1. Urinalysis and Body Fluids CRg
Welcome to Unit 4 the Serous Body Fluids
Please use your unit course objectives as you study this material.
Unit 4
Serous Body Fluids

2. Serous Fluids Serous fluids
small amount of fluid that lies between the membranes lining the body cavities (parietal) and those covering the organs within the cavities (visceral).
acts as lubricant,
provide nutrients,
remove wastes
Serous fluids - the small amount of fluid that lies between the membranes that line the enclosed body parietal cavities and those covering the organs within.
Serous fluids function as a lubricant, provide nutrients, & remove wastes

3. Serous Fluids Body cavities Membranes
Pericardial - heart
Pleural - lungs
Peritoneal – abdominal
Membranes
Lined with mesothelial cells
Parietal – lines cavity wall
Visceral – covers organs contained within
Serous fluids fill the space between
The Body cavities from which serous fluids are obtained are the
Pericardial cavity which encloses the - heart,
The Pleural cavity where the lungs are housed and the Peritoneal or– abdominal cavity
The Membranes in these cavites are Lined with mesothelial cells
The membrane that lines the cavity wall is called the Parietal membrane and the Visceral membrane – covers organs contained within
Serous fluids fill the space between

4. Serous Fluids “ultra filtrate” of the plasma
closely resembles the plasma (as opposed to CSF)
Appearance
Possible reason / condition
Pale yellow & clear
Normal
White, turbid
WBCs / infection
Bloody
RBCs/ hemorrhage
Milky
Chyle – lymph & emulsified fats
Viscous
Increased hyaluronic acid / malignant mesothelialoma
Unlike the CSF, Serous fluids are an “ultra filtrate” of the plasma and closely resemble it.
The serous fluids are normally pale yellow to yellow and clear.
Turbidity often indicates pus cells, while a bloody appearance is due to a hemmorage
The table is a very brief overview or correlation of the serous fluid appearance with possible causes. - and is certainly not meant to be a complete listing.

5. Serous Fluids
Produced by hydrostatic and oncotic (protein) pressure in the capillaries lining the membranes
Normally produced at a constant rate.
Production (☛ parietal membrane)
Re-absorption (☛ visceral membrane)
Serous fluid is normally Produced at a constant rate by hydrostatic and oncotic / protein pressures in the capillaries lining the membranes
Production occurs – at the cavity wall (☛ parietal membrane) -
And its Re-absorption - occurs at the (☛ visceral membrane) covering the organs contained within. .

6. Serous Fluids Production and re-absorption are influenced by:
Changes in osmotic and hydrostatic pressure in the blood
Concentration of chemical constituents in the plasma
Permeability of blood vessels and the membranes
Serous fluid Production and re-absorption are influenced by:
Changes in osmotic and hydrostatic pressure in the blood
Concentration of chemical constituents in the plasma
Permeability of blood vessels and the membranes

7. Serous Fluids Types of serous fluids Reasons for analysis
Pericardial fluid – around heart
Pleural fluid (thoracic fluid) – lung cavity
Peritoneal (ascitic fluid) – abdominal cavity
Reasons for analysis
Infections
Hemorrhages
malignancies,
and other disorders.
The serous fluid that surrounds the heart is called the Pericardial fluid.
Pleural fluid / thoracic fluid – is from the lung cavity and
Peritoneal / (ascitic fluid) – is from the abdominal cavity
From the laboratory’s perspective, Primary Indications or reasons for analyzing a serous fluids includes
obtaining samples to culture in a suspected Infection
determining presence and extent of a hemorrhage
or cytology evaluation of a malignancy .

8. Serous Fluids Specimen Collection and Handling Needle aspiration
Paracentesis
Thoracentesis
Pericardiocentesis
Lavage ( ie. peritoneal lavage)
Ringer’s lactate / saline is infused into abdomen then retrieved for analysis.
Specimen sometimes called ascites fluid.
The serous fluid is normally collected from a needle aspiration performed by a physician
Needle aspiration
Paracentesis – is the term for the removal of the peritoneal / abdominal fluid;’
Thoracentesis - is the removal of fluid from the thorax or lung cavity and
Pericardiocentesis is removing fluid from around the heart
A similar procedure, called a lavage involves infusing a sterile fluid such as
Ringer’s lactate / saline into the cavity and then retrieving it for analysis.
peritoneal lavage would be the term when the fluid is infused into the abdominal cavity and is probably the most common application.
Specimen sometimes called ascites fluid.

9. Serous Fluids - Composition & Formation
Effusion
an increase in the serous fluid due to some disruption in production &/ re-absorption processes.
Classification of cause of an effusion is aided by determining if the fluid is a “transudate” or an “exudate”.
An Effusion is an increase in the serous fluid due to some disruption in the production or reabsorption processes.
Determining the of cause of an effusion is aided by classifying or determining if the fluid is a “transudate” or an “exudate”.

