Blood fraction red blood cell count (RBC): Measures the number of red blood cells in a unit volume of blood. [Counting method] Microscopic counting method: after diluting the blood with isotonic diluent to a certain number of times (generally 200 times), drop it into a blood cell counting disc, and then count the number of red blood cells within a certain range under a microscope, and obtain it after conversion The number of red blood cells per liter of blood.
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Calculation: number of red blood cells/L=red blood cells in 5 squares×5×10×200×10^6/L 【Reference value】
Adult male: (4. 0~5. 5) ×10^12/L, adult female: (3. 5~5. 0) ×10^12/L; newborn: (6. 0~7. 0) Anemia can be diagnosed when ×10^12/L is lower than 3.5×10^12/L, and blood transfusion should be considered if it is lower than 1.5×10^12/L.
【Clinical Significance】
1. Pathological increase
Relative increase: Plasma water loss, relative increase in formed components, no change in absolute value
Absolute increase: secondary (heart, lung disease, abnormal hemoglobinopathy, certain tumors, etc.); primary (polycythemia vera)
2. Pathological reduction
Low bone marrow hematopoietic function (aplastic anemia); lack of hematopoietic raw materials (iron deficiency anemia, megaloblastic anemia); increased red blood cell destruction (anemia); excessive red blood cell loss
Hematocrit (HCT/PCV): Refers to the volume percentage of red blood cells in whole blood.
【Reference value】(Wen's method)
①Adults: 0.40-0.50 for males, 0.37-0.48 for females; ②Newborns: 0.47-0.67; ③Children: 0.33-0.42.
【Clinical Significance】
Increased: 1. Hemoconcentration; 2. Polycythemia; 3. Newborns. Reduce: 1. Anemia; 2. Thin blood of other causes
Application: 1. Curative effect observation; 2. Calculation of red blood cell index
Hemoglobin (Hb): It is a binding protein containing pigment prosthetic groups synthesized in human nucleated red blood cells and reticulocytes, and is a transport protein in red blood cells.
【Detection principle】
After the blood is hemolyzed in the hemoglobin conversion solution, all kinds of hemoglobin except SHb can be oxidized into methemoglobin (Hi) by potassium ferricyanide, and Hi and the cyanide root (CN-) of potassium cyanide generate stable brown-red ferricyanide Hemoglobin (HiCN), HiCN has an absorption peak at 540nm. Under specific experimental conditions, absorbance can be measured and Hb (G/L) can be calculated. However, in actual work, the spectrophotometer in the general laboratory cannot meet the standard conditions stipulated by WHO, so the standard curve is prepared by using the Hb reference solution, and the Hb (G/L) is converted.
【Reference】
Adult male: 120-160 g/L, adult female: 110-150 g/L; newborn: 170-200 g/L
Men over 70 years old: 94.2-122.2 g/L; Women over 70 years old: 86.5-111.8 g/L
[Related] Anemia (anaemia): Red blood cells, hemoglobin, and hematocrit per unit volume of circulating blood are lower than the lower limit of the reference value, which is called anemia.
Clinically, hemoglobin is usually used as the standard:
Mild anemia: male <120g/L, female <110g/L, >90g/L;
Moderate anemia: 90~60 g/L; severe anemia: 60~30 g/L; extreme anemia: <30 g/L;
Below 45g/L blood transfusion should be considered.
Reticulocyte (RET): It is a transitional (immature) red blood cell between late immature red blood cells after denucleation and fully mature red blood cells, slightly larger than mature red blood cells, and the residual basophilic substance RNA in the cytoplasm is detected by basic dyes After vital staining, blue or purple dot-like or silk-like precipitates are formed, hence the name.
[Type] ①corolla type (0): in bone marrow; ②spherical type (I): in bone marrow; ③network type (II): in bone marrow; ④broken mesh type (III): visible in peripheral blood; ⑤spot Granular type (IV): the most common in peripheral blood
[Counting method] Microscopic counting method: (living staining)
dye
Huang tar orchid: Commonly used, good dyeing effect, but more sediment.
New methylene blue: recommended by WHO, the staining effect is good, but the reagent is expensive.
experiment method
Test tube method: the dyeing time is long (30min), the effect is good, and it is easy to count repeatedly.
Slide method: the staining time is short, the water is easy to evaporate, and the result is low.
Thin sections were made without restaining, and the number of Ret in 1000 RBCs was counted under the oil immersion immersion microscope (reduced field of view method or Miller peep disk).
【Reference value】Adult: 0.005~0.015 or (24-84)×10^9/L; Child: 0.02~0.06
【Clinical Significance】
1. Reflect the hematopoietic function of the bone marrow
Ret增高：骨髓生长旺盛，溶血性贫血时高达0.2以上；急性失血5~10d，Ret升高明显，2周后恢复；巨幼贫、缺铁贫时轻度升高；慢性失血时Ret持续增高。
Ret下降：造血机能减弱。再生障碍性贫血：治疗后增高不明显，低于0.005。如低于15ⅹ10^9/L可作为 急性再障 的诊断指标。
2. 疗效判断和治疗性试验的观察指标
缺铁性贫血、巨幼细胞性贫血病人在治疗前，Ret仅轻度升高（正常or轻度减少）。给予相应药物，Ret的升高先于红细胞之前，在用药3~5d后Ret升高，7~10d达高峰，2周后，Ret下降，Hb和RBC才开始升高。
3、放/化疗/骨髓移植 后监测：观察骨髓恢复造血的情况
网织红细胞生成指数（RPI）=（被测HCT * 被测Ret%）/（正常人HCT * Ret成熟天数）
红细胞平均容积(MCV)：指每个红细胞平均体积的大小，以飞升(fl)为单位。
红细胞平均血红蛋白含量(MCH)：指每个红细胞内平均所含血红蛋白的量，以皮克(pg)为单位。
红细胞平均血红蛋白浓度(MCHC)：指平均每升红细胞中所含血红蛋白浓度，单位为(g/L)
【计算】
手工法：MCV=HCT/RBC；MCH=Hb/RBC；MCHC=Hb/HCT；
血液分析仪法：MCH=Hb/RCB；MCHC=Hb/（RBC*MCV）。
血细胞沉降率（ESR）：是指红细胞在一定条件下沉降速度，简称血沉。
血沉（仪器法）分三个阶段：①红细胞缗钱样聚集期，约10min；②红细胞快速沉降期（聚集减弱，以恒定速度下沉，约40min）；③红细胞堆积期。约10min。
【参考值】（魏氏法）
男：＜15mm/h ；女：＜20mm/h。
【临床意义】
一、ESR增快：＞25mm/h 轻度↑、 50mm/h 中度↑、＞50mm/h 重度↑。
生理性增快：①妇女月经期；②妊娠＞3月；③＞60岁的高龄者；④女比男快；晚比早快；热天比冷天快；④过劳、紫外线、X线、服用鸦片等ESR增快
Pathological acceleration: ① Various inflammations: bacterial acute inflammation, rheumatic fever, tuberculosis; ② Tissue damage and necrosis: ESR ↑ 3-4 days after the onset of myocardial infarction, lasting 1-3 weeks; angina pectoris ESR is normal. ③ Malignant tumor ESR ↑, benign tumor ESR is mostly normal; malignant tumor treatment is effective ESR ↓, metastasis and recurrence is ESR ↑. ④ Hyperglobulinemia caused by various reasons: subacute infective endocarditis, kala-azar, SLE, chronic nephritis, liver cirrhosis, multiple myeloma, macroglobulinemia; ⑤ anemia; ⑥ hypercholesterolemia :
Two, ESR slow down: dehydration concentration, polycythemia vera, DIC.
