HMCL223 Clinical Diagnostic Techniques
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1 HMCL223 Clinical Diagnostic Techniques Session 8: Stool Testing Endeavour College of Natural Health endeavour.edu.au 1
2 Session Objectives Stool Testing o GIT integrity, inflammation and immunity o Culture growth and antimicrobial sensitivity o Genetic/PCR testing o Parasites Endeavour College of Natural Health endeavour.edu.au 2
3 Stool Analysis o Stool studies are used to evaluate the function and integrity of the small and large intestine, and to a lesser degree, other digestive processes within the stomach, liver, gall bladder and pancreas. o Stool represents the waste products of digested food, bile, mucous, shed epithelial cells, bacteria and inorganic salts. o The colour, form, consistency and digestive markers of faeces may provide an important insight into various conditions such as maldigestion, malabsorption, inflammation or infection. (Pagana & Pagana, 2014) Endeavour College of Natural Health endeavour.edu.au 3
4 Stool Analysis Symptoms which could indicate the need for stool analysis: o Diarrhoea, Constipation, Fluctuating bowel movement consistency o Indigestion or undigested food particles o Gas and bloating o Pale floaty stool o Frank blood o Dark and/or offensive smelling stool o Abdominal pain o Unexplained weight loss (Pagana & Pagana, 2014) Endeavour College of Natural Health endeavour.edu.au 4
5 GIT integrity, inflammation and immunity Endeavour College of Natural Health endeavour.edu.au 5
6 Faecal Calprotectin Endeavour College of Natural Health endeavour.edu.au 6
7 Stool: Integrity, Inflammation & Inflammatory Bowel Disease Immunity o Faecal calprotectin is a stool test. o The protein S100A12 related to faecal caiprotectin (sensitivity marker for gut inflammation) is elevated in children with IBD. o Levels are used to assess degree of inflammation. o This can be used to reduce the number of endoscopy & colonoscopy procedures required for children. (Labtests online, 2015) Endeavour College of Natural Health endeavour.edu.au 7
8 Faecal Occult Blood Endeavour College of Natural Health endeavour.edu.au 8
9 Stool: Integrity, Inflammation & Faecal Occult Blood Test Immunity o Blood in the stool can be visible / frank (distal large intestines or the anus), or unseen / occult (stomach, small intestines, proximal end of the large intestines). The tests look for haem or globulin. o NB: chronic & prolonged occult blood loss develop irondeficiency anemia. (Labtests online, 2015) Endeavour College of Natural Health endeavour.edu.au 9
10 Stool: Integrity, Inflammation & Immunity Faecal Occult Blood: Positive reading Drugs that may cause false positive results include colchicine, iron, oxidizing drugs (e.g. iodine, bromides, boric acid) and rauwolfia alkaloid derivatives (used in the treatment of hypertension) Ingestion of red meat within the 3 days before testing (red meats contain animal haemoglobin) Bleeding gums post dental procedure Ingestion of fish, turnips, and horseradish. Peroxidase rich vegetables. Drugs causing GI bleeding: anticoagulants, aspirin, colchicine, iron preparations (large doses), NSAIDs, steroids Faecal Occult Blood: Negative Reading False negative: bleeding in the upper GIT has the globulin digested as it descends through the intestines False negative: taking vitamin C supplements (Pagana & Pagana, 2014) Endeavour College of Natural Health endeavour.edu.au 10
11 Complete Digestive Stool Analysis (CDSA) Endeavour College of Natural Health endeavour.edu.au 11
12 Stool: Integrity, Inflammation & Immunity Complete Digestive Stool Analysis (CDSA) o Functional tests that overviews the digestion, absorption, intestinal function & microbial flora. Pathogenic bacteria, parasites & yeasts can also be identified. o Level 1: bacteriology, yeast & parasites o Level 2 & 3: level 1 & SCFA & biochemical markers o Level 4 & 5: Levels 1-3 parasitology & 3 day & sensitivity NB: Levels 1-3 requires 1 stool collection and levels 4 & 5 require 3 day consecutive collection (Nutripath, 2016) Endeavour College of Natural Health endeavour.edu.au 12
13 Stool: Integrity, Inflammation & Immunity Complete Digestive Stool Analysis (CDSA): General Components o Macroscopic examination colour, form and consistency o Microscopic examination mucous, pus, food fibres, fat o Digestive markers ph, pancreatic elastase, valerate and iso-butyrate (protein digestion) o Metabolic markers SCFAs, butyrate, propionate, acetate o Absorption markers cholesterol, long chain fatty acids o Microbiology bacteriology, parasitology and mycology (Healthscope, 2011) Endeavour College of Natural Health endeavour.edu.au 13