10. Serous Fluids - Effusion
Transudate
an effusion that is a result of a systemic disorder that disrupts the balance of fluid production / fluid re-absorption.
Examples:
Pleural transudate – congestive heart failure;
Pericardial transudate – nephrotic syndrome, metastatic cancer
The Transudate is an effusion that is a result of a systemic disorder that has disrupted the balance of fluid production / fluid re-absorption.
A hint or clue to remember transudates – is to think about the “trans” part of the transudate. The problem has been transferred from other location.
A problem somewhere else is causing the fluid problem in the cavity
Examples: of transudates are
Pleural transudate – congestive heart failure;
Pericardial transudate – nephrotic syndrome, metastatic cancer

11. Serous Fluids Exudates
term to classify the effusion that is a result of a problem with the membranes themselves.
Produced by conditions that directly involve the membranes of the particular cavity, ex. infections, inflammation, and malignancies
Thought of as an inflammatory process
Exudate examples:
Pleural exudate – carcinoma, pneumonia, trauma
Pericardial exudate – infection, cardiovascular disease (CV) trauma, cancer
Exudates is the term to classify the effusion that is a result of a problem with the membranes themselves.
Exudates are generally Thought of as an inflammatory process
Exudate examples:
Pleural exudate – carcinoma, pneumonia, trauma
Pericardial exudate – infection, cardiovascular disease (CV) trauma, cancer

12. Differentiation Between Transudates and Exudates
CHARACTERISTIC / TEST
TRANSUDATE
EXUDATE
Color
Pale yellow
Any abnormal color
Clarity
Clear
Bloody cloudy, purulent, turbid
Specific gravity
< 1.015
>1.015
Glucose
Equal to serum
Over 30 mg less than serum level
Protein
<3.0 g/dL
>3.0 g/dL
Fluid / serum protein ratio
<0.5
>0.5
Fibrinogen / Spontaneous clotting No
Possible
Fluid / serum amylase
<2.0
>2.0
Fluid / serum bilirubin ratio
<0.6
>0.6
Lactate dehydrogenase
< 60% of serum
> 60% of serum
Fluid/ serum LD ratio
Cell counts (total)
<300/L
>1000/L
Using various resources, I have consolidated information and testing results that are used to differentiate transudate effusions from exudate effusions.
Please take a few minutes to review this table.

13. Serous Fluids Specimen Collection and Handling
EDTA tube for cell count & differential
Heparin tube for chemistries, serology, microbiology and cytology.
Since procedure not performed unless an effusion exists, large amount of fluid often collected.
Blood specimens usually collected at same time and comparisons of test results made.
Specimen Collection and Handling
Serous fluids are not usually obtained unless there is an effusion taking place, therefore there is usually a large amount of fluid collected.
Specimens used for laboratory testing are usually collected into EDTA and heparinized tubes. In addition, a non-additive / clot tube may also be collected to see if the specimen contains enough fibrinogen to form a clot.
The EDTA tube is sent to hematology for the cell count & differential,
The Heparin tubes are used for chemistries, serology, microbiology and cytology studies.
It is important that a Blood specimen is collected at same time so that the results of the chemistry tests of the fluid and serum can be compared.

14. Serous Fluids - Testing overview
Variety of tests used to aid in determining the cause of the effusion
Appearance
Evaluation of clotting ability whether or not it will form a clot, etc.
Cell counts
Protein level
Both fluid and current serum level to make comparison: fluid protein / serum protein
LDH enzymes
Both fluid and current serum level to make comparison: fluid LDH/ serum LDH
Cultures
Serology – rarely done on serous fluids as blood testing is adequate
Cytology / Pathology – if malignancy is suspected.
ATesting overview
A Variety of tests are used to aid in determining the cause of the effusion
The specimens appearance - color, clarity and whether it formed a clot are noted
Cell counts and differenital are performed in the hematology department
And chemistry will perform the evaluation of the proteins and enzymes - such as LDH on both the fluid and the patient’s serum.
Cultures are performed if infection is suspected.
Serology – rarely done on serous fluids as blood testing is adequate
Cytology / Pathology studies will be performed – if malignancy is suspected.