Spotted erythrocytes: a kind of immature erythrocytes that are damaged during development, and the remaining denatured basophilic RNA in the cytoplasm appears blue granules of various sizes and shapes during Wright staining. Normally not more than 0.0003 (0.03%).
【Clinical Significance】
When heavy metals such as lead, bismuth, silver, mercury, nitrobenzene, and aniline are poisoned, the number of stippling red blood cells increases significantly. In hemolytic anemia, pernicious anemia, sideroblastic anemia, leukemia and malignant tumors, the number of stippling red blood cells can also increase.
Platelet count (PLT)
【Reference value】(100～300)×10^9/L
When it drops to (20~50)×10^9/L, there may be mild bleeding or bleeding after surgery; if it is lower than 20×10^9/L, there may be severe bleeding; if it is lower than 5×10^9/L May cause severe bleeding.
【Clinical Significance】
1. Pathological thrombocytopenia: ①Thrombocytopenia (acute leukemia, aplastic marrow tumor, radiation injury, megaloblastic anemia); ②Increased platelet destruction (hypersplenism, systemic lupus erythematosus, idiopathic thrombocytopenic purpura); ③ Increased platelet consumption (DIC, thrombotic thrombocytopenic purpura); ④ abnormal platelet distribution (splenomegaly, hemodilution); ⑤ congenital.
2. Pathological thrombocytosis: ①Myeloproliferative disease; ②Acute hemorrhage, acute hemolysis; ③After surgery/splenectomy; ④Infection and inflammatory disease; ⑤Tumor; ⑥Others.
White blood cell count: similar to red blood cell count
【Counting method】Microscopic counting method
Dilute the blood with dilute acetic acid and destroy the red blood cells. After mixing, drop it into a counting plate, count the number of white blood cells within a certain range under a microscope, and calculate the total number of white blood cells per liter of blood after conversion.
【Reference】
Adult: (4-10)×10^9/L; Newborn: (15-20)×10^9/L; June-2 years old: (11-12)×10^9/L.
【Clinical Significance】
When the total number of white blood cells is higher than the normal value (10×10^9/L for adults), it is called leukocytosis, and if it is lower than the normal value (4×10^9/L for adults), it is called leukopenia. The critical value of its reduction is usually set at (4-2.5)×10^9/L, and it is definitely abnormal if it is lower than 2.5×10^9/L.
The clinical significance of the change in the total number of white blood cells is basically the same as that of the change in the number of neutrophils, but the specific situation should be analyzed in detail.
1. Physiological changes
Age: Neonatal WBC rises, generally at 15×10^9/L; it drops to about 10×10^9/L in 3 to 4 days; it approaches adult level after 3 months.
Exercise, Pain, and Emotional Effects: During intense exercise, pain, and agitation, WBC ↑↑, dominated by N, is the result of re-deployment of circulating and limbic pool cells.
Diurnal changes: WBC is lower when resting and resting, higher after activities and eating, higher in the afternoon than in the morning, and the highest value within a day is about 1 to 2 times the lowest value.
Pregnancy and childbirth: Pregnancy > 5 months, WBC ↑ (12~17) × 10^9/L, pain and birth trauma during childbirth may be higher, and return to normal about 2 weeks after delivery without complications.
White blood cell differential count
[Technical method] Microscope visual classification and counting method
The specimens were made into blood smears, stained by Wright, classified and counted one by one according to the morphological characteristics of white blood cells under a microscope, and the relative ratios (or percentages) of various white blood cells were obtained, and the changes in their shape and quality were observed.
Instrumental methods are now used clinically.
[Reference interval (adult)]
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【Clinical Significance】
1. The total number of white blood cells and neutrophils: The reference standards for the total number of white blood cells and the number of neutrophils increase and decrease are shown in Table 2-45.
In peripheral blood, since neutrophils account for 50% to 70% of the total number of white blood cells, the increase or decrease in their number can directly affect the changes in the total number of white blood cells. Therefore, the clinical significance of the changes in the total number of white blood cells is basically the same as that of the changes in the number of neutrophils.
1. Physiological changes of white blood cells or neutrophils: The physiological increase of white blood cells or neutrophils is generally temporary, and can return to normal after removing the influencing factors. Physiological fluctuations in the number of white blood cells are large, and the fluctuation of white blood cell count results within 30% is meaningless. Only regular and continuous observation can have diagnostic value. The significance of the physiological changes of neutrophils is shown in Table 2-46.
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2. Pathological increase of neutrophils: There are many reasons for pathological increase of neutrophils, which can be roughly classified into two categories: increased reactivity and increased abnormal proliferation.
In addition, certain drugs can also cause neutropenia, such as acetylcholine, steroids, digitalis, epinephrine, histamine, heparin, potassium chloride, lithium, lead, etc.
(1) Increased reactivity: It is caused by the body's stress response to various pathological factors, mobilizing the release of granulocytes from the bone marrow storage pool and (or) the release of granulocytes from the marginal pool into the circulation pool. The causes of increased white blood cell (neutrophil) reactivity are shown in Table 2-47.
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We all know that acute infection is the most common cause of neutropenia, and the degree of increase is related to the type of pathogen, the site of infection, the scope and severity of infection, and the reactivity of the body.