14 Stool: Integrity, Inflammation & Immunity CDSA Stool ph: Alkaline Faeces is normally alkaline note that the distal small bowel and the large bowel have a far greater influence on stool ph than the stomach and proximal small bowel where stool composition is finalized Indicative of: inadequate dietary fibre, dysbiosis, hypochlorhydria or increased ammonia production in the GIT (meat putrefaction) CDSA Stool ph: Acidic Indicative of: digestive problem such as lactose intolerance, increased SCFA production (constipation), a rapid transit time or an infection such as E. coli or Rotavirus. (Healthscope, 2011) Endeavour College of Natural Health endeavour.edu.au 14
15 Stool: Integrity, Inflammation & Immunity Complete Digestive Stool Analysis (CDSA): Short Chain Fatty Acids (SCFA) o SCFA (acetate, propionate from non-starch sources, butyrate from starch). o These 3 SCFAs represent 75% of total SCFA in colon. o Stool levels reflect fermentation of SCFAs in the large bowel to a greater degree than that in the small bowel. o The ratios of the various SCFAs remain relatively constant in the healthy gut, but become imbalanced in certain disease states i.e. dysbiosis. (Healthscope, 2011) Endeavour College of Natural Health endeavour.edu.au 15
16 Stool: Integrity, Inflammation & Total SCFA Decreased production: o Prebiotic deficiency (lack dietary fibre) o Probiotic numbers low (deficiency dysbiosis) o Probiotic function low (high ph) Increased Consumption: o Slow transit time / constipation Valerate / Iso-butyrate Decreased production: o malabsorption (especially if other indicators of malabsorption) Immunity Total SCFA Increased Production: o Small bowel bacterial overgrowth o Maldigestion (increased substrate for fermentation) Decreased Consumption: o Rapid transit time / diarrhoea Valerate / Iso-butyrate Increased Production: o increased bacteria fermenting (bacterial overgrowth: compete with host for food) o increased protein / amino acids to ferment (protein maldigestion, hypochlorhydria, pancreatic insufficiency) Endeavour College of Natural Health endeavour.edu.au 16 (Healthscope, 2011)
17 Chymotrypsin Endeavour College of Natural Health endeavour.edu.au 17
18 Stool: Integrity, Inflammation & Immunity Chymotrypsin o Chymotrypsin is a proteolytic enzyme produced by the exocrine pancreatic cells (acinar), that acts in the duodenum to break down the peptide bonds in proteins. o Although not a common test, where protein maldigestion is suspected chymotrypsin may be helpful in determining gut motility and pancreatic digestive function. o The level of chymotrypsin seen in the stool is a reflection of the balance between production (from pancreas) and consumption (intestinal absorption). (RCPA, 2015) Endeavour College of Natural Health endeavour.edu.au 18
19 Stool: Integrity, Inflammation & Immunity Decreased Chyotrypsin Increased Consumption: o Slow gut motility ( absorption) Decreased Production: o Chronic pancreatitis o Pancreatic insufficiency o Hypochlorhydria Elevated Chymotrypsin Decreased Consumption: o Rapid gut motility ( absorption) Increased Production: o Acute pancreatitis o Pancreatic hypersecretions (rare) (RCPA, 2015) Endeavour College of Natural Health endeavour.edu.au 19
20 Faecal Fat Endeavour College of Natural Health endeavour.edu.au 20
21 Stool: Integrity, Inflammation & Faecal Fat Immunity o Measures fat content in stool & confirm the diagnosis of steatorrhea related to fat maldigestion or malabsorption. o Steatorrhea presents with large, greasy, pale and foulsmelling stools. o Three days prior to faecal collection, clients need to limit their fat intake to about 100g/day (adults) for 3 days prior to the fecal collection. They will then need to collect the entire amount of all bowel motions over the next 3 days. (RCPA, 2015; Pagana & Pagana, 2014) Endeavour College of Natural Health endeavour.edu.au 21
22 Stool: Integrity, Inflammation & Faecal Fat Immunity o Children (especially breastfed infants) have a high fat diet and an immature digestive tract so a low level steatorrhea is normal. o Due to this, a fat retention coefficient is used to determine the difference between ingested fat and fecal fat when reporting results. The fat retention coefficient should be at least 95%. A lower value indicates pathologic steatorrhea. (Pagana & Pagana, 2014) Endeavour College of Natural Health endeavour.edu.au 22
23 Stool: Integrity, Inflammation & Immunity Faecal Fat: Results & Clinical Significance o Malabsorption: due to sprue, celiac disease, Whipple disease, Crohn disease, or radiation enteritis. o Maldigestion: due to obstruction of the pancreatobiliary tree (e.g. cancer, stricture, gallstones), impaired synthesis of bile or pancreatic lipase. Cystic fibrosis: mucous plugs within the pancreatic duct o Short-gut syndrome secondary to surgical resection, surgical bypass, or congenital anomaly. (Pagana & Pagana, 2014) Endeavour College of Natural Health endeavour.edu.au 23
