Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka s12

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

PERFORMA FOR REGISTRATION OF SUBJECT OF DISSERTATION

NAME OF THE CANDIDATE : SADIK.K.Y. ADDRESS : M.SC. MLT STUDENT ST. JOHN’S MEDICAL COLLEGE, BANGALORE

COURSE OF STUDY AND : M.SC., MLT (HAEMATOLOGY AND TRANSFUSION SUBJECT MEDICINE)

DATE OF ADMISSION TO : 04.08.2008 THE COURSE

TITLE : ANALYSIS OF CELL PATTERN IN ASCITIC FLUID CYTOLOGY NEED FOR STUDY : The portal hypertension in a person with cirrhosis often causes Ascites which is the accumulation of fluid in the abdominal cavity (1) In advanced cirrhosis the accumulation of fluid in the abdominal cavity and a significant reduction in serum albumin, and renal retension of sodium(2) Half of cirrhotic patients with ascites die within two years . Causes of Ascites(1) o Portal hypertension o Cirrhosis of liver o Peritoneal carcinomatosis o Pancreatic ascites o Hypoalbuminaemia

Laboratory analysis will include 1) Cytological analysis: the total leucocyte and differential count of the inflammatory cells are analyzed Ascites may be due to uncomplicated cirrhosis and spontaneous bacterial peritonitis .To distinguish between these two conditions total white blood cell(WBC) count may be useful . White blood cell (WBC)count over 500/μl (with more than 50% neutrophils) has an estimated specificity of 90% in spontaneous bacterial peritonitis. For diagnosis of spontaneous bacterial peritonitis, absolute neutrophil count with a cut off level of 240-500 neutrophils /μl have been used.(5).Once this cut-off has been reached, antibiotic therapy must be started immediately, without waiting for a culture from ascitic fluid. (4) o Early diagnosis of the aetiological cause is mainly based on the cytological parameters o A high level of precision in these analytical parameters will therefore go a long way in treating and better management of patient. REVIEW OF LITERATURE

The pleural, pericardial, and peritoneal cavities are lined by a single layer of flat or cuboidal mesothelial cells called serosa. Normally these cavities contain only a small amount of fluid, enough to lubricate the adjacent visceral and parietal surfaces as they move over each other with intestinal peristalsis(5).

When there is an increase in the volume of fluid in a cavity this is referred to as an effusion. Aspiration of fluid may be necessary if the fluid is interfering with normal body function. Examination of the fluid may help to determine the cause of the effusion and thus guide appropriate therapy for the condition.(6)

Peritoneal cavity is lined by mesothelial cells and it normally contain up to 50ml of clear, straw coloured fluid . Peritoneal fluid is produced as an ultrafiltrate of plasma and its production is dependent on vascular permeability, hydrostatic pressure and oncotic pressure(2).In diseased condition greater amount of fluid accumulates in the cavity by a process of effusion.(1) The patient with peritoneal effusion is said to have ascities and the fluid is called Ascitic fluid(2) Effusions are classified clinically as transudates or exudates. Transudate results form an imbalance between hydrostatic and oncotic pressure. This occurs in congestive heart failure, cirrhosis, and nephrotic syndrome(7) - Transudate has low specific gravity and low protein concentration(5) - Exudate results from injury to the mesothelium, as with infection, lupus, rheumatoid pleuritis, pancreatitis, radiation or malignant tumours(5) - Exudate has high specific gravity and a high protein content.

Causes of Peritoneal effusion Transudates  Congestive heart failure  Hepatic cirrhosis  Hypo proteinemia (nephrotic Syndrome)

Exudates  Neoplasm  Metastatic carcinoma  Lymphoma  Mesothelioma

Infection  Tuberculosis  Primary bacterial peritonitis,  Secondary bacterial peritonitis (Appendicitis)  Trauma  Pancreatitis  Bile peritonitis(8) The procedure of collecting ascitic fluid is called as abdominal paracentesis(6) INDICATIONS FOR ABDOMINAL PARACENTESIS 1. Intra abdominal hemorrhage due to trauma 2. Acute abdominal pain of unknown etiology, 3. Post operative hypotension 4. Instillation of therapeutic drugs in case of malignant ascitis.

