STOOL EXAMINATION

Stool Examination
INTRODUCTION
• Stool Examination is useful in diagnosis of amoebic
dysentery ,bacillary dysentery Ca colon,ulcerative colitis.
• It is used to find out diarrhoeal types of adult worms,their eggs ,cysts
or ova .
• Stool examination is advised in or when patient complaints persistent
abdominal pain ,diarrhoea, passing black stool or with Malena
• Faces are composed of- waste material of indigestible material in
food,bile, intestinal secretion including mucous ,shed epithealial
cells,large no of bacteria that may form 1/3rd of total solids ,inoeganic
material that is chieply calcium and phosphate.
Sample for stool examination
• The fresh stool can be examined immediately for the moving
organisms.
• Stool in 10% formalin can be used for Helminths and protozoa.
• Stool in formalin-ethyl acetate is used to concentrate the stool.
• The smallest amount of stool needed for the examination is 2 to 5
grams.
• For ova and parasites, there are three methods:
• Direct stool examination.
• Concentration method.
• The permanent stain of the stool.
Precautions for stool examinations:
• Advise patients for the following things for at least 48 hours before
the collection of the stool:
• Avoid mineral oils.
• Do not take bismuth.
• Don’t take antibiotics like tetracyclines.
• Anti-diarrheal drugs are non-absorbent.
• Avoid anti-malarial drugs.
• The patient should not have a barium swallow examination before the
stool examination.
• For occult blood, stop iron-containing drugs, meat, and fish 48 hours
before the collection.
Precautions for stool
examinations
• Warm stools are better for the ova and parasites.
• Don’t refrigerate the stool for ova and parasites.
• Stools for ova and parasites can be collected in formalin and polyvinyl
alcohol. These are used as a fixative.
• If there is blood or mucus, that should be included in the stool
because most of the pathogens are found in this substance.
• Exam the stool before giving antibiotics or other drugs.
 Precautions for stool
examinations
• The semi-formed stool should be examined within 60 minutes of
collection.
• The liquid stool should be examined within the first 30 minutes.
• The solid stool should be examined within the first hour of collection.
• Trophozoites degenerate in liquid stool rapidly, so exam the stool within
30 minutes.
• In the case of constipated cases, use non-residual purgative on the night
before collecting the stool.
Indications for stool
examination:
• To evaluate the function and integrity of the GI tract.
• To rule out the presence of WBCs and RBCs.
• To find ova or parasites.
• To see the presence of fat for malabsorption syndrome.
• For screening for colon cancer.
• For asymptomatic ulceration of GI tract.
• Evaluate diseases in the presence of diarrhea and constipation.
• Summary of stool studies are done to evaluate:
• Intestinal bleeding.
• Infestation.
• Inflammatory diseases.
• Malabsorption.
• Different causes of diarrhea.
Stool preservatives are:
• Preservatives for the wet preparation are:
• 10% formol-saline for the wet preparation. This is the best
preservative as it kills the bacteria and preserves the protozoa and
helminths.
• Sodium acetate formalin.
• Methionate iodine formalin. This is a good preservative for the field
collection of the stool.
• For staining, use Polyvinyl alcohol.
• Avoid preservatives for the culture of stool.
• Usually, three parts of the preservatives and one part of the stool.
Gross Stool examination includes