(2) Hyperplastic hyperplasia: it is a hematopoietic stem cell clonal disease, which is caused by a large number of abnormal hyperplasia of granulocytes in hematopoietic tissues and released into the peripheral blood. The increased granulocytes are mainly pathological granulocytes or immature granulocytes, often accompanied by Other cellular changes, such as an increase or decrease in red blood cells or platelets.
Dysplastic increases are seen mainly in:
① Leukemia: Malignant tumor of the hematopoietic system, caused by a large number of abnormal proliferation of pathological leukocytes in the hematopoietic tissue and released into the peripheral blood. Common in acute myeloid leukemia (acute myeloid) and chronic myeloid leukemia (CML).
②Myeloproliferative neoplasms (MPN): formerly known as myeloproliferative diseases (MPD), it is a group of diseases caused by pluripotent stem cell lesions. In fact, CML also belongs to this category of diseases. In addition to CML, this type of disease also includes polycythemia vera (true red), essential thrombocythemia, and primary myelofibrosis.
3. Pathological reduction of neutropenia: There are many reasons for neutropenia (Table 2-50).
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Among physical and chemical factors, drug-induced neutropenia is the most common (Table 2-51), with an annual incidence of about (3-4)/10^6, accounting for about 10% in children and young patients, and about 10% in elderly patients Accounted for 50%.
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[related noun]
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1. Left shift of neutrophil nuclei: cells with more than 5% rod-shaped nuclei in peripheral blood and (or) cells before the appearance of rod-shaped nuclei are left-shifted. It is common in purulent infection, acute hemolysis, and application of cytokines, etc., and is often accompanied by toxic changes such as toxic particles, vacuole formation, and degeneration. The left shift of the nucleus is accompanied by an increase in the total number of white blood cells, but it can also be normal or even reduced.
①Regenerative nuclear left shift: left nuclear shift accompanied by an increase in the total number of white blood cells is called regenerative left shift, which indicates that the bone marrow has strong hematopoietic function and release ability, and the body's resistance is strong.
②Degenerative left shift: left nuclear shift accompanied by normal or reduced total number of white blood cells is called degenerative left shift, which indicates that the release function of bone marrow is inhibited and the body's resistance is poor.
核左移分为轻、中、重度三级，与感染的严重程度和机体的抵抗力密切相关。
2、中性粒细胞核右移：外周血中性粒细胞五叶核以上者超过3％称为核右移。
严重核右移常伴有白细胞总数减少，提示骨髓造血功能衰退，与缺乏造血物质、DNA合成障碍和骨髓造血功能减退有关。核右移常见于巨幼细胞性贫血、内因子缺乏所致的恶性贫血、感染、尿毒症、MDS等，应用抗代谢药物治疗肿瘤时也会出现核右移。
二、嗜酸性粒细胞
【参考区间】（0.05～0.50）×10^9/L，0.5%~5%。
【临床意义】
1、生理性变化
①日间变化：健康人早晨的嗜酸性粒细胞较低，夜间较高；上午波动大，波动可达40%，下午较恒定。
②运动和刺激：劳动、运动、饥饿、冷热及精神刺激等，均可引起交感神经兴奋，使血液中的嗜酸性粒细胞减少 。
2、嗜酸性粒细胞增多： 嗜酸性粒细胞增多是指成人外周血液嗜酸性粒细胞绝对值大于0.5×10^9/L。
①轻度增多：（0.5～1.5）×10^9/L。 ②中度增多：（1.5～5.0）×10^9/L。 ③重度增多：大于5.0×10^9/L。引起嗜酸性粒细胞增多的原因及可能机制见表2-58。
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某些药物也可以引起嗜酸性粒细胞增多。
2、嗜酸性粒细胞减少： 嗜酸性粒细胞减少是指成人外周血液嗜酸性粒细胞绝对值小于0.05×10^9/L。其临床意义主要有：
①用于观察急性传染病的病情及预后判断。
②作为观察预后的指标。
③判断垂体或肾上腺皮质功能。
三、嗜碱性粒细胞
【参考区间】（0～1）×10^9/L，0~1%。
【临床意义】
1、嗜碱性粒细胞增多：外周血液嗜碱性粒细胞绝对值大于0.1×10^9/L。嗜碱性粒细胞增多的临床意义见表2-52。
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2、嗜碱性粒细胞减少：由于嗜碱性粒细胞数量很少，其减少多无临床意义，可见于过敏性休克、促肾上腺皮质激素或糖皮质激素应用过量以及应激反应等。
四、淋巴细胞
【参考区间】（0.80～4.00）×10^9/L，20%~40%。
【临床意义】
1. Lymphocytosis: refers to the increase in the absolute value of peripheral blood lymphocytes. The number of lymphocytes is affected by certain physiological factors, for example, it is higher in the afternoon and evening than in the morning; the lymphocytes in infants can reach more than 50% one week after birth, and can last until 6 to 7 years old, and then gradually decrease to adult levels (Figure 2- 52).
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The causes and significance of the pathological increase of lymphocytes are shown in Table 2-53.
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2. Lymphopenia: refers to the decrease in the absolute value of peripheral blood lymphocytes. All kinds of reasons that lead to a significant increase in neutrophils can lead to a relative decrease in lymphocytes. The causes and significance of lymphopenia are shown in Table 2-54.
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Certain drugs can also cause lymphopenia, such as asparaginase, chlorambucil, cortisone, epinephrine, lithium, niacin, nitrogen mustard, and steroids.
[Explanation of related terms]
Atypical lymphocytes: Under the stimulation of certain viral infections or allergens, lymphocytes proliferate and undergo certain morphological changes, which are called atypical lymphocytes. These include: type I (left), foamy, plasmacytic; type II (right), irregular, monocytic; and type III (middle), naive.
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5. Monocytes:
【Reference interval】(0.12～0.80)×10^9/L, 3%~8%.
【Clinical Significance】
Adult mononuclear cells account for 3% to 8% of the total white blood cells. Children's peripheral blood mononuclear cells can be slightly higher than adults, with an average of 9%; infants within 2 weeks can reach 15% or more; Time can also increase, are physiological increase.
Mononucleosis refers to the absolute value of peripheral blood mononuclear cells in adults greater than 0.8×10^9/L. The causes and significance of the pathological increase of monocytes are shown in Table 2-55.
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The reduction in monocytes is of little significance.
