicates: urinary tract infection, sexually
transmitted disease, kidney infection, abscess near the kidney or inflammatory disorder, may also
be a sign of stones in the urinary passage.
Sometimes pus cells in urine also result from old age, pregnancy and certain medications.
WBCs is reported semi-quantitatively as number seen per high power field (HPF) and up to 5/HPF
are commonly normal. Pus count greater than 30\HPF suggest acute infection and urine culture is
recommended.
Sometimes there wont be any symptoms of urinary tract infection or the presence of pus in the
urine. When the symptoms occur they are as follows:
1. Foul smelling urine.
2. Cloudy urine.
3. Fever.
4. Frequent urination.
5. Pain or discomfort while urinating or intercourse.
6. Vomiting.
7. Abdominal cramps.
Drinking plenty of water and fluids will help in removing the pus cells out of the urinary tract.
Holding the urine for long keeps the harmful bacteria inside the bladder.
Note:
1. Leukocytes have lobed nuclei and granular cytoplasm.
2. Like erythrocytes, WBC may lyse in very dilute or highly alkaline urine.
3. WBC cytoplasmic granules released into the urine often resemble cocci bacteria.
4. To differentiate between neutrophils and RBCs cells a small drop of Acetic Acid is added
which enhance the nuclear details and lyse the red blood cells.

Sterile pyuria
Sterile pyuria is urine which contains white blood cells (>10 white cells/mm3) while appearing sterile
by standard culturing techniques (Show No Growth in Culture Sensitivity Test).
Causes:
1. A recently (within last 2 weeks) treated urinary tract infection (UTI).
2. It is often caused by sexually transmitted infections, such as gonorrhea, or viruses which
will not grow in bacterial cultures.
3. As a side effect from some medications such as paracetamol (acetaminophen).

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2. Urine RBCs:
Theoretically, no red cells should be found, but some find their way into urine even in very healthy
individuals.
Increased red cells in urine above normal level are termed hematuria and the presence of hemoglobin
is known as hemoglobinuria.
A positive result may indicate bleeding somewhere along the urinary tract, which may be caused
by urinary tract infection, trauma, neoplasms, stones, shcistosoma or other urinary system
abnormalities.
RBCs is reported semi-quantitatively as number seen per high power field (HPF) and up to 5/HPF
are commonly normal.
The appearance of red blood cells (RBC) in urine depends largely on the concentration of the
specimen and the length of time the red cells have been exposed.
RBC's may appear normally shaped, swollen by dilute urine (in fact, only cell ghosts and free
hemoglobin may remain), or crenated by concentrated urine. Both swollen, partly hemolyzed
RBC's and crenated RBC's are sometimes difficult to distinguish from WBC's in the urine. In
addition, red cell ghosts may simulate yeast.
1. Fresh red cells tend to have a red or yellow color and appear as retractile disks.
2. Prolonged exposure results in a pale or colorless appearance as hemoglobin may be lost from
the cells and the RBC's begin to have a crenated appearance especially in concentrated urine
(hypertonic urine).
Note: RBC's in urine may be confused with oil droplets or yeast cells but remember that Oil droplets exhipt
great variation in size and highly refrectile and yeast cells usually show budding, But if there are drought
about identification a few drops of Acetic Acid is added to the slide causing RBCs is lyses by acidification.

Hematuria:
It means presence of increased amount of RBCs (erythrocytes) in urine.
1. Microscopic hematuria:
Microscopic hematuria means that the urine is normal in color, but there are an increased number of red
blood cells seen with a microscope.
2. Macroscopic hematuria ("frank" or "gross") hematuria:
Gross hematuria means that you can see blood with the naked eye because the urine is pink, red, purplish-
red, brownish-red, or tea-colored.
Note: Typically, microscopic hematuria indicates damage to the upper urinary tract (kidneys),
while visible blood indicates damage to the lower tract (ureters, bladder, or urethra). But this is
not always the case.

What are Causes of hematuria?

1. Urinary Schistosomiasis.
2. Bladder infection (also called acute cystitis), which typically causes burning or pain with
urination.
3. Kidney infection (also called pyelonephritis).
4. Kidney stones, which usually present with one-sided back or flank pain that can be severe.

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5. Certain kidney diseases

6. Vigorous exercise or injury (for example, after falling off a bike and bruising a kidney).
7. Enlargement of the prostate (called benign prostatic hyperplasia), which is a common problem
in older men.
8. Cancer of the bladder, prostate, or kidney, more often in patients over age 50 years.

3. Urine Casts:
Urinary casts are cylindrical structures produced by the kidney and present in the urine in certain disease
states. They form in the distal convoluted tubule and collecting ducts of nephrons, then dislodge and pass
into the urine, where they can be detected by microscopy.
They form via precipitation of Tamm-Horsfall mucoprotein (Uromodulin) which is secreted by renal
tubule cells, and sometimes also by albumin in conditions of proteinuria.
Uromodulin may act as a constitutive inhibitor of calcium crystallization in renal fluids, and it may
provide defense against urinary tract infections.
Note: Casts are quantified for reporting as the number seen per low power field (10x objective)
and classified as to type (e.g., hyaline casts).
An absence of casts does not rule out renal disease. Casts may be absent or very few in cases of
chronic, progressive nephritis. Even in cases of acute renal disease, casts can be few or absent in
a single sample since they tend be shed intermittently. Furthermore, casts are unstable in urine
and are prone to dissolution with time, especially in dilute and/or alkaline urine.
The various types of casts that can be found in urine sediment may be classified as follows:

1. Hyaline casts:
The most common type of casts, are cylindrical and clear, with a low
refractive index, so that they can easily be missed under bright field
microscopy or on an aged sample where dissolution has occurred.
Hyaline casts are not always indicative of clinically significant
renal disease and may be association with:
1. Fever (dehydration).
2. Emotional stress.
3. Strenuous exercise.
4. Heat exposure.

2. Granular casts:
It is the second-most common type of cast generally more cigar-
shaped and of a higher refractive index than hyaline casts.
It can result either from the breakdown of cellular casts (remain in
the nephron for some time before they are flushed into the urine), or
the inclusion of aggregates of plasma proteins (albumin) or
immunoglobulin light chains.
Depending on the size of inclusions, they can be classified as fine
or coarse, though the distinction has no diagnostic significance.
Its appearance is most often indicative of chronic renal disease such as:
1. Glomerulonephritis.
2. Pyelonephritis.
Note: amorphous materials and crystals may precipitate on mucus threades and give the
appearance of true granular casts.

3. Waxy casts:
Thought to represent the end product of cast evolution, waxy casts
suggest the very low urine flow associated with severe, longstanding
kidney disease such as renal failure. Additionally, due to urine stasis
and their formation in diseased, dilated ducts, these casts are
significantly larger than hyaline casts. They are cylindrical. They
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possess a higher refractive index. They are more rigid, demonstrating sharp edges, fractures, and broken-off
ends.

4. Fatty casts:
Formed by the breakdown of lipid-rich epithelial cells, these are hyaline casts with fat globule inclusions,
yellowish-tan in color. If cholesterol or cholesterol esters are present, they are associated with the Maltese
cross sign under polarized light. They are pathognomonic for high urinary protein nephrotic syndrome.