15. Serous Fluids Hematology / Gross examination
Color & clarity
NV = yellow & clear (other terms as for CSF are sometimes used, EXCEPT ‘xanthrochromic’
Cell count
same as for CSF
Differential
any cell in peripheral blood,
mesothelial cells,
malignant cells
Usually the initial evaluation of the serous fluid sample is performed in the hematology department.
The normal serous fluid is yellow & clear
Other terms describing the color and clarity of the fluid are the same as those used for CSF samples: EXCEPT for the term ‘xanthrochromic’ – which is used exclusively for CSF
The Cell count procedure is basically the same as was performed on CSF samples; if a dilution is needed – saline is the diluent of choice.
The differential may include any cell found in peripheral blood, as well as mesothelial cells, and
malignant cells

16. Serous Fluids
1991 CAP CM 20
A CAP survey slide with sketches of some of the cells seen in serous fluids. Included are a mesothelial cell, couple of macrophages / monocytes and a plasma cell at the arrow.

17. Abdominal fluid – plasma cells / multiple myeloma
This aceties fluid is from a multiple myeloma patient and has many other examples of plasma cells.

18. Mesothelial cells
Unique to serous fluids, originate from lining of peritoneal, pleural, and pericardial cavities.
Large round cell with abundant blue cytoplasm and purple nucleus which may be eccentric
Cell sometimes described as having a "fried egg" appearance. - usually are single or may be in sheets
Nucleus round to oval & has a smooth outline, takes 1/3 - ½ of the space.
Smooth spherical nuceoi may be seen.
Mesothelial cells are Unique to serous fluids,
They originate from lining of peritoneal, pleural, and pericardial cavities.
Mesothelials are generally Large round cells with abundant blue cytoplasm and purple nucleus which may be eccentric – or off center
These Cells are sometimes described as having a "fried egg" appearance. –
They are usually found as singles but may be in sheets
Nucleus of the cell is round to oval & has a smooth outline,
The nucleus takes 1/3 - ½ of the space within the cell and may have Smooth spherical nuceoi.

19. Mesothelial cells Pleomorphic
If ‘reactive’ may appear in clusters, have prominent nucleoli and be multinucleated
Nucleus still distinct and round with uniform staining characteristics.
A cluster of reactive mesos may resemble malignant cell clusters, but the mesos display "cell windows."
Mesothelial cells are Pleomorphic - meaning that they can have different appearances.
These cells can become ‘reactive’, appear in clusters, and have prominent nucleoli
- or they may appear to be multinucleated with each Nucleus still distinct and round with uniform staining characteristics.
A cluster of reactive mesos may resemble malignant cell clusters, but the mesos display "cell windows.”
There are several examples of this in this microphotograph, -
look for the cleared areas between the cells in the upper right side and also the lower left.
Reactive mesothelial cells

20. Serous Fluids
Macrophage engulfed Candidia species in a pleural fluid, mesothelial cells.
Here is another example of pleomorphic mesothelial cells – located at on the right side. Note also the macrophage on the left – it has engulfed yeast cells which appear as dark bodies in its cytoplasm.

21. Serous Fluids Malignant cells
A frequent concern in any serous fluid due to possibility of cancer of any organ and/or metastasis of CA from one location to another.
Cells have irregular size, shape, and staining characteristics of nucleus and cytoplasm. Usually deeply basophilic, molded or balled up clusters of cells with little distinction from one cell to the next. May be vacuolated.
Malignancy is frequently the cause of an effusion; therefore finding Malignant cells in the differential is always a possibility. These cells can be from the ‘insitu’ or on-site cancer or may be the result of a metastases of cancer elsewhere in the body . .
There is great variability in the appearance of malignant cells. In general the Cells have irregular size, shape, and staining characteristics of nucleus and cytoplasm.
They are Usually deeply basophilic, and may be molded or balled up clusters of cells with little distinction from one cell to the next and May be vacuolated.

22. Serous Fluids Malignant cells Characteristics
Irregular shape
Uneven chromatin distribution
Prominent large irregular nucleoli,
Community borders
Increased nuclei / cytoplasm ratio.
Always send suspicious cells to cytology / pathology
Malignancy is frequently the cause of an effusion; therefore finding Malignant cells in the differential is always a possibility. These cells can be from the ‘insitu’ or on-site cancer or may be the result of a metastases of cancer elsewhere in the body . .
There is great variability in the appearance of malignant cells.
In general malignant Cells have irregular size, and shape, They are Usually deeply basophilic, and may be molded or balled up clusters of cells with little distinction from one cell to the next and May be vacuolated.
Their nucleus often has an uneven chromatin distribution, and prominent large irregular nucleoli .
Always send slides with suspicious cells to cytology / pathology
The next series of slides are examples of malignant cells. Remember we are not training cytologist, but you should begin to acquire some knowledge regarding what the ‘unclassified ‘or ‘other’ cells look like – so you can take them to the pathologist for further evaluation.
The pictures and information on the next couple of slides came from ASCP survey case study materials.

23. Serous Fluid Malignant cells
ACSP 7, Case 1 peritoneal fluid, malignancy
I have no narration for the next 5 slides and placed all of the information I have about them on the sides themselves.
Please evaluate these microphotographs to observe the abnormal characteristics of the cells.