The detection principle of blood analyzer
1. Electrical impedance method (Coulter's principle, three-group blood cell analyzer): The blood cells suspended in the electrolyte solution are non-conductive particles relative to the electrolyte solution. When blood cells (or similar particles) with different volumes pass through the counting holes, It can cause changes in the current or voltage inside and outside the small hole, forming a pulse voltage equivalent to the number of blood cells and corresponding to the size of the blood cells, thereby indirectly distinguishing the blood cell groups and counting them separately.
White blood cell counting and differential counting principles: The instrument divides blood cells with a volume of 35 to 450 fL into 256 channels. 1.64fl per channel. According to the cell size, put them in different channels respectively, and display the histogram of blood cell volume distribution (Histogram).
Blood cell histogram (histogram): refers to the curve graph that shows the distribution of cell populations when the hematology analyzer counts the number of cells, with the volume of blood cells as the abscissa and the relative frequency of different volume cells as the ordinate.
2. VCS technology: VCS is the abbreviation of volume, conductivity and scatter respectively. It is one of the technologies adopted by the quintile hematology analyzer. It uses three independent energy sources to detect in the flow cell White blood cells, combining these three, can be divided into five groups of white blood cells (three kinds of granulocytes and lymphocytes, monocytes).
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Red blood cell mean distribution width (RDW): It is a parameter of red blood cell volume heterogeneity and an objective indicator reflecting the uneven size of red blood cells. Its enlargement suggests the presence of a mixed cell population with heterogeneously sized RBCs.
【Reference value】RDW-CV: 11.5%~14.5%. RDW-SD: 42±5 fl.
【Clinical significance】Classification and differential diagnosis of anemia
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Hematology analyzer inspection graphics: According to the different detection principles of BCA, there are two kinds of cell distribution graphics: histogram and scatter diagram.
1. Blood cell histogram: the abscissa is the volume of blood cells, and the ordinate is the relative frequency of cells with different volumes.
A cell histogram is a statistical graph representing the distribution of cell populations. It can display the average cell volume, cell distribution and presence or absence of obviously abnormal cell populations of a particular cell population.
Contents observed in the histogram: ① The position of the peak reflects whether there is any abnormality in the position of the main cell group. ② The height of the peak roughly reflects the number of the main cell population. ③The width of the peak bottom reflects the heterogeneity or dispersion of the cell population size, such as RDW, PDW, etc. ④Whether there are abnormal peaks, compared with the normal histogram, there are abnormal peaks, indicating that there are abnormal cell groups or interference factors in the blood. ⑤Whether there is any abnormality at the beginning or end of the peak, if there are many, it indicates that there are interference factors.
Two, blood cell scatter diagram
Five-group BCA, while measuring the parameters of blood cells, can also display a visual white blood cell classification color scatter diagram, also known as a scatter diagram. It should be noted that: ①When analyzing the graph, it should be compared with the normal graph, combined with the comprehensive analysis of cell parameters and alarm prompts. ② Pay attention to observe the size, density and color depth of each cell group area in the scatter diagram. Particular attention should be paid to the presence or absence of cell populations in areas other than normal cell populations.
(1) White blood cell histogram
Electrical impedance type hematology analyzer divides white blood cells into 3 groups within the range of 35~450 fl. The left side of the normal white blood cell distribution histogram is high and steep, and the channel at 35-95 fl is the peak group of small cells (mainly lymphocytes); the channel at 160-450 fl is the peak group of large cells (mainly neutrophils); There is a small peak in the relatively flat area between the two peaks, which is an intermediate cell population (mainly mononuclear cells, mainly monocytes, and also contains eosinophils/basophils)
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【Abnormal change alarm】
Abnormalities to the left of the lymphocyte peak: possible platelet aggregation, giant platelets, nucleated red blood cells, unlysed red blood cells, white blood cell fragments, protein/lipid particles.
Abnormal area between lymphocyte peak and mononuclear cell peak: possible atypical lymphocytes, plasma cells, blasts, eosinophilia/basophilia.
Abnormal areas between mononuclear cells and neutrophils: possible immature neutrophils, abnormal cell subpopulations, eosinophilia/basophilia, left shift of nuclei.
Abnormal area to the right of the neutrophil peak: possible absolute increase in neutrophils.
Multi-part alarm (RM): Indicates that there are two or more abnormalities at the same time.
(2) Red blood cell histogram
The normal red blood cell histogram is a unimodal curve with approximately normal distribution, usually in the range of 36-360 fl, the abscissa indicates the RBC volume, and the ordinate indicates the frequency of red blood cells of different volumes.
Normal red blood cells are concentrated in the range of 50-200 fl, and two cell groups can be seen: one is the main red blood cell group, from 50 to 125 fl, which is a normal distribution curve that is basically symmetrical on both sides, relatively narrow, and presents an inverted bell shape; The other group is the large cell group, which is located on the right side of the main group and does not coincide with the X-axis trailing part. It is distributed in the area of 125 fl ~ 200 fl, also known as the "toe", which is the secondary of some large red blood cells, reticulocytes, and red blood cells. A mixture of aggregates, polymers, and leukocytes.
(3) Platelet histogram
The normal platelet histogram is a unimodal smooth curve with a skewed distribution, usually in the range of 2-30fl, mainly concentrated at 2-15fl.
When there are large platelets, platelet aggregates, small red blood cells, and red blood cell fragments in the blood sample, abnormal platelet histograms may appear.
urine part
Urine output: Refers to the total amount of urine excreted from the body within 24 hours.
【Reference interval】
Adults 1~2L/24h, that is, 1ml/(h*kg); children's urine volume is calculated by weight, which is about 3~4 times that of adults.
【related information】
1. Polyuria (polyuria): refers to the 24-hour urine output of adults exceeding 2.5L, and the 24-hour urine output of children exceeding 3L.
Under normal circumstances polyuria is common in drinking too much water, mental stress and so on. In addition, excessive intravenous infusion or application of certain drugs (such as caffeine, diuretics, etc.) can also lead to polyuria.
Pathological polyuria is often caused by decreased renal tubular reabsorption and concentration, and can be seen in the following situations:
Diabetes mellitus: It is caused by increased glucose content in the urine, which is a solute diuresis.
Kidney disease: A variety of kidney diseases can lead to polyuria, which is characterized by increased nocturia due to the impairment of urine concentration function due to the destruction of renal tubules.