5. Red blood cell casts:

The presence of red blood cells within the cast is always pathological,
and is strongly indicative of glomerular damage, which can occur
in glomerulonephritis from various causes or vasculitis,
including granulomatosis with polyangiitis, systemic lupus
erythematosus, post-streptococcal
glomerulonephritis or Goodpastures syndrome. They can also be
associated with renalinfarction and subacute bacterial endocarditis.
They are a yellowish-brown color and are generally cylindrical with sometimes ragged edges; their fragility
makes inspection of a fresh sample necessary. They are usually associated with nephritic syndromes or
urinary tract injury.

6. White blood cell casts:

Indicative of inflammation or infection, the presence of white blood
cells within or upon casts strongly suggestspyelonephritis, a direct
infection of the kidney. They may also be seen in inflammatory
states, such as acute allergicinterstitial nephritis, nephrotic
syndrome, or post-streptococcal acute glomerulonephritis.

7. Epithelial cell casts:

This cast is formed by inclusion or adhesion of desquamated
epithelial cells of the tubule lining. Cells can adhere in random order
or in sheets and are distinguished by large, round nuclei and a lower
amount of cytoplasm. These can be seen inacute tubular necrosis and
toxic ingestion, such as from mercury, diethylene glycol, or salicylate.
In each case, clumps or sheets of cells may slough off simultaneously,
depending of the focality of injury. Cytomegalovirus and
viral hepatitis are organisms that can cause epithelial cell death as
well.

4. Urine Crystals:
When the amount of solutes in urine increase (due to dehydration, dietary intake, or medications) urine
super-saturation occurs and crystals will be formed either while the urine in the body or after the urine is
voided. They can be identified by their specific appearance and solubility characteristics.
Crystals in the urine may present no symptoms, or they may be associated with the formation of urinary
tract calculi and give rise to clinical manifestations associated with partial or complete obstruction of
urine flow.
The pH of urine is an important aid to identification of crystals and must be noted.

A) Non Pathologic Crystals:

1. Uric Acid Crystals:
Uric acid is a breakdown product of purines that are part of many foods we eat and tend to form in acidic
urine.
Pure uric acid crystals are colorless but Multicolored when polarized. Uric acid crystals may appear as
yellow to brown rhombic or hexagonal plates, needles or rosettes.

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It may be found in gout, kidney stones, chronic nephritis.

2. Amorphous Urate Crystals:

Amorphous urates of Na, K, Mg or Ca are yellow, yellow-brown or pinkish in color; tend to form in acidic
urine.
These crystals have no distinct form and appear as sand-like granules, appear as pink sediment after
centrifugation.
They usually develop as a result of the refrigeration process of the urine sample.

3. Calcium Oxalate Crystals:

Calcium oxalate crystals in urine are the most common constituent of kidney stones, tend to form in acidic,
neutral or alkaline urine, exist in monohydrate and dihydrate forms which can be distinguished by the shape.
Calcium oxalate dihydrate crystals typically are seen as colorless squares whose corners are connected
by intersecting lines (resembling an envelope). But Multicolored when polarized.
Note: In some cases, large numbers of tiny oxalates may appear as amorphous unless examined
at high magnification.

Calcium oxalate monohydrate crystals vary in size and may have a spindle, oval, or dumbbell shape.

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4. Triple Phosphate Crystals:

They are also called magnesium ammonium phosphate or struvite crystals that appear as colorless, 3-
dimensional, prism-like crystals and are classically described as rectangular "coffin lid" shape.
Though they can be found in urine of any pH, their formation is favored in neutral to alkaline urine.
These are sometimes associated with a bacterial urinary tract infection caused by urea splitting bacteria.
They are found in urine in cases of chronic cystitis.

5. Ammonium Urate (or Biurate) Crystals:

Ammonium urate (or biurate) crystals generally appear as brown or yellow-brown spherical bodies with
irregular protrusions (thorn-apples). In some urine samples, they do not have irregular protrusions but
have smooth borders and can resemble calcium carbonate.
Though possible in urine of any pH, their formation is favored in neutral to alkaline urine. They are
frequently seen with amorphous urates.

6. Calcium Phosphate crystals:

The solubility level of calcium
phosphate becomes lower as
temperature increases. Thus
heating causes precipitation.
These crystals are found in
neutral to alkaline pH.

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 19

7. Amorphous Phosphate Crystals:

Amorphous phosphates are similar in general appearance, tend to form in alkaline urine, they are colorless.
These crystals have no distinct form and appear as sand-like granules, appear as white sediment after
centrifugation.

Difference Between Amorphous Urate & Phosphate:

The distinction between amorphous urates and amorphous phosphates is often made on the urinary pH
basis but the following can help in differentiation:
1. Phosphate is seen in alkaline pH, Urate is seen in acidic pH.
2. The precipitate of Phosphate is white, the precipitate of Urate is pink (known as brick dust).
3. Phosphate is precipitated by heating; Urate is precipitated by cooling (refrigeration).
4. Phosphate is soluble in acetic acid, Urate are insoluble in acetic acid (by acidification it converts
to uric acid).

8. Ca Carbonate Crystals:
It is Very small colorless granules, slightly larger than amorphous material.
Multicolored when polarized, easily confused with bacteria, tend to form in alkaline urine.

B) Pathologic Crystals:
9. Cystine:
Cystine crystals are flat colorless plates and have a characteristic hexagonal shape with equal or unequal
sides. They often aggregate in layers. Their formation is favored in acidic urine.
The presence of cystine in urine is often indicative of amino acid reabsorption defects.
Both Acidic but Cystine doesn't polarize light while Uric acid multi colored when polarized.

10. Leucine Crystals:

It is Yellow-brown spheroids with concentric rings around the outer edge and radial striations in the center.
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Found in acidic/neutral urine.

Leucine crystals may be seen in liver disorders in which amino acid metabolism is impaired.
The presence of leucine crystals is often accompanied by a positive biochemical test for bilirubin and is often
accompanied by tyrosine crystals in the same sediment.

11. Bilirubin Crystals:

Bilirubin crystals form conjugated bilirubin (water soluble) and are Yellow-brown small clusters of needles or
granules
Bilirubin crystals are seen in urine when the serum bilirubin level is increased.

12. Tyrosine Crystals:

Tyrosine crystals appear as colorless/yellow fine needles in acidic/neutral urine.
May be seen in tyrosinemia and in certain liver disorders in which amino acid metabolism is impaired.
The presence of tyrosine crystals is usually accompanied by a positive biochemical test for bilirubin and often
accompanied by the presence of leucine crystals in the sediment.

13. Cholesterol Crystals:

Appear as colorless rectangular plates (Multicolored when polarized) with a notch in one or more corners
and are found in acidic urine.
The appearance of cholesterol is associated with the Nephrotic Syndrome.