• Color.
• Consistency.
• Quantity.
• Odor.
• Mucous.
• Helminths.
The consistency of the Stool (gross
appearance):
• Normal is soft and formed.
Abnormal stool
• Loosely formed stools.
• Watery stools.
• Thin stools.
• Pellet-like stools.
• Dry or hard stools are found in constipated patients.
• Puttylike stools.
• The small round hard stool is due to habitual constipation.
• Pasty stools are due to high-fat contents and are seen in:
common bile duct obstruction.
In Celiac disease, the stool looks like aluminum paint.
Cystic fibrosis due to pancreatic involvement and are greasy.
Abnormal stool
• Diarrheal stools are watery.
• Steatorrhea stool is:
• Large in amount.
• Frothy.
• Foul-smelling.
• Constipated stools are firm and may see spherical masses.
• Ribbon-like stool suggests the spastic bowel, rectal narrowing,
stricture, or partial obstruction.
• The very hard stool is due to excessive water absorption due to
prolonged contact with colonic mucosa.
Colour:
• The normal color is due to the presence of stercobilinogen and is
brown.
• Yellow or yellow-green color is seen in diarrhea.
• Black and tarry (related with consistency) stools are due to bleeding
of the upper GI tract from tumors.
• The maroon or pink color is from the lower GI tract due to tumors,
hemorrhoids, fissures, or inflammatory processes.
• Clay-colored stools are due to biliary tract obstruction.
• Mucous in the stool indicate constipation, colitis, or malignancy.
• Pale color with a greasy appearance is due to pancreatic deficiency
leading to malabsorption.
Causes of different colors of the stool:
Quantity:
• Normally there is 100 to 200 G/day.
• With a vegetable diet, maybe 250 g/day.
• Many disorders cause large, bulky stools, even in people who don’t
eat a lot.
• Like malabsorption syndrome and carbohydrate indigestion.
• Your stool size has more to do with how well you digest your foods
than what you eat.
• Some foods produce larger stools because they don’t break down
completely.
• Some gastrointestinal disorders also cause poor food breakdown and
absorption, which leads to large, bulky stools.
Odour:

• The foul odor is caused by the undigested protein and by excessive

intake of carbohydrates.
• Stool odor is caused by indole and skatole, formed by bacterial
fermentation and putrefaction.
• A bad odor is sickly produced by undigested lactose and fatty acids.
• The odor is increased due to excess intake of proteins.
• The putrid odor is due to severe diarrhea of malignancy or
gangrenous dysentery.
 Mucus:
• The mucosa of the colon produces mucus in response to parasympathetic stimulation.
• Pure mucous is translucent, gelatinous material clinging to the stool’s surface. This may be seen
in:
• Severe constipation.
• Mucous colitis.
• Excessive straining of the stool.
• Emotionally unstable patient.
• Mucus in diarrhea with microscopically present RBCs and WBCs are seen in:
• Bacillary dysentery.
• Ulcerative colitis.
• Intestinal tuberculosis.
• Amoebiasis.
• Enteritis.
• Acute diverticulitis.
• Ulcerating malignancy of the colon.
Stool physical character and possible
causes:
 The chemical examination includes:

• Stool pH.
• Reducing substances.
• For occult blood.
• Presence of fat, carbohydrate, and proteins.
pH:
• Normally stool is slightly acidic or alkaline, or neutral.
• pH is 7.0 to 7.5, depending on the diet.
• Newborn pH = 5.0 to 7.5.
• The pH of the stool depends upon the diet and bacterial fermentation in
the small intestine.
• Carbohydrate changes the pH to acidic while the protein breakdown
changes to alkaline.
• The breastfed infant’s pH has a slightly acidic stool.
• Bottle-fed infants have a slightly alkaline stool.
• The pH stool test helps to evaluate carbohydrate and fat malabsorption.
• pH stool also helps to know disaccharidase deficiency
PH
• Alkaline (Increased pH) stool is seen in:
• Colitis.
• Villous adenoma.
• Diarrhea.
• Antibiotic therapy.
• Excess intake of proteins.
Acidic (Decreased pH) stool seen in:
• Fat malabsorption.
• Disaccharidase deficiency.
• Carbohydrate malabsorption.
• Excess intake of carbohydrates.
• Precautions for pH estimation:
• Barium intake and laxatives change the pH.
• If the specimen is contaminated with urine, we will need to discard the sample.
Presence of Fat:
• The fat in the stool shows the possibility of :
• Malabsorption.
• Deficiency of pancreatic digestive enzyme.
• Deficiency of Bile.