Endocrine diseases: such as diabetes insipidus, which is caused by damage to the hypothalamus-pituitary gland, decreased secretion or lack of antidiuretic hormone, or decreased sensitivity of renal tubular epithelial cells to antidiuretic hormone, and the specific density of urine is usually less than 1.010, which can be distinguished from diabetes.
Other factors: such as hypertensive nephropathy, potassium depletion nephropathy, chronic renal failure, etc., may also cause polyuria. In addition, hysterical drinking a lot of water can also lead to polyuria.
2. Oliguria: 24-hour urine output is less than 0.4L or hourly urine output is continuously less than 17ml (less than 0.8ml/kg for children). Physiological oliguria occurs when the body lacks water or sweats excessively.
Pathological oliguria can be seen in:
Prerenal oliguria: ①Dehydration caused by various reasons (such as severe diarrhea, vomiting, severe burns, etc.), massive blood loss, shock, cardiac insufficiency, renal vascular embolism, renal artery stenosis, etc. can all cause decreased renal blood flow, Decreased urine output. ② Severe liver disease and hypoproteinemia can cause a decrease in effective blood volume and oliguria. ③ Under stress conditions (such as severe trauma, infection, etc.), sympathetic nerve excitement, adrenal cortex hormone and antidiuretic hormone secretion increase, which can increase renal tubular reabsorption and cause oliguria.
Renal oliguria: ① In acute glomerulonephritis, the filtration membrane is damaged, the renal afferent arterioles are constricted, the capillary lumen is narrowed and blocked, and the filtration rate is reduced, resulting in oliguria. This urine is hyperosmolar urine (ratio density > 1.018). ②All kinds of chronic renal failure, acute exacerbation of chronic nephritis, oliguric period of acute renal failure, etc. may also occur oliguria. ③Acute rejection after kidney transplantation.
Postrenal oliguria: seen in urethral obstruction caused by various reasons, such as urethral stones, injury, tumor, congenital malformation of urethra, bladder dysfunction, prostatic hypertrophy, etc.
3. Anuria: Anuria for 12 hours or less than 100ml of urine in 24 hours.
Appearance of urine:
Including color and turbidity.
The color of normal urine is from light yellow to dark yellow, which changes with the amount of urine, diet, drugs and pathological changes. The color is mainly due to urochrome and urobilinogen.
混浊度可分为【清晰、轻浑、混浊、明显混浊】4个等级。正常尿液混浊的原因主要为结晶所致。病理性混浊尿的原因为尿中含有白细胞、红细胞及细菌。尿中如有粘蛋白、核蛋白也可因pH变化而析出后产生混浊。
血尿（hematuria）：尿液内含有一定量的红细胞时称为~
1、肉眼血尿：1L尿液内含有1ml以上血液，且尿液外观呈红色，称为~。
2、镜下血尿：如尿液外观未见红色，离心尿液镜下红细胞>3个/HP，称为~。
血尿可见于泌尿系统结石、肾肿瘤、肾结核、急性肾小球肾炎、肾盂肾炎、膀胱炎、外伤等；亦可见于出血性疾病如血小板减少性紫癜、血友病等；女性亦可因月经血污染，而出现血尿。
1、血红蛋白尿：血管内溶血时，血浆游离血红蛋白增多，超过珠蛋白结合能力（约1.3g/L），可通过肾小球滤出而形成的暗红、棕红甚至酱油色的尿液，称为~。
主要见于各种原因引起的溶血性贫血、血型不合的输血等，尿液隐血试验呈阳性反应。
2、肌红蛋白尿：当肌肉组织广泛损伤、变性时血浆肌红蛋白含量增高，经肾脏排出，产生的粉红色或暗红色尿液。
3．胆红素尿：尿液中含有大量的结合胆红素所致。外观呈深黄色，振荡后泡沫亦呈黄色，见于阻塞性黄疸和肝细胞性黄疸。若在空气中久置可因胆红素被氧化为胆绿素而使尿液外观呈棕绿色。服用一些药物（如呋喃唑酮、核黄素等）后尿液可呈黄色或棕黄色外观，但是胆红素定性为阴性，有助于鉴别。
乳糜尿：由于泌尿系统淋巴管破裂或深部淋巴管阻塞致使乳糜液或淋巴液进入尿液，尿液呈乳白色浑浊，称为~。
【临床意义】
淋巴管阻塞：常见于丝虫病，其尿沉渣中可查到微丝蚴。腹内结核、肿瘤压迫、先天性淋巴管畸形也可以出现乳糜尿。
损伤：胸腹创伤、手术伤及腹腔淋巴管或胸导管也可出现乳糜尿。
脂血症：糖尿病脂血症、类脂性肾病综合征及长骨骨折骨髓脂肪栓塞也可出现乳糜尿。
其他：如过度疲劳、妊娠及分娩后、包虫病、疟疾等也偶见乳糜尿。
脓细胞：在炎症过程中被破坏、变性或坏死的中性粒细胞。其外形多变不规则，胞质内常充满颗粒，胞核模糊不清，常聚集成团，边界不清。
Pyuria: urine that is yellowish-white or white in appearance due to the large number of white blood cells. Seen in urinary system infection, prostatitis, seminal vesiculitis, etc. Microscopic examination shows a large number of pus cells, and the qualitative protein is often positive.
1. Microscopic pyuria: urine white blood cells > 5/HP.
2. Gross pyuria: the urine contains a large number of white blood cells and is milky white, or even lumpy, called ~
[Supplement] Flash cells: In hypotonic urine, the particles in the cytoplasm of neutrophils show Brownian motion. Under the oil lens, gray-blue light can be seen due to the refraction of light. The movement is like star-shaped flashes, hence the name.
Urine specific gravity (SG): Refers to the mass ratio of urine to the same volume of pure water at 4°C, and is an indicator of the concentration of solutes contained in urine. It can roughly reflect the concentration and dilution function of the kidney.
1. Hypoosmolar urine/low specific gravity urine: the specific gravity of urine is usually lower than 1.015;
2. Isotonic urine: The specific gravity of urine is fixed at 1.010±0.003, which is close to the specific gravity of glomerular filtrate
【Reference interval】
Adult: random urine 1.003~1.030; morning urine >1.020.
Newborn: 1.002~1.004
【Clinical Significance】
High specific density of urine: It can be seen in high fever, heart failure, dehydration, peripheral circulatory failure, etc. Although diabetic patients have increased urine output, due to the large amount of glucose in the urine, the increased specific density of urine can sometimes be as high as 1.040 or above. Patients with acute glomerulonephritis have increased specific density due to concentrated urine. In addition, the application of iodine contrast agent can also increase the urinary specific density.