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5. Urine Epithelial Cells:

The epithelia cells are simply cells that are gotten from the epithelium, which is the lining found in and
outside the body. These cells are produced often, and old cells shed away to give room for the new cells.
Urine epithelial cells are cells that line your hollow organs and are three kinds: Renal tubule, Bladder,
and squamous epithelial cells.
They are the largest cells which can be present in normal urine samples, flat cells with irregular borders, a
single small nucleus, and abundant cytoplasm
Epithelial cells in urine are generally of little specific diagnostic utility because Old cells lining the urinary
tract at any level may continually slough into the urine.
Cells from renal tunes are characterized by round shapes and large nuclei which point to nephrotic
syndrome.
Women suffering from vaginal infections caused by bacteria may show large amounts of squamous
epithelial cells in their urine. These cells mostly come with bacteria attached and are referred to as clue
cells.
Increased number of epithelial cells can indicate renal disease such as:
1. Acute tubular necrosis.
2. Acute glomerulonephritis.
3. Pyelonephritis.
Note: In cases of acute tubular necrosis, renal tubular epithelial cells containing large non lipid
vacuoles may be seen, these are referred to as bubble cells. When lipids cross the glomerular
membrane, the renal epithelial cells absorb the lipids and become highly refractive. These are
called oval fat bodies and seen in cases of nephritic syndrome.

6. Urine Ova:
Parasites which may be found in urinary sediments include Trichomonas vaginalis, Enterobius
vermicularis and Schistosoma haematobium.
It is also important to note that parasites and parasitic ova may be seen in urine sediments as a result of
fecal or vaginal contamination.

1. Trichomonas vaginalis:
Trichomonas is highly motile, sexually transmitted infection of the urogenital tract.
Infection rates between men and women are similar with women being symptomatic, while infections in
men are usually asymptomatic.
Medication should be prescribed to any sexual partner as well because he may be asymptomatic carrier.

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In female:
Usually found as a contaminant from vaginal infection and is often accompanied by an increase in the
number of white cells.
Symptoms in women include:
1. Dysuria [painful urination].
2. Painful sexual intercourse.
3. Burning sensation of the vagina.
4. Green/Yellow, frothy vaginal discharge with a strong foul-smelling odor.
5. Trichomonas infection may cause Vaginitis , and Cervicitis as it lives in vagina, and cervix.

In male:
Men can display symptoms of urethritis, prostatitis as it lives in urinary bladder, urethra, and prostate.

2. Schistosoma Haematobium:
The ova are initially deposited in the muscularis propria which leads to ulceration of the overlaying tissue.
Infections are characterized by pronounced acute inflammation, squamous metaplasia, blood and reactive
epithelial changes. Granulomasand multinucleated giant cells may be seen.
Adults are found in the venous plexuses around the urinary bladder and the released eggs travels to the
wall of the urine bladder causing haematuria and fibrosis of the bladder. The bladder becomes calcified,
and there is increased pressure on ureters and kidneys otherwise known as hydronephrosis.
Inflammation of the genitals due to S. haematobium may contribute to the propagation of HIV.
Clinical signs & symptoms of urinary schistosomiasis include:
1. Haematuria is a common nding.
2. Proteinuria is frequently present.
3. Eosinophils can often be found in the urine.
4. There is usually also a blood eosinophilia.

3. Enterobius Vermicularis (Oxyuris) on Femals:

Appear only in Females and Cause Itching and pain during urination.

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7. Urine Other Findings:

1. Bacteriuria:
Bacteriuria means the presence of bacteria in urine.
Indicate a urinary tract infection (either cystitis or pyelonephritis), although bacteriuria can also occur
in prostatitis.

Gram-negative bacilli Escherichia coli are the most common bacterium isolated from urine samples
(>80% of UTIs are caused by E. coli).
Smaller percent are caused by Gram-positive cocci (5% to 20%).
Bacteria can be identified in unstained urine sediments when present in sufficient numbers. Rod-shaped
bacteria and chains of cocci can be found.

When urine is allowed to remain at room temperature, the number of bacteria doubles every 30 to 45
minutes.
Bacteriuria of clinical significance is usually accompanied by pyuria in ~90% of cases.
Asymptomatic bacteriuria is bacteriuria without accompanying symptoms of a urinary tract infection
(such as frequent urination, painful urination or fever). It is more common in women, in the elderly, in
residents of long-term care facilities, and in patients with diabetes, bladder catheters and spinal cord
injuries. Patients with a long-term Foley catheter uniformly show bacteriuria.
The symptoms of a urinary tract infection include burning during urination, an increased urgency to
urinate, and increased frequency of urination.

2. Mucus:
Most of the mucus in the urine originates from the lining of
the urethra and the bladder. Both membranes are
composed of epithelial cells. Once you urinate, some of the
mucus flows with the urine.
The exact function of mucus is unknown. Some think
that this substance is a protection against bacterial
infection. This action is done by coating the bacterial's
pilis, essential to colonization of the lower urinary tract wall then the mucus coated bacteria are
eliminated. Mucus can also protect the lower urinary tract against irritating chemical agents.
In the majority of cases, presence of mucus threads is a benign situation but sometimes irritating factor
could stimulate mucus secretion.
Note: the presence in male is normal due to increased secretion of Cowper gland
Some of the possible reasons for the presence of mucus in urine are:
1. Urinary Tract infection or UTI.
2. Irritable bowel syndrome or IBS.
3. Sexually transmitted disease or STD.
4. Ulcerative colitis.
5. Kidney stones.

3. Sperm (Spermatorroea):
Its generally rare for men to experience sperm in urine, but the two most
common reasons this happens are prostatitis which is a medical issue related
to prostate gland swelling, and retrograde ejaculation which can happen

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when semen flows backward during ejaculation and gets stuck usually due to bladder problems.
Also may be found in case of prostatitis and orchitis.

4. Yeast:
Yeasts in unstained urine sediments are round to oval in shape, colorless, and may have obvious budding.
They are often difficult to distinguish from red cells and amorphous crystals but are distinguished by their
tendency to bud.
The presence of yeast may be the result of a contamination with vaginal secretion which may colonize in
bladder, urethra, or vagina.
Yeast cells may represent a true yeast infection most often they are Candida albicans, Yeasts are often
observed in specimens that contain sugar. It is important to be careful with these specimens because a
yeast infection is a frequent finding with diabetic patients.

5. Debris:
Sediments in urine can be particles of debris, cells and/or other solid material.

6. Fat Droplets:
Oil or fat droplets may appear as uniformly round bright globules of various sizes
under high power brightfield. Oil droplets from catheter lubricants may be confused with cells, especially red
cells. Lipid material from vaginal creams also forms droplets in urine.

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Complete Stool Analysis

Stool Formation:
Human feces are the (solid or semisolid metabolic waste) of the human digestive system, including bacteria.
They vary significantly in appearance (i.e. size, color, texture), according to the state of the digestive
system, diet and general health.