The specimen is divided in to 3 plain tubes  Tube I – cell count and differential count  Tube II – Biochemical examination  Tube III – Microbiological examination Cell count and culture: White cell count and polymorphonuclear (PMN) leucocyte count are useful to detect ascitic fluid infections. A polymorphonuclear count of 250 cells/cmm with growth of bacteria in the absence of external or intraabdominal source of infection are diagnostic for spontaneous bacterial peritonitis. When the culture is negative in patients not treated with antibiotic treatment over one month, it is called culture negative neutrocytic ascites(CNNA), which is an important variant of spontaneous bacterial peritonitis. Another variant of ascitic fluid infection is the monomicrobial non-neutrocytic ascites(MNA) , also known as bacterascites. A lymphocyte predominance indicate peritoneal tuberculosis, or maliganant ascites(9). Diagnosis of spontaneous bacterial peritonitis and its variants, monomicrobial non-neutrocytic bacterascites(MNB) and culture -negative neutrocytic ascites (CNNA) was made as per the following criteria: Spontaneous bacterial peritonitis (SBP) – Growth in asciitic fluid culture and ascitic fluid polymorphonuclear (PMN) count >250 cells / cmm without evidence of an intraabdominal surgically treatable source of infection. Monomicrobial non-neutrocytic bacterascites(MNB)- pure growth in ascitic fluid culture with ascitic fluid polymorphonuclear count < 250 cells/cmm. Culture-negative neutrocytic ascites(CNNA)- no growth in ascitic fluid culture,ascitic fluid polymorphonuclear count at least 250 cells/ cmm.

(10) AIMS AND OBJECTIVES OF THE STUDY  To evaluate the cell count and morphology present in the Ascitic fluid

MATERIALS AND METHODS 100 samples of Ascitic fluid received in the central diagnostic laboratory of St. John’s medical college hospital for analysis during a period of 1 year between 2009- 2010. The following parameters will be assessed 1) Total Count: Done manually with modified Newbeaur’s counting chamber 2) Differential count – The fluid is centrifuged at 1000 rpm for 1 minute and with the sediment a smear is made. After drying the smear, stain it with Leishman stain. A count is made and expressed as percentage Morphology of cells will be evaluated. INCLUSION CRITERIA All the ascitic fluid samples received in the Central Diagnostic Laboratory . EXCLUSION CRITERIA Clotted samples. Samples which recieved after 24 hours . REFERENCES:

1. Jens J.J, Hanne H. Ascites fluid in the abdomen. British Medical Journal 2001(322):416-418.

2. Walter J.B,.Talbot I.C . Hepetic Failure And Jaundice. In: Walter And Israel General Pathology, 7th Edition; Churchill Living Stone: 1996, pp.785-786

3. Landy. J. M. Serous fluid analysis. In: Text book of urinalysis and body fluids, 1St Edition; California: 1998, pp.242-245.

4. Lucia L.B.C, Marcellus H.L ,Alzira M.C , Felipe M.F, Diagnosis of spontaneous bacterial peritonitis in cirrhotic patients in northeastern Brazil by use of rapid urine-screening test. In: Sao Paulo medical journal 2006(124)

5. Edmund.S.C, Berbara.S.D. Plural, pericardial and peritoneal fluids. In: Cytology diagnostic principles, and clinical correlates, 2nd Edition; Boston;2003, pp.119-125.

6. Praful B.G. Cavity fluid. In: Text book of medical laboratory technology; 2nd edition; Mumbai:2007,pp.976-979 7. Leopold .G. K. Anatomy and Histology of the pleural, peritoneal, and the pericardial cavities. In: Diagnostic cytology, 4th edition;Volume II,Newyork:1992, pp.1082-1113.

8. John Bernard Henry M.D. Cerebrospinal Fluid and other bodyfluid. In: Clinical diagnosis and management by laboratory methods; 17th edition; Washington:1998, pp. 483-488.

9. Ibrahim A.A.M, Rashed S.A.R, Ascites : Tips on diaganosis and management In : Saudi journal of gastroenterology 1996(2) : 80-86

10. Agarwal M.P, Choudhury B.R , Banarjee B.D . Ascitic fluid examination for diagnosis of spontaneous bacterial peritonitis in cirrhotic ascites In : Journal of Indian academy of clinical medicine 2008(9)

SIGNATURE OF THE CANDIDATE

NAME AND DESIGNATION OF Dr.SIDDHI G.S . KHANDEPARKAR .MD THE GUIDE T. LECTURER, DEPT. OF CLINICAL PATHOLOGY, ST.JOHN’S MEDICAL COLLEGE HOSPITAL, BANGLORE.

REMARKS OF THE GUIDE

SIGNATURE OF THE GUIDE

Dr.KARUNA RAMESHKUMAR HEAD OF THE DEPARTMENT MD,DCP,PhD. PROFESSOR AND HEAD, DEPT. OF CLINICAL PATHOLOGY, ST.JOHN’S MEDICAL COLLEGE HOSPITAL, BANGLORE.

SIGNATURE