Low specific density of urine: Chronic glomerulonephritis, pyelonephritis, etc. are due to decreased specific density of renal tubular concentration. When the concentrating function is lost due to renal parenchyma damage, the specific density of urine is usually fixed at 1.010±0.003 (close to the specific density of glomerular filtrate), and this type of urine is called isotonic urine. In patients with diabetes insipidus, due to damage to the hypothalamus-pituitary gland, the secretion of antidiuretic hormone is reduced, or because the epithelial cells of the renal tubules are less sensitive to antidiuretic hormone, a large amount of water is excreted from the body, resulting in a decrease in specific density.
Urine osmolality (Osm): refers to the total number of all solute particles with osmotic activity in urine, regardless of particle size and charge, and reflects the relative excretion rate of solute and water. It is superior to urine specific gravity in evaluating the concentration and dilution function of the kidneys.
【Reference interval】
①Urine osmolality: 600~1000mmol/kg H2O (equivalent to urine specific gravity 1.015~1.025). The maximum range is 40~1400mmol/kg H2O. ②Urine osmolarity/plasma osmolarity (3.0~4.7): 1.0.
[Clinical significance] Urine osmolality mainly reflects the concentration of solutes such as electrolytes and urea, which is directly related to the function of concentration and dilution, so it can more accurately reflect the condition of renal function. If the water deprivation 12h urine osmolarity > 800mmol/kg H2O, it is normal, if it is lower than this value, it means that the renal concentrating function is insufficient.
Increased plasma osmolarity is seen in dehydration, hyperosmolar nonketotic coma, ethanol poisoning, hypercalcemia, and diabetes insipidus; decreased plasma osmolarity is seen in adrenocortical hormone deficiency, water intoxication, and hypopituitarism.
Reduced urine osmolarity is seen in diabetes insipidus; decreased urine osmolarity/plasma osmolarity ratio is seen in the use of diuretics or renal tubular damage.
urine smell
【Reference interval】
Faint aromatic odor, derived from esters and volatile acids in urine. If the urine specimen is stored for a long time, ammonia odor may appear due to the decomposition of urea.
【Abnormalities and clinical significance】
① Fresh urine has an ammonia smell, which is mostly caused by chronic cystitis and chronic urinary retention. ② When diabetic ketoacidosis occurs, the urine may smell like rotten apples. ③ The urine of patients with phenylketonuria may have a special "mouse droppings"-like odor. ④ In the case of intestinal fistula in the urinary system, there may be fecal odor in the urine.
urine pH
【Reference interval】
Under normal dietary conditions: ①Morning urine pH 5.5-6.5, with an average of 6.0; ②Random urine pH 4.5-8.0. Urine titratable acidity: 20~40mmol/24 hours of urine.
【Clinical Significance】
Increased acidity: metabolic acidosis, DM, taking ammonium chloride, etc. Increased alkalinity: alkalosis, cystitis, renal tubular acidosis, taking baking soda, etc.
The protein content in the final urine is very small, only 30~130mg/24h.
Proteinuria (proteinuria): When the protein in the urine exceeds 150mg/24h (or exceeds 100mg/L), the protein qualitative test is positive, which is called ~.
【Small Knowledge Points】
Methods for detecting proteinuria include: test strip method (qualitative or semi-quantitative), sulfosalicylic acid method (qualitative or semi-quantitative, sensitivity 0.05-0.1 g/L), heating acetic acid method (classic method, sensitivity 0.15 g/L) /L).
【Reference】
① Qualitative: Negative. ②Quantitative: <0.1g/L or ≤0.15g/24h urine.
【Clinical Significance】
(1) Physiological proteinuria: proteinuria caused by changes in internal and external environmental factors of the body, called ~.
1. Functional proteinuria: There is no organic disease in the urinary system, and a small amount of protein temporarily appears in the urine, which is called ~.
2. Orthostatic proteinuria: also known as orthostatic proteinuria, proteinuria appears when standing upright and disappears when lying down, and there is no hematuria, high blood pressure, edema and other phenomena.
3. Occasional proteinuria: also known as pseudoproteinuria. Proteinuria is a positive proteinuria test due to the mixing of blood, pus, mucus, reproductive system secretions, or menstrual blood into the urine.
(2) Pathological proteinuria
1. Glomerular proteinuria: After the glomerular filtration membrane is damaged due to factors such as inflammation, immunity, and metabolism, the pore size of the glomerular filtration membrane increases, breaks and (or) the electrostatic barrier function is weakened, and plasma proteins, especially albumin, filter Proteinuria that exceeds the reabsorptive capacity of the proximal renal tubules. (The protein content in glomerular proteinuria is usually greater than 2g/24h urine, usually mainly albumin, accounting for about 70% to 80%, in addition, β2 microglobulin can also be slightly increased)
It is mainly seen in glomerular diseases, such as acute glomerulonephritis, chronic nephritis, membranous nephropathy, membranous proliferative nephritis, etc.; it can also be seen in some secondary kidney diseases, such as diabetic nephropathy and lupus erythematosus nephropathy.
①. The glomerular filtration membrane has a certain selectivity for the passage of plasma proteins. Proteins with relatively large molecular weights are filtered slowly, while proteins with relatively small molecular weights are relatively easy to pass through. Therefore, when the proteinuria formed When it is dominated by small molecular proteins, it is called selective proteinuria. Selective proteinuria can be used to determine the filtration capacity of the glomerular filtration membrane for macromolecular proteins. In selective proteinuria, there are mainly proteins with a relative molecular mass (40,000 to 90,000) in the urine, while proteins with a relative molecular mass greater than 90,000 hardly appear.
Selective proteinuria indicates mild glomerular filtration membrane damage, which is seen in early glomerulonephritis.
②. The glomerular filtration membrane loses its selective filtration ability and can filter proteins with different relative molecular masses. The proteinuria formed at this time is called non-selective proteinuria.
Nonselective proteinuria indicates that the glomerular filtration membrane is severely damaged, which can be seen in membranous proliferative nephritis, focal glomerulosclerosis, diabetic nephropathy, and severe connective tissue diseases such as systemic lupus erythematosus. Prompt poor prognosis.