1. Fluid Absorption:
Fecal matter is the remaining material after food is
digested along with water, bacteria and other substances
secreted into the gastrointestinal tract. About 1.5 liters of
fluid chyme passes from the small intestine into the large
intestine each day. Most of the nutrients from the food
have been absorbed at this stage.
As the chyme moves through the first half of the colon,
large amounts of water and electrolytes are absorbed.
Despite this, water makes up about 70% of the fecal
weight. Water absorption transforms the fluid chyme into
a mush-like consistency by the time it passes through the
transverse colon. It solidifies further along its passage
down the descending colon.
2. Colonic Bacterial Action:
The bacteria in the colon play integral roles in nutrient
absorption and the formation of feces. Colonic bacteria
digest cellulose thereby releasing residual nutrients which
are absorbed by the colon. In addition, the action of
colonic bacteria contributes to the formation and absorption of vitamin B12, thiamin, riboflavin and vitamin
K. The bacteria also produce the gases, carbon dioxide, hydrogen and methane, which make up flatus. The
action of the bacteria plays a major part in determining the color and odor of fecal matter.
3. Stool Formation:
Water and Electrolytes in the Colon like bicarbonate are secreted by the wall of the large intestine into the
lumen. This helps to neutralize any acidic byproducts of bacterial metabolism. At the same time sodium and
chloride are absorbed by the intestinal wall which creates a concentration gradient to facilitate water
absorption.

Stool Analysis:
A stool analysis is a series of tests done on a stool (feces) sample to help diagnose certain conditions
affecting the digestive tract. These conditions can include infection (such as from parasites, viruses, or
bacteria), poor nutrient absorption, or cancer.

Why It Is Done?
1. As a general evaluation of health.
2. Find the cause of symptoms affecting the digestive tract including prolonged diarrhea, bloody
diarrhea, an increased amount of gas, nausea, vomiting, loss of appetite, anemia, bloating,
abdominal pain and cramping, and fever
3. When stool color or odor is changed.
4. Patient with skin disease as Urticaria which may due to parasitic infection with helminthes.
5. Look for intestinal parasites cause of an infection, such as bacteria, fungus, or virus.
6. Check for poor absorption of nutrients by the digestive tract (malabsorption syndrome).
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 26

Preparation Methods:
1. Direct Saline Wet Mount:
1. Place a drop of saline on the slide.
2. Pick up a small amount of fecal material on the end of an applicator stick.
3. Emulsify in the saline and cover with a cover slip.
4. Examine on low and high power.
5. The entire preparation must be examined for the presence of eggs, larvae and protozoa.
Note: Take small amounts of material from several different areas (stool surface and deep
inside), especially from bloody and/or mucoid areas.

2. Saline Sedimentation Method:

1. Add saline to the stool container.
2. Mix well in the container.
3. Pour the solution from the container into a tube.
4. Leave the tube to stand in the rack for 20-30 minutes.
5. Examine the stool precipitate under microscope with low power then high.

.
.) (
.) (
.) ( :
.
.
.
.)... (
.
.

.

.) (
. :

A) Macroscopic Examination:
1. Color:
The characteristic normal brown color of feces is due to stercobilin and urobinin, both of which are produced
by bacterial degradation of bilirubin.
Stool color is generally influenced by what you eat as well as
by the amount of bile (yellow-green fluid) that digests fats in
your stool.
1. Black color: The black color is caused by oxidation of
the iron in the blood's hemoglobin indicate iron
medication (for treatment of anemia) or upper GIT
bleeding (due to peptic ulcer, stomach carcinoma or
esophageal varices).
Feces can be black due to the presence of red blood cells
that have been in the intestines long enough to be
broken down by digestive enzymes.
2. Bright red color (Hematochezia): indicate lower GIT
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 27

bleeding (due to piles and anal fissure). Conditions that can cause blood in the stool include
hemorrhoids, anal fissures, diverticulitis, colon cancer, and ulcerative colitis
3. Clay color (gray-white): could indicate a problem with your biliary tree, such as bile duct stones or
obstructive jaundice, hepatitis, chronic pancreatitis, or cirrhosis.
4. Pale brown color: with a greasy consistency indicate pancreatic deficiency causing malabsorption of
fat (often with offensive odor).
5. Yellow or green color: occurs in the stool of breast-fed infants who lack normal intestinal flora (low
bil. conversion) and May also occurs due to rapid transit of feces through the intestines. Yellowing
of feces can be caused by an infection known as Giardiasis.
6. Red brown color: indicate drugs as Tetracyclines, and Rifambicin antibiotics.
Note: if stool color is black and there is no history of iron medication Fecal Occult Blood Test
(FOBT) is recommended.

2. Odor:
Fecal odor normally offensive results from gases produced by bacterial metabolism, bacterial fermentation
and putrefaction.
However, foul-smelling stools can also indicate a serious health problem. Diarrhea, bloating, or
flatulence may occur with foul-smelling stools. These stools are often soft or runny.
Changes in diet are a common cause of foul-smelling stool.
Additional causes include the following: Malabsorption, Infection, Medications and supplements,
chronic pancreatitis, cystic fibrosis, and short bowel syndrome.

3. Reaction (PH):
Human feces are normally alkaline (7 -7.5). An acidic stool can indicate a digestive problem such as lactose
intolerance or a contagion such as E. coli or rotavirus.
PH variable and diet dependent and is based on bacterial fermentation in the small intestine.

4. Consistency:
Stool is normally well formed.
1. Very hard: seen in cases of constipation.
2. Semi formed: seen in the cases of parasitic infection.
3. Soft: seen in the cases of parasitic infection.
4. Loose: seen in the cases of diarrhea.
5. Watery: mostly seen in cases of bacterial infection.

Bristol stool chart is a medical aid designed to classify the

form of human feces into seven categories:
1. Type 1: Separate hard lumps, like nuts (hard to pass)
2. Type 2: Sausage-shaped, but lumpy
3. Type 3: Like a sausage but with cracks on its surface
4. Type 4: Like a sausage or snake, smooth and soft
5. Type 5: Soft blobs with clear cut edges (passed easily)
6. Type 6: Fluffy pieces with ragged edges, a mushy stool
7. Type 7: Watery, no solid pieces, entirely liquid

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5. Mucus:
Some amount of mucus in the stool is normal; however significant amounts of mucus and
mucus accompanied by diarrhea, pain or blood may signify an intestinal condition such as infection or
inflammation.
Increased amounts of mucus in the stool can also occur with cancers of the colon or rectum or with
bowel obstruction.
Abnormal mucus in the sample appears as white patches and
according to the amount of mucus it can be graded using signs (+, ++,
+++)
Mucus abnormally can be found in the stool in the following cases:
1. Excessive straining at stool.
2. Spastic colon (translucent mucus on the surface of stool).
3. Ulcerative colitis.
4. Bacillary dysentery (mucus with fresh pus).
5. Amoebic dysentery (mucus with fresh blood).

6. Pus:
Normally not found. (You cannot see it by naked eye).
Usually detected with mucus and appear as white patches in the stool, it indicates ulcerative colitis or
bacterial infection as bacillary dysentery. Also it can be graded using signs (+, ++, +++).
Presence of detectable pus by naked eye means that the microscopic pus must be over 100.