• Normally absent, which is less than 7 grams / 24 hours during three days
period.
• This is less than 30% of dry weight (On a diet of 50 grams of fat per day).
• Normal
• 2 to 6 grams/24 hours (7 to 21 mmol/day).
• Calcium:
• This is about 0.6 gram / 24 hours.
• Stercobilinogen:
It is normally 40 to 280 mg/day with an average of 150 mg/day.
• Nitrogen:
It depends upon the nature of the diet.
• The normal amount is 1 to 1.5 g/day (<2.5 gram/day).
• Urobilinogen:
This is normally found 40 to 280 mg/24 hours (100 to 400 Ehrlich
units/100 gm).
• Coproporphyrin:
400 to 1000 mg/24 hours.
Microscopic stool Examination:
• Presence of leukocytes (pus cells).
• Presence of Red Blood Cells.
• Ova and parasites.
• Presence of meat fibers and muscle fibers.
• Presence of fat.
• Yeast and molds.
• Bacteria.
• Viruses and parasites don’t cause the presence of WBCs in the stool.
• Increased number of WBCs seen in the stool:
• Bacillary dysentery.
• Chronic ulcerative colitis.
• Shigellosis.
• Salmonella infection.
• Yersinia infection.
• Invasive E.coli diarrhea.
• Fistula of anus or rectum.
• Localized abscess.
• Few WBCs are seen in amoebiasis.
• Also, WBCs are seen in typhoid.
 The absence of WBCs seen in some of the
diarrhoeal conditions alike:
• Cholera.
• Viral diarrhea.
• Drug-induced diarrhea.
• Amoebic colitis.
• Non-invasive E.coli diarrhoea.
• Parasitic infestation.
• Toxigenic bacterial infection
Presence of Leukocytes
• Normally, there are no WBCs.
• WBCs only appear in infection or inflammation.
• Their presence is important in case of diarrhea or dysentery.
• >3 WBCs /high fields are seen in ulcerative colitis and bacterial
infection.
• Greater numbers of WBCs indicate invasive pathogens.
 Presence of Red Blood Cells in the stool:
• Normally RBCs are absent.
• Epithelial cells are present, and these are increased with GI tract irritation.
• Few WBCs are seen, which may be increased due to GI tract inflammation.
Blood in the stool can be:
• Bright red from the bleeding in the lower GI tract.
• Maroon in color.
• Black and tarry from bleeding from the upper GI tract.
• Occult blood (not visible to the naked eye).
• Causes of blood in stool:
• Hemorrhoids.
• Cancer.
Ova and parasites:
• Normally there are no parasites or eggs in the stool sample.
• Multiple stool samples are needed to rule out the parasitic infestation for at
least three consecutive days.
• An abnormal result means parasites or eggs are present in the stool. Such
infections include:
• Roundworms: Ascaris lumbricoides.
• Hookworms: Necator americanus.
• Pinworms: Enterobius vermicularis.
• Whipworm: Trichuris trichiura.
• Tapeworms: Diphyllobothrium latum, Taenia saginata, and Taenia solium.
• Protozoa: Entamoeba histolytica (an amoeba) and Giardia lamblia (a
flagellate)
Presence of crystals and other substances:
• Crystals of calcium oxalate, fatty acids, and triple phosphate are
commonly present.
• Charcot-Leyden crystals are seen in parasitic infestation, especially in
amoebias
• Undigested vegetable fibers and meat fibers are seen sometimes.
• Neutral fat globules stained with Sudan may be seen normally at 0 to
2 +.
• Hematoidin crystals are sometimes seen after GI tract hemorrhage.
Muscle fibers:
These are usually light brown. Sometimes it
may show striations.
Meat fibers and muscle fibers are seen in
the stool. Their presence shows defective
indigestion.
The increased amount of meat fibers is
found in:
Malabsorption syndrome.
A pancreatic functional defect like cystic
• Macrophagic cells:
• Thes have numerous inclusions
in the dark staining cytoplasm.
• These need to differentiate
from the intestinal amoebae.
There are large particles in the
cytoplasm.
• The nucleus has no
karyosomes.
• Degenerated macrophagic cells
lost their nucleus and have few
ingested materials.
• Also, the nucleus has a fine
network of chromatin and large
particle scattered.
Summary of the normal stool examination:
Biochemical features
Microscopic findings
Procedures In routine stool examination consists of:
• Direct wet film.
• Saline: Can make a smear with normal saline.
• Check the clarity of the saline solution, microscopically.
• Iodine preparation is used for the identification of the cysts in the stool.
• Keep iodine solution in the dark brown bottles with a tight cap.
• Methanol is used to fix the slide.
• Concentration method.
• Permanently stained slide.
• The stained slide can be preserved by the use of the DPX, permount, or
Hystomount.
• Place a drop of the above preservatives over the stained slide and leave it to
dry.
• After drying remove the excess of the mount.
drawing shows how to make a thin
smear for a permanent stain.