2. Tubular proteinuria: refers to the proteinuria mainly composed of proteins with relatively small molecular weight when the renal tubules are infected, poisoned or secondary to glomerular diseases, and the reabsorption ability is reduced or inhibited. (Characterized by increased β2 microglobulin, lysozyme, etc., normal or slightly increased albumin. Simple renal tubular proteinuria, low urinary protein content, generally less than 1g/24h urine)
常见于：①肾小管间质病变：如肾盂肾炎、间质性肾炎，遗传性肾小管疾病如Fanconi综合征、慢性失钾性肾病等。②中毒性肾间质损害：肾小管性酸中毒、重金属（汞、镉、铋等）中毒，应用庆大霉素、多粘菌素B等。③肾移植术后。尿中β2微球蛋白与清蛋白的比值，有助于区别肾小球与肾小管性蛋白尿。
3、混合性蛋白尿：病变同时或相继累及肾小球和肾小管而产生的蛋白尿，兼具以上两种蛋白尿的特点。(低相对分子质量的β2微球蛋白及中相对分子质量的清蛋白同时增多)
可见于：①各种肾小球疾病后期，先侵犯肾小球，后累及肾小管，如慢性肾炎、肾移植排斥反应等。②各种肾小管间质疾病，先侵犯肾小管间质，后累及肾小球，如间质性肾炎、慢性肾盂肾炎。③全身性疾病同时侵犯肾小球和肾小管，如狼疮性肾炎、糖尿病肾病等。
4、溢出性蛋白尿：（肾小球/肾小管功能均正常）因血浆中相对分子质量较小或阳性电荷蛋白异常增多，经肾小球滤过，超过肾小管重吸收能力所形成的蛋白尿，即~。
可见于：①浆细胞病，如多发性骨髓瘤、巨球蛋白血症、重链病、轻链病等。②急性、慢性血管内溶血可出现血红蛋白尿。③急性肌肉损伤，如挤压综合征、横纹肌溶解综合征等。④其他，如急性白血病时血溶菌酶增高而致尿溶菌酶升高、胰腺炎时的尿
5、组织性蛋白尿：指来源于肾小管代谢产生的、组织破坏分解的、炎症或药物刺激泌尿系统分泌的蛋白质，进入尿液而形成的蛋白尿。
还可按其发生的部位分为肾前性、肾性和肾后性蛋白尿。
健康人的尿液中可有微量葡萄糖，一般<2.8mmol/24h，普通方法检测为阴性。血糖浓度超过8.88mmol/L （1.6g/L）时，尿液中卡是开始出现葡萄糖
糖尿(glucosuria)：尿糖定性试验呈阳性的尿液，取决于血糖浓度、肾血流量和肾糖阀。一般指葡萄糖尿。
肾糖阈：尿中开始出现葡萄糖时最低血糖浓度，称为~。
【小知识点】
检测尿糖的方法有：试带法，班氏法，薄层层析法。
【参考值】：
①定性：阴性。②定量：＜2.8mmol/24h（0.1～0.8mmol/L）。
【临床意义】
1. Hyperglycemic diabetes: Many hormones in the body can regulate blood sugar. Insulin can reduce blood sugar concentration, while growth hormone, thyroxine, adrenaline, cortisol, glucagon, etc. can increase it.
(1) Diabetes: Absolute or relative insufficiency of insulin secretion leads to elevated blood sugar, and urine sugar is often negative in patients with mild symptoms on an empty stomach. The fasting blood glucose level of critically ill patients has exceeded the renal threshold, and the 24-hour urine glucose reaches 100g or more. The total daily urine glucose is positively correlated with the severity of the disease. Therefore, urine glucose measurement is also one of the important monitoring indicators for the treatment effect of diabetes.
(2) Endocrine diseases: Hyperthyroidism, pheochromocytoma, anterior pituitary hyperfunction, Cushing syndrome, etc. can all increase blood sugar, and urine sugar can be positive.
(3) Stress diabetes: also known as transient diabetes, which occurs in stressful situations such as cerebrovascular accident, craniocerebral trauma, acute myocardial infarction, emotional agitation, and anesthesia. A large amount of glucagon is released, so transient hyperglycemia and glycosuria may occur.
In addition, short-term intake of a large amount of sugar (more than 200g) or intravenous infusion of glucose solution can also cause diabetes.
2. Normoglycemic diabetes: Also known as renal diabetes, it is caused by a decrease in the renal threshold due to a decrease in the reabsorption of glucose by the renal tubules. Familial renal diabetes is caused by congenital defects in the absorption of sugar by the proximal convoluted tubule, which is seen in Fanconi syndrome. Renal glycosuria can result from renal tubular damage in chronic nephritis or nephrotic syndrome. Newborns can also cause diabetes due to imperfect renal tubular function. During pregnancy, due to the increase in extracellular fluid volume, the reabsorption function of the proximal convoluted tubule is inhibited, which can also reduce the renal glucose threshold and cause glycosuria. The results of fasting blood glucose and glucose tolerance test were normal during renal glycosuria.
3. Other diabetes: In addition to glucose, lactose, galactose, fructose, pentose, mannitol, etc. may also appear in the urine. The reabsorption rate of the latter in the renal tubules is lower than that of glucose. When the blood concentration increases, corresponding diabetes may appear. If a woman is breastfeeding, due to the excessive lactose produced by the mammary gland, it can be excreted with urine to form lactose in urine. In liver cirrhosis or liver dysfunction, the utilization of fructose and galactose by the liver decreases, and fructose and galactose can occur.
Ketone body: It is the general term for acetoacetate (20%), β-hydroxybutyrate (78%) and acetone (2%), which are intermediate products of body fat oxidation metabolism. Once the plasma ketone body concentration exceeds the renal threshold, ketonuria will occur.
【Reference interval】①Qualitative: Negative. ②Quantitative: ketone body (calculated as acetone) 170~420mg/L; acetoacetic acid≤20mg/L
【Clinical Significance】
1. Diabetic ketoacidosis: due to the decline in the function of utilizing glucose, a large amount of fat is decomposed to produce too much ketone body, which causes ketosis. Urine ketone examination is of great value when acidosis or coma occurs in diabetes.
2. Non-diabetic ketosis: ketonuria can occur after severe vomiting, diarrhea, hunger, long-term fasting, infection and fever, and general anesthesia. Pregnant women may develop ketonuria due to severe pregnancy reactions, vomiting of pregnancy, eclampsia, inability to eat, and digestive and absorption disorders.