7. Blood:
Normally no blood seen in the stool (you cannot see it by naked eye).
Bleeding may result in bright red blood in the stool as well as maroon colored or black stool.
Bleeding also may be occult (not visible with the human eye). Rectal bleeding also may be seen with
bleeding that is coming from higher in the instestinal tract, from the stomach, duodenum, or small
intestine.
Small amounts of bright red blood that is not mixed with stool are likely due to schistosoma mansoni
infection, hemorrhoids or a scratch in the rectal area.
Blood that is mixed with stool likely due to ulcerative colitis or colorectal cancer.
Blood with diarrhea and mucus likely due to amoebic dysentery.
Common causes of blood in the stool include:
1. Anal fissure.
2. Colorectal cancer.
3. Ulcerative colitis.
4. Internal hemorrhoids.

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5. Inflammatory enteritis - inflammation of the small intestine.

6. Upper gastrointestinal bleeding.
7. Peptic ulcer disease.
8. Gastric cancer.
9. Constipation.
Presence of detectable Blood by naked eye means that the microscopic RBCs must be over 100.

8. Naked Eye Parasite(Worms):

In some cases the whole worm or parts of its body appear in the
stool and can be seen by naked eye.
Two worms can be seen by naked eye in the stool:
1. Ascaris Lumbericoides:
Ascaris lumbricoides is the small roundworm of humans, growing to
a length of up to 35 cm.

2. Enterobius Vermicularis:
The worms are small, white, and threadlike, with the larger females
ranging between 8-13 mm x 0.3-0.5 mm and the smaller males
ranging between 2-5 mm x 0.1-0.2 mm. Females also possess a long,
pin-shaped posterior end from which the parasite's name is derived.
They dwell primarily in the cecum of the large intestine, from where
the gravid females migrate at night to lay up to 15,000 eggs on the
perineum.

B) Microscopic Examination:
1. RBCs:
Normally few amounts of RBCs (0 - 5) are seen under high power field of microscope.

2. PUS:
Normally few amounts of pus (0-5) are seen under high power field of microscope.
Note: if pus count is over 100 stool culture is recommended.

3. Parasites:
An organism which lives in or on another organism (its host) and benefits by deriving nutrients at the other's
expense.
What are the types of parasites that attack human?
1. Protozoa: are microorganisms classified as unicellular eukaryotes.
2. Helminthes or Parasitic Worms: are large multicellular organisms, which when mature can generally
be seen with the naked eye.

What is the forms of protozoa that can appears in stool?

1. Trophozoite: metabolically active invasive stage, growing stage in the life cycle of some protozoan
parasites, when they are absorbing nutrients from the host.
2. Cyst: "vegetative" inactive form resistant to unfavorable environmental conditions they are refractile
and more easily detected unstained. can be identied by their shape, size, nuclei, and inclusions as
seen in an iodine preparation.
In saline preparations protozoan cysts can be recognized as refractile bodies (shine brightly when
focused) Such as :
1. Entamoeba Histolytica:
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 30

Amoebiasis is an anaerobic parasitic protozoan, usually transmitted by contamination of drinking water and
foods with feces (Oral-faecal route).
Infection can be transmitted through
autoinfection (by anal-oral contact).
The active (trophozoite) stage exists only in the
host and in fresh loose feces, cysts survive
outside the host in water, soils, and on foods,
especially under moist conditions on the latter.
The cysts are readily killed by heat and by
freezing temperatures, and survive for only a
few months outside of the host.
Symptoms appear after about 1 to 4 weeks later
but sometimes more quickly or more slowly.

Asymptomatic amboebiasis:
About 90% of cases are asymptomatic,The infected
individual is still a carrier, able to spread the
parasite to others through poor hygienic practices.
In asymptomatic infections the amoeba lives by
eating and digesting bacteria and food particles in
the gut.
It does not usually come in contact with the intestine itself due to the protective layer of mucus that lines
the gut.
Cysts are found in the stool and can be present in an infected person for several years.

Amoebic dysentery (Amoebic colitis):

Disease occurs when amoeba comes in contact with the cells lining the intestine. It then secretes enzymes
that destroy cell membranes and proteins.
It is the severe form of amboeiasis and it is generally known as invasive amoebiasis.
Amebic dysentery usually starts slowly over several days with abdominal cramps, and occasional loose
stools, but progresses to diarrhea with blood and mucus.
A few patients may develop fever, vomiting, abdominal tenderness, weight loss, or dehydration (especially
children) as the severity of the disease increases.

Complication of amboebiasis:
1. Intestinal complications:
Severe ulceration of the gastrointestinal mucosal surfaces occurs in less than 16% of cases leading to rectal
hemorrhage.
Trophozoite invades mucosa of the large intestine and multiplies in submucosa forming abcesses which
breaks to form ulcers.
Invasion of appendix leads to clinical picture of appendicitis (surgery in this case may leads to peritonitis)
2. Amoebic liver abscess:
In fewer cases, (In about 10% of invasive cases) the
amoebae enter the bloodstream and invades the soft
tissues, most commonly the liver causing abscesses.
Amoebic hepatitis is characterized by: Fever, nausea,
vomiting, weight loss, right abdominal pain, and
hepatomegaly.

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2. Giardia lamblia:
Giardia lamblia is anaerobic flagellated protozoan parasite that colonizes and reproduces in the small
intestine, causing giardiasis. The parasite attaches to the epithelium by a ventral adhesive disc, and
reproduces via binary fission.
Giardiasis usually transmitted by
contamination of drinking water and foods
with feces (Oral-faecal route).
G. lamblia cysts in more formed specimens, are
excreted irregularly. Often large number may
be present for a few days followed by fewer
numbers for a week or more,the cysts are
resistant to conventional water treatment
methods, such as chlorination and ozonolysis.
The motile form (trophozoite) can be seen in
fresh liquid feces, in fresh diarrhoeic specimens
particularly in mucus. They are often difcult to
detect because they attach themselves to the
wall of the intestine.
Infection can be transmitted through
autoinfection (by anal-oral contact).
Since the cysts and trophozoites are not shed
consistently so many false negatives are found,
some patients should be treated based on symptoms.
Giardiasis does not spread via the bloodstream or other parts of the gastro-intestinal tract, but remains
confined to the lumen of the small intestine.

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In humans, infection is Asymptomatic in about 70% of the patients, Only about 30% of patients exhibit
symptoms, in this case Symptoms typically begin 12 weeks after infection and it includes:
1. Fatty explosive diarrhea [Steatorrhea].
2. Loose or watery stool with foul smelling.
3. Epigastric pain.
4. Stomach cramps.
5. Malabsorption.
6. Loss of body weight.
7. Excessive gas (often flatulence or a foul or
sulphuric-tasting belch, which has been known
to be so nauseating in taste).
8. An oily anal leakage or some level of fecal
incontinence may occur.

Complications of Giardiasis:
Lactase deficiency may develop in an infection with Giardia, however this usually does not persist for more
than a few weeks, and a full recovery occurs.
Giardia relies on glucose as its major energy source.
B vitamins and bile salts, as well as glucose, are necessary for Giardia to survive, Some studies have shown
that giardiasis should be considered as a cause of Vitamin B12 deficiency, this a result of the problems
caused within the intestinal absorption system.
Under a normal compound light microscope, Giardia often looks like a "clown face," with two nuclei
outlined by adhesive discs above dark median bodies that form the "mouth." Cysts are oval, have four
nuclei, and have clearly visible axostyles.