24 Stool: Culture growth and antimicrobial sensitivity Endeavour College of Natural Health endeavour.edu.au 24
25 Stool: Culture Growth & Sensitivity Stool Culture o Detects higher than normal numbers & identifies bacteria, fungi & / or yeast. Identifies a new infestation. Signs & Symptoms Warranting investigation Ongoing diarrhoea, fever, abdominal bloating: Post antibiotics Overseas travel Infants or children Immuno-compromised clients Pet owners Organisms Bacteria (Salmonella, Shigella, Campylobacter, certain types of Escherichia coli [E. coli], or Yersinia enterocolitica Enterococcus, Proteus, Psuedomonas, Staphylococcus aureus) grow in the culture. Fungi (Candida albicans) or Protozoan parasites (Giardia lamblia) Worms: Ascaris (hook worm), Strongyloides (tapeworm) are found. (Pagana & Pagana, 2014) Endeavour College of Natural Health endeavour.edu.au 25
26 Stool: Culture Growth & Sensitivity Stool Culture Collection o One specimen is usually required from each bowel motion: (up to 3 samples over 3 days may be required) (Pagana & Pagana, 2014) Endeavour College of Natural Health endeavour.edu.au 26
27 Clostridium difficile Endeavour College of Natural Health endeavour.edu.au 27
28 Clostridium difficile Stool: Culture Growth o Clients presenting with profuse watery diarrhea (can lead to severe dehydration requiring IV fluids), severe abdominal pain & fever while on broad-spectrum antibiotics or presenting in immuno-compromised individuals. o Depression of the normal bowel flora can rarely result in a bacterial overgrowth. The clostridial toxins can cause mild to severe inflammation and necrosis of the colonic epithelium (psuedomembranous colitis) which can be potentially life threatening. (Pagana & Pagana, 2014; RCPA, 2015) Endeavour College of Natural Health endeavour.edu.au 28
29 Stool: Culture Growth o Clostridium difficile is a significant problem in health-care facilities where broad-spectrum antibiotic use is common (hospitals, nursing homes) especially in elderly & immuno-compromised patients. o Strict infection control practices must be adhered to when in contact with any person believed to have an active C. diff infection. o Stool culture requires 48 hours but is identified quickly. Can also be diagnosed by obtaining colonic-rectal tissue biopsy (uncommon). (Pagana & Pagana, 2014; RCPA, 2015) Endeavour College of Natural Health endeavour.edu.au 29
30 Stool: Genetic/PCR testing Endeavour College of Natural Health endeavour.edu.au 30
31 Stool: Genetic/PCR testing Familial Polyposis Coli test o PCR testing to identify the dominant inherited disorder characterized by polyp growth within the colon. o Untreated, 100% of clients with the condition will present with colorectal cancer by years old. Clinical presentations: o 75-80% familial history of polyps & / or colorectal cancer at 40yo. or younger. o Unexplained rectal bleeding, diarrhoea, abdominal pain. o Potential link between Familial Polyposis Coli & type II diabetes mellitus. (Labtests online, 2012; Medscape, 2015) Endeavour College of Natural Health endeavour.edu.au 31
32 Stool Parasites Endeavour College of Natural Health endeavour.edu.au 32
33 Stool Parasites Ova & Parasite Examination (OCP) o Individuals presenting with diarrhoea & colitis (including immunocompromised patients), unexplained anaemia or eosinophilia & / or unexplained perianal pruritis. o Up to three specimens of stool for identification of protozoa and amoeba, helminths & ova. (RCPA, 2015) (RCPA, 2015, O&P or OCP, viewed 22/08/ Endeavour College of Natural Health endeavour.edu.au 33
34 Stool Analysis Checklist Endeavour College of Natural Health endeavour.edu.au 34
35 Stool Analysis Checklist Endeavour College of Natural Health endeavour.edu.au 35
36 Stool Analysis Checklist Endeavour College of Natural Health endeavour.edu.au 36
37 References Labtestsonline (2015). Retireved from Lord, R.S. & Bralley, J.A. (Eds.). (2012). Laboratory evaluations for integrative and functional medicine. (2 nd ed.). Duluth, Georgia; Metametrix institute. Pagana K.D. & Pagana, T.J. (Eds.). (2014). Mosby s manual of Diagnostic and Laboratory tests (5 th ed.). Missouri, USA; Elsevier Royal College of Pathologists of Australasia, 2015, RCPA Manual. Retrieved from Manual/Home) Medscape (2015). Familial Adenomatous Polyposis Retrieved from Endeavour College of Natural Health endeavour.edu.au 37
38 COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 WARNING This material has been reproduced and communicated to you by or on behalf of the Australian College of Natural Medicine Pty Ltd (ACNM) trading as Endeavour College of Natural Health, FIAFitnation, College of Natural Beauty, Wellnation - Pursuant Part VB of the Copyright Act 1968 (the Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice. Endeavour College of Natural Health endeavour.edu.au 38
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