24. Serous Fluid Malignant cells
ASCP 9 Case 2 pleural fluid 42 year old, breast cancer

25. Serous Fluid Malignant cells
ASCP 10 Case 3, ascitic fluid, 62 year old admitted for GI bleeding

26. Serous Fluid Malignant cells
ASCP 12 Case 4, 30 year old with back pain and inability to work. Pleural effusion fluid – malignant tumor on spinal cord

27. Serous Fluid Malignant cells
sheets of atypical cells with irregular nuclear contours, nuclear hyperchromasia, basophilic cytoplasm, and jagged outline of cell borders.
Squamous cell carcinoma (x400 , Diff-Quik staining)

28. Serous Fluids-LE cells
Seen in patients with Systemic Lupus Erythmatosis (SLE) a systemic disease in which an autoantibody attacks the patients organs and body systems
LE cell is a neutrophil that has engulfed a homogeneous mass of purple staining nuclear material
The LE cell is sometimes seen in patients with Systemic Lupus Erythmatosis (SLE) a systemic disease in which an autoantibody attacks the patients organs and body systems
LE cell is a neutrophil that has engulfed a homogeneous mass of purple staining nuclear material \
The microphotograph on This slide is also an from an ASCP case study set.

29. Serous Fluids Chemistry
Total protein, and ratio to serum protein
LDH and ratio to serum LDH
Glucose
Amylase & Lipase – pancreatic disorders
Bilirubin - peritoneal fluid
suspicion of perforated GI or gall bladder
Alkaline phosphatase - peritoneal fluid
suspicion of perforated intestine
pH & ammonia
Chemistry tests ordered on serous fluids vary greatly depending on the diagnosis or suspected problem.
Total protein and the enzyme LDH are generally performed on both the fluid and the patients serum,
The information obtained from these test are then used to form a ratio between the serum and fluid
Serous fluid Glucose levels are usually similar to those in the patient’ serum.
Amylase & Lipase - like LDH are enzymes. These enzymes provide information about pancreatic disorders
Bilirubin test and alkaline phosphatase (another enzyme) may be ordered on peritoneal fluid when there suspicion of perforated intestine or gall bladder
Serous fluid pH & ammonia levels are occasionally ordered as well.

30. Serous Fluids Microbiology Gram stain & acid fast
Cultures – aerobic & anaerobic
If an infection is suspected, aerobic and anaerobic cultures are ordered.
Gram stain and acid fast stain of the fluids are also routinely performed.

31. Serous Fluids – pericardial fluid
1987 CAP CM21 Pericardial fluid, intracellular bacteria
This is a great microphotograph of peritoneal fluid from a 1987 CAP survey .
At the arrow is a cell with obvious intracellular bacteria.

32. Serous Fluids – peritoneal fluid
1992 CAP CM41 Peritoneal fluid. Seg, macro, yeast
This is a microphotograph from a 1992 CAP survey set.
This peritoneal fluid differential demonstrated numerous segmented neutrophils , some macrophages - including the one at the arrow and ….most significantly yeast which are seen in the lower left –as the elongated dark purple structure at about 7 o clock and in the upper right at about 1 o'clock on the picture.

33. Serous Fluids Quality control no commercial controls
use serum controls.
Since serous fluids are so similar in composition to serum, there are no commercially prepared special controls. So laboratories use serum controls during the testing procedures.

34. Summary Serous fluids are serum-like ultrafiltrates of plasma
Volumes are maintained by tissue and capillary pressures
Effusions are excessive accumulations of fluids – and can occur in the pericardium, pleural and abdominal cavities.
Laboratory testing is required to differentiate exudates from transudates.
Various causes contribute to the accumulation of fluids in the serous body cavities.
Laboratory testing
Hematology (physical properties, cell counts and differential)
Chemistry (serum &fluid values are compared. QC is same as for serum)
Serology – rarely
Cytology – if suspicious cells are seen during differential
In summary
Serous fluids are serum-like ultrafiltrates of plasma
Volumes are maintained by tissue and capillary pressures
Effusions are excessive accumulations of fluids – and can occur in the pericardium, pleural and abdominal cavities.
Laboratory testing is required to differentiate exudates from transudates.
Various causes contribute to the accumulation of fluids in the serous body cavities.
Laboratory testing involves the hematology and chemistry department
Slides containing suspicious appearing cells must be evaluated by the cytologist or pathologist.
This concludes the serous fluid session of Unit 4.
Hematology (physical properties, cell counts and differential)
Chemistry (serum &fluid values are compared. QC is same as for serum)
Serology – rarely
Cytology – if suspicious cells are seen during differential