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What is the forms of helminthes that can appear in stool?

1. Ova: that is results from sexual reproduction of helminthes.
Eggs are recognized by their: size, color (colorless, pale yellow, brown), Morphological features.
2. Larva: the stage that is come from the ova.
In a fresh faecal specimen, S. stercoralis is the only larva that will be found. It can be easily detected in a
saline preparation by its motility and large size.

The failure to demonstrate Ova or larvae does not necessarily mean that no parasites are present; they
may be present in an immature stage or the test used may not be sufficiently sensitive.
There are several types of Ova that found in stool such as:

1. Strongyloides Stercoralis (Dwarf Threadworm):

It is a nematode (roundworm) and a common intestinal parasite or helminth.
You can become infected by direct contact with contaminated soil, through Skin penetration, Autoinfection
larva penetrates the wall of the lower ileum or colon external through perianal skin penetration.
Many people infected are usually asymptomatic at first while infection passes in 4 stages:
1. Skin penetration stage:
Dermatologic manifestations include swelling, itching (also called ground itch or dew itch), urticarial rashes
and mild hemorrhage at the site where the skin has been penetrated and usually persists for 1-2 weeks.
2. Migratory stage:
Larva pass to the lung leads to Loffler`s syndrome during pulmonary migration of the filariform larvae.
Loeffler's syndrome is a disease in which
eosinophil accumulates in the lung in response to
a parasitic infection.
Eosinophil enzymes cause destruction of lung
tissue leading to:
Dry cough chest pain, wheezing, haemoptysis and
fever will sometimes be experienced by people
who have been exposed to very large numbers of
larvae
3. Intestinal stage:
It is characterized by abdominal pain, nausea,
anorexia, indigestion, tissue damage, sepsis, ulcers
and Chronic diarrhea that usually develop
around one month after infection.
Stool may have yellow mucus with a recognizable
smell.
4. Chronic stage:
Infection last for many years due to autoinfection
and this stage is characterized by: staetorrhea ,
weight loss and malabsorption syndrome.
Persistent infection may leads to inflammation of
mucosa and necrosis.
Strongyloidiasis resulting from persistent infection
can greatly mimic peptic ulcer and gallbladder disease.
It can be diagnosed by detection of the juvenile larvae in stool microscopically (appear 5 weeks after
infection).
Larvae is actively motile, large measuring about 250 mm, show a typical large bulbed oesphagus.
Leukocytosis is common,Increase in eosinophils may also be present; indicates hyper infection but the
number usually decreases with chronicity.

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2. Enterobius Vermicularis (Oxyuris, Pinworm, Seat worm, Threadworm):

It is a nematode (roundworm) and a common intestinal parasite or helminth.
You can become infected by Ingestion of egg via the fecal-
oral route, External auto-infection occurs by transferring
infective eggs to the mouth with hands that have scratched
the perianal area.
Retroinfection, or the migration of newly hatched larvae
from the anal skin back into the rectum, may occur
Person-to-person transmission can also occur through
handling of contaminated clothes or bed linens.
Some eggs may become airborne and inhaled. These would
be swallowed and follow the same development as
ingested eggs.
Most symptoms of pinworm infection are mild; many
infected people have no symptoms Except for itching
[Pruritus ani or itchy assis due to migration of female
to peri-anal region] pinworm infestation does not
usually cause any damage to the body.
Symptoms of heavy infection:
1. Painful itching around the anus.
2. Restless sleep [insomnia].
3. Poor appetite.
4. Failure to gain weight.
5. Passage of worm to vagina or fallopian tube lead to vaginitis and salpingitis.
Diagnosis is often made clinically by observing the female worm (or many worms) in the peri-anal region,
It can be diagnosed by detection of the larvated egg in stool microscopically
Egg : One side is flatter than the other (D shape) and have a surface that adheres to objects, Thin double
wall, colorless and transparent.
Eggs may contain a developing embryo or a fully developed pinworm larva.
The eggs are hardy and can remain infectious in a moist environment up to three weeks.
The eggs can enter the mouth and nose through inhalation.
The reason the female emerges from the anus is to obtain the oxygen necessary for the maturation of
the eggs.

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3. Ascaris Lumbricoides (Giant intestinal worm):

It is a nematode (roundworm) growing to a length of up to 35 cm and a common intestinal
parasite or helminth.
You can become infected by Ingestion of
fertilized egg through contaminated food or water.
Transmission from human to human by direct
contact is impossible.
The eggs have a lipid layer which makes them
resistant to the effects of acids and alkalis, as
well as other chemicals, These fertilized eggs
become infectious after two weeks in soil; they
can persist in soil for 10 years or more.
Fertilized eggs are oval to round in shape and
are 4575 m long and 3550 m wide with a
thick outer shell. Unfertilized eggs measure 88
94 m long and 44 m wide.
The characteristic feature of the egg is the
coarse mammilated coating.
Infections are usually asymptomatic, especially
if the number of worms is small, infection
passes in 4 stages:
1. Migratory Stage:
larva pass to the lung leads to loffler`s syndrome.
In heavy infection, larva passes to venous circulation then to the heart then go to different body organs
causing visceral larva migrains.
2. Intestinal Stage:
In this stage Ascariasis symptoms include: Nutritional deficiency (Ascaris takes most of its nutrients from the
partially digested host food in the intestine), Indigestion and malabsorption due to production of anti
enzymes interfere with digestion (especially protein indigestion).
Note: Ascaris infection does not produce the anemia associated with some other roundworm
infections.

Heavy infection may cause intestinal obstruction as :

1. Appendicular obstruction leading to appendicitis.
2. Bile duct obstruction leading to jaundice.
3. Pancreatic duct obstruction leading to pancreatitis.
4. Intestinal wall perforation leading to peritonitis.

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In rare cases some worm may ascend to pharynx and either:

1. Pass to larynx leading to suffocation.
2. Pass to middle ear leading to destruction.
3. Come out of mouth, nose.
Ascaris-mediated anaphylactic shock syndrome:
This is a case of sudden death which my due to that ascaris worms release toxic substances causing mast cell
de-granulation in all body tissues
Blood counts may demonstrate peripheral eosinophilia during symptomatic phase.

4. Hymenolepiasis Nana Or Hymenolepiasis Diminuta (Taenia Nana, Dwarf Tapeworm):

It is cestodes and a common intestinal parasite or helminth.
One can get infected by ingesting fecally contaminated
foods and water, by touching your mouth with
contaminated fingers, or by ingesting contaminated
soil.
H. nana, like all tapeworms, contains both male and
female reproductive structures in each proglottid.
This means that the dwarf tapeworm, like other
tapeworms is hermaphroditic. Each segment
contains three testes and a single ovary.
Internal autoinfection: An alternate mode of
infection consists of internal autoinfection, where
the eggs release their embryo, which penetrates
the villus continuing the infective cycle without
passage through the external environment.
Most people who are infected do not have any
symptoms.
Heavy infection may cause:
Nausea, weakness, loss of appetite (anorexia), diarrhea,
and abdominal pain.
Young children, may develop, itching around the anus or have difficulty sleeping.

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5. Ancylostoma Duodenale (Hookworm):

It is a nematode (roundworm) and a common intestinal parasite or helminth.
You can become infected by direct contact with contaminated soil, through Skin penetration.
Infection occurs by accidentally swallowing
contaminated soil.
Trans lactational transmission of infection:
In a pregnant woman, after childbirth some or all of
these larvae are stimulated to re-enter the
circulation (presumably by sudden hormonal
changes), then to pass into the mammary glands, so
that the newborn baby can receive a large dose of
infective larvae through its mother's milk.
Trans placental from mother to the fetus.
Note: Hookworm cannot be spread person to
person.

Many people infected are usually asymptomatic

at first while infection passes in 4 stages:
1. Skin penetration stage:
Dermatologic manifestations include swelling, itching (also called ground itch or dew itch), urticarial rashes
and mild hemorrhage at the site where the skin has been penetrated and usually persists for 1-2 weeks.
2. Migratory stage:
Larva pass to the lung leads to Loffler`s syndrome during pulmonary migration of the filariform larvae.
Loeffler's syndrome is a disease in which eosinophil accumulates in the lung in response to a parasitic
infection.
Eosinophil enzymes cause destruction of lung tissue leading to:
Dry cough chest pain, wheezing, haemoptysis and fever will sometimes be experienced by people who have
been exposed to very large numbers of larvae
3. Intestinal stage:
It is characterized by abdominal pain, nausea, anorexia, indigestion, tissue damage, sepsis, ulcers and
Chronic diarrhea that usually develop around one month after infection.
Stool may have yellow mucus with a recognizable smell.

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4. Chronic stage:
This stage depend on number of worms and duration of infection.
The most significant risk of hookworm infection is anemia (Iron deficiency anemia), secondary to loss of iron
(and protein) in the gut. The worms suck blood voraciously and damage the mucosa. However, the blood
loss in the stools is occult blood loss.
Effects of anemia include: weakness, palpation, Pallor, chlorosis (greenish yellow skin discoloration),
tachycardia
Edema is caused by protein deficiency.
Continuously infected children will have deficits in physical and intellectual growth, which may be
irreversible.
Hookworms may cause, intrauterine growth retardation, prematurity, and low birth weight among newborns
born to infected mothers.
Cases of hookworm disease exhibit characteristic blood indices of iron deficiency anemia (hypochromic
microcytic).

6. Fasciola Hepatica:
It is a parasitic trematode also known as
the large liver flukes, common liver
fluke or sheep liver fluke.
It infects the livers of various mammals,
including humans.
Humans can often acquire these
infections through eating
freshwater plants such as watercress.
It is one of the largest flukes of the
world, reaching a length of 75 mm. It
is leaf-shaped.
Inside the duodenum of
the mammalian host, the
metacercariae are released from
within their cysts. From
the duodenum, they burrow through
the lining of the intestine and into
the peritoneal cavity. They then

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migrate through the intestines and liver, and into the bile ducts. Inside the bile ducts, they develop into
an adult fluke. In humans, the time taken for F. hepatica to mature from metacercariae into an
adult flukeis roughly 3 to 4 months. The adult flukes can then produce up to 25,000 eggs per fluke per
day. These eggs are passed out via stools and into freshwater and the life cycle begins again.
Human symptoms vary depending on if the disease is chronic or acute:
During the acute phase, the immature worms begin penetrating the gut, causing symptoms of fever, nausea,
swollen liver, skin rashes and extreme abdominal pain.
The chronic phase occurs when the worms mature in the bile duct, and can cause symptoms of intermittent
pain, jaundice and anemia.
Stool examination for detection of eggs.the egg is characterized by its large size and opercalated shell.
Usually appears 2 monthes after infection.
Examinations of stool alone are generally not adequate because infected humans have important clinical
presentations long before eggs are found in the stools. Moreover, in many human infections, the fluke
eggs are often not found in the faeces, even after multiple faecal examinations.
Serological test : Antibody detection tests using ELISA or IHA are useful especially in the early invasive
stages, when the eggs are not yet apparent in the stools, or in ectopic fascioliasis.
Note: Antibodies appear within 2 to 4 weeks after infection (57 weeks before eggs appear in stool).

7. Trichostrangylus Colubriformis (The hairworm or bankrupt or black scour worm):

They are nematodes (round worms).
Infections occur via ingestion of infective
larvae from contaminated vegetables or
water.
The majority of human infections are
asymptomatic or associated with mild
symptoms.
Symptomatic individuals may experience
abdominal pain, nausea, diarrhea,
flatulence, dizziness, generalized fatigue,
and malaise. Eosinophilia is frequently
observed.
Infections with a heavy worm burden can
lead to anemia,cholecystitis, and
emaciation.
The adult worms live in the small intestine.
The diagnosis is based on the observation of
eggs in the stool. The eggs are 85115 um,
oval, elongated, and pointed at one or both ends.
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Note: Trichostrongylus eggs must be differentiated from hookworm eggs, which are smaller and do not
have pointed ends Examination of the stool for eggs confirms the diagnosis.
Note: WBC and eosinophils Increased when patient is symptomatic.

8. Trichuris Trichiura (trichocephalus trichuris = whip worm):

It is a round worm infects a human large intestine. It is commonly known as the whipworm which refers to
the shape of the worm; it looks like a whip with wider "handles" at the posterior end.
Eggs are deposited from human feces
to soil where, after two to three weeks,
they become embryonated and enter
the infective stage.
These embryonated infective eggs are
ingested and hatch in the human small
intestine exploiting the intestinal
microflora as hatching stimulus. This is
the location of growth and molting.
The infective larvae penetrate
the villi and continue to develop in the
small intestine.
The young worms move to
the caecum and penetrate
the mucosa and there they complete
development to adult worms in
the large intestine.
The life cycle from time of ingestion of
eggs to development of mature worms
takes approximately three months.
During this time, there may be limited
signs of infection in stool samples due to
lack of egg production and shedding.
The female T. trichiura begin to lay eggs after three months of maturity. Worms can live up to five years
[citation needed], during which time females can lay up to 20,000 eggs per day.
Most people who are infected do not have any symptoms. Those who have heavy infection may
experience: Nausea, bloody diarrhea, and abdominal pain.
Heavy infection is characterized by profuse mucus with blood in the stool.
Complications:
1. Long-standing blood loss may lead to iron-deficiency anemia [hypochromic anemia].
2. Toxic secretions of the worms cause hyperchromic anemia known as trichocephalic pernicious
anemia.
3. Rectal prolapse is possible in severe cases due to weakness of vator ani muscle.

Note: The Trichuris eggs are lemon or football shaped and has terminal plugs at both ends.
Note: WBC and eosinophils Increased in Trichuriasis .

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9. Schistosoma Mansoni:
It is a significant parasite of humans, a trematode.
During washing or playing in infected
canals cercaria can penetrate skin So
Human contact with water is thus
necessary for infection by
schistosomes.
Schistomiasis can be divided into 4
phases:
1. Stage of invasion:
Penetration of the infective stage to the
skin cause cercarial dermatitis
It is also known as Swimmers itch, duck
itch, Bather`s itch or Clam Diggers' Itch
It is an immune reaction occurring in the
skin of humans that have been infected
by cercaria
It is commonly occur within hours of
infection and do not generally last more
than a week.
Symptoms Include itchy, raised papules,
dermatitis
2. Migratory phase:
This phase lasting from penetration to maturity of worms
Katayama syndrome: develops a few weeks after 1st infection and characterized by allergic manifestations
by metabolic products of worms,Fever, cough, influenza-like symptoms, abdominal pain, eosinophilia,
splenomegaly.
3. Acute phase (Stage of egg deposition):
Occurs when the schistosomes begin producing eggs and lasts 3-4 months.
The eggs pass through the intestinal wall and escape in faeces accompanied by bleeding with dysentery in
stool , abdominal tenderness, weight loss and headache.
4. Chronic phase (Stage of tissue proliferation and fibrosis):
Occurs mainly in endemic areas and symptoms of this stage is different from tissue to other.
Continuing infection may cause granulomatous reactions (bilharzioma or bilharzial granuloma) and fibrosis in
the affected organs [eggs swims into circulation and reach many organs].
Granuloma formation is initiated by antigens secreted by the miracidium through microscopic pores within
the rigid egg shell
Intestinal bilharzioma:
When ova is trapped in the intestinal wall it lead to granuloma in the submucosa,
Necrosis of mucosa cause ulcers and hemorrhage which lead to microcytic hypochromic anaemia,
Sever prolonged infection cause sandy patches, a lesion contain a large number of calcified ova healed by
fibrosis.

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Hepatic bilharzioma:
When ova reach the liver via portal vein branches it initiate acute inflammatory reaction that ends in chronic
granuloma giving rise to fibrosis of the liver which occur only many years after the infection.
Complications:
1. Portal hypertention that cause Hepatosplenomegaly, esophageal varices , and pils.
2. Hypoalbuminaemia that leads to ascites.
3. Disordered liver functions.
Eggs of Schistosoma mansoni are approximately 140 by 60 m in size and have a lateral spine.

4. Digestive State:
1. Starch:
Normally found in the stool and graded as (+) when seen under HPF.
Increased starch in stool (++ or +++) indicate a case of
indigestion.
Dyspepsia (indigestion): It is a medical condition
characterized by indigestion with chronic or recurrent pain in the
upper abdomen, upper abdominal fullness and feeling full earlier
than expected with eating. It can be accompanied by bloating,
belching, nausea or heartburn.
The characteristic symptoms of dyspepsia are upper
abdominal pain, bloating, fullness and tenderness on
palpation.
Note: Pain worsened by exertion and associated with nausea and
sweating may also indicate angina.

Causes :
Over eating , spicy food , too fast eating , drinking water during eating due to dilution of digestive enzymes ,
alcohol drug eat ,stress , and peptic ulcers.
Occasionally dyspeptic symptoms are caused by medication, such as calcium antagonists (used for angina or
high blood pressure), nitrates (used for angina), theophylline (used for chronic lung disease), corticosteroids
and non-steroidal anti-inflammatory drugs.

2. Fat:
Normally found in the stool and graded as (+) when seen under HPF.
Increased fat in stool may due to Malabsorption:
Malabsorption: It is a state arising from abnormality in digestion or absorption of food nutrients across
the gastrointestinal (GI) tract.
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Steatorrhea (fat malabsorption): is the presence of excess fat

in feces.
Stools may also float due to excess lipid, have an oily appearance and be
especially foul-smelling.
Causes:
1. Lack of bile acids due to: liver damage, Hypolipidemic drugs,
Gallbladder removal (cholecystectomy),
choledocholithiasis (obstruction of the bile duct by a gallstone), pancreatic cancer
(if it obstructs biliary outflow), Cholangiocarcinoma (cancer of the biliary tracts or
gallbladder).
2. Defects in pancreatic juices (enzymes).
3. Giardiasis (a protozoan parasite infection).
4. Inflammation of the lining of the intestines, which may occur with conditions such as ulcerative
colitis or Crohns disease.

3. Vegetable cells:
Normally found in the stool and graded as (+) when seen under HPF.
Increased vegetable cells in stool have no clinical significance and
considered as residual food.

4. Muscle fibers:
Normally found in the stool and graded as (+) when seen under HPF.
Increased muscle fibers in stool have no clinical significance and considered as
residual food.

Note: The presence of large amount of undigested meat fibers may be caused by
pancreatitis

5. Other Findings:

1. Bacteria:
Normally non pathogenic bacteria are found in the stool and usually
bacilli such as Escherichia coli and Lactobacillus sp.

Note: pathogenic bacteria may be found in stool (such as Salmonella,

Shigella, and Staphylococcus aureus) and this will leads to pus
formation, stool culture can differentiate between pathogenic and
non pathogenic bacteria.

2. Yeast:
Normally stool contains harmless yeast cells such as blastocystis
hominis.

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3. Crystals:
Normally stool contain triple phosphate, calcium oxalate and cholesterol crystal due to food ingestion.

Diarrhea:
Diarrhea is an increase in the volume of stool or frequency of defecation (having three or more loose or
liquid bowel movements per day). It is one of the most common clinical signs of gastrointestinal disease.
Note: The loss of fluids through diarrhea can cause dehydration and electrolyte imbalances.

There are numerous causes of diarrhea, but in almost all cases, this disorder is a manifestation of one of
the four basic mechanisms:
1. Secretory diarrhea:
Means that there is an increase in the active secretion, or there is an inhibition of absorption. The most
common cause of this type is bacterial toxins such that associated with cholera.
In addition to bacterial toxins, a large number of other agents can induce secretory diarrhea by turning on
the intestinal secretory machinery, including: Hormones secreted by certain types of tumors (e.g. vasoactive
intestinal peptide), a broad range of drugs (e.g. some types of asthma medications, antidepressants, cardiac
drugs)
2. Osmotic diarrhea:
Occurs when too much water is drawn into the bowels, typically results from one of two situations:
Ingestion of a poorly absorbed substrate: as carbohydrate or divalent ion.
Malabsorption: A common example of malabsorption, afflicting many adult humans and pets is lactose
intolerance resulting from a deficiency in the brush border enzyme lactase.
3. Motility-related diarrhea:
Caused by the rapid movement of food through the intestines (hypermotility), if the food moves too quickly
through the GI tract, there is not enough time for sufficient nutrients and water to be absorbed. This can be
due to a diabetic neuropathy, as a complication of menstruation or Hyperthyroidism which can produce
hypermotility.
In order for nutrients and water to be efficiently absorbed, the intestinal contents must be adequately
exposed to the mucosal epithelium and retained long enough to allow absorption. Disorders in motility than
accelerate transit time could decrease absorption, resulting in diarrhea even if the absorptive process per se
was proceeding properly.
4. Inflammatory diarrhea:
Occurs when there is damage to the mucosal lining or brush border, which leads to a passive loss of protein-
rich fluids, and a decreased ability to absorb these lost fluids. It can be caused by bacterial infections as
Salmonella, viral infections as rotaviruses, parasitic infections as Giardia, or autoimmune problems such as
inflammatory bowel diseases.