3. Others: Ketoneuria occurs during poisoning, such as chloroform, ether anesthesia, phosphorus poisoning, etc. In addition, when taking biguanide hypoglycemic drugs (such as Jiangtangling), the blood sugar has been lowered, but the ketoneuria is positive.
Urinary bile pigments include bilirubin, urobilinogen and urobilin, commonly known as urinary three gallbladders.
Bilirubin: Metabolites of red blood cell destruction, can be divided into free bilirubin and conjugated bilirubin.
1. Free bilirubin is insoluble in water, binds to protein in blood, and cannot be filtered out by glomerulus;
2. Conjugated bilirubin has a small relative molecular weight and high solubility, and can be filtered out by the glomerulus. Conjugated bilirubin in normal human blood is very low, so bilirubin cannot be detected in urine.
Urobilinogen: It is produced by the reduction of bilirubin by bacteria in the intestinal tract, and urobilinogen is transformed into yellow urobilin (fecal bilein) after being oxidized by air and exposed to light.
【Reference】
Urobilinogen: ① Qualitative: Negative or weakly positive (negative after 1:20 dilution). ②Quantitative: male: 0.30-3.55 μmol/L; female: 0.00-2.64 μmol/L; child: 0.13-2.30 μmol/L.
Urobilin: negative.
【Clinical Significance】
Urine tricholesterolemia examination can help to identify the type of jaundice and find out the cause.
1. Hepatocellular jaundice: urine bilirubin, urobilinogen, and urobilin are all positive, which can be seen in acute viral hepatitis. Hepatocellular jaundice caused by other causes, such as toxic hepatitis caused by drugs and poisons, can also have similar results .
2. Hemolytic jaundice: clinically seen in various hemolytic diseases, large area burns, etc.
3. Obstructive jaundice: It can be seen in intrahepatic and external obstruction caused by various reasons, such as cholelithiasis, bile duct cancer, pancreatic head cancer, liver cirrhosis, etc.
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Urinary nitrite (NIT): mainly from the reduction reaction of pathogenic bacteria to nitrate, and secondly from nitric oxide (NO) in the body. Endothelial cells, macrophages, granulocytes, etc. in body fluids make arginine generate NO under the action of enzymes, and NO is easily oxidized into nitrite and nitrate under aerobic conditions in the body.
[Detection principle] Griess method, the sensitivity is 0.3-0.6 mg/L
The positive detection rate of NIT in urine depends on three conditions: ①Whether there is nitrate reductase in the pathogenic bacteria in the urine; ②Whether the urine stays in the bladder for a long enough time (4h); ③Whether there is nitrate reductase in the urine Appropriate amount of nitrates.
[Reference interval]: Negative.
【Clinical significance】:
It is mainly used for rapid screening of urinary tract infection. The correlation with Escherichia coli infection is high, positive results often indicate the presence of bacteria, but the positive degree is not directly proportional to the number of bacteria. There are many influencing factors for a single test of NIT. A negative result cannot rule out the possibility of bacteriuria, and a positive result cannot be completely sure that it is a urinary system infection. Therefore, when interpreting the results, it can be combined with the results of leukocyte esterase and urine sediment microscopy for comprehensive analysis. Urine bacterial culture is a confirmatory test.
The urine albumin of healthy people is generally less than 20mg/L, and it is abnormal when it is greater than 30mg/L.
Microalbuminuria: refers to the low concentration of albumin in which the albumin content in urine exceeds the level of healthy people, but the routine urine protein test is negative.
[Detection method] ELISA, RIA, immunoturbidimetric method
【Reference interval】Adult: (1.27±0.78) ng/mmol Cr or (11.21±6.93) mg/gCr, AER: 5~30 mg/24h
【Clinical significance】: Early diagnosis and monitoring of diabetic nephropathy. Cardiovascular disease/hypertension complicated by indications of renal injury.
Protein of the Week (BJP): Abnormal immunoglobulin synthesized by myeloma cells with excess light chain (LC) that passes freely through the glomerular filtration membrane when the concentration exceeds the reabsorption capacity of the proximal convoluted tubule , can be excreted from the urine, that is, proteinuria or light chain urine this week. This light chain is the week protein (BJP),
Under the condition of pH 4.9±0.1, protein can coagulate when heated to 40°C-60°C, dissolve when the temperature rises to 90°C-100°C, and re-solidify when the temperature is reduced to about 56°C, so it is also called for coagulation proteins.
[Detection method]: p-toluenesulfonic acid precipitation screening experiment (sensitivity 3mg/L), immunofixation electrophoresis (the best method).
[Reference interval]: Negative
【Clinical significance】: multiple myeloma (MM), primary amyloidosis, macroglobulinemia, others.
Urinary sediment: the formed components that can be seen under a microscope after the urine is excreted and centrifuged. It is a general term for the visible sediment components in urine.
centrifuged urine direct smear
Take 10~15ml of fresh urine sample, centrifuge at 1000~1500rpm for 3~5 minutes, take out the centrifuge tube, slowly discard the supernatant with a straw, do not mix the sediment, finally keep 0.2ml, mix well and drop in On the glass slide, use a 18mm×18mm cover glass for microscope inspection.
When observing, first use a low magnification lens to observe the overall appearance of the formed elements and casts, and then use a high magnification lens to identify the cell components. Use a high magnification lens to observe 10 fields of view for cells, and use a low magnification lens to observe 20 fields of view for casts, and record the results.
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Cast: It is a cylindrical protein aggregate formed by coagulation of protein, cells and their disintegration products in renal tubules and collecting ducts.
The necessary conditions to form a cast are:
① There is a small amount of albumin in the original urine and TH protein secreted by the renal tubules, which are the matrix of the cast;
② Renal tubules have the ability to concentrate and acidify urine;
③ There must be nephrons available for alternate use.
【Clinical Significance】
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Epithelial Cells
Due to metabolism or inflammation, after the epithelial cells of the genitourinary tract fall off, they can be mixed into the urine and excreted. Epithelial cells in urine, including cuboidal epithelium from renal tubules, transitional epithelium from calices, renal pelvis, ureter, bladder, and parts of urethra, pseudostratified columnar epithelium from midurethra, and stratified urethral meatus and vagina Squamous epithelium (the largest epithelial cells in urine).
Principle of urine dry chemical method
The chemical composition of the urine changes the color of the reagent module on the multi-strip, and the color depth is proportional to the concentration of the chemical composition in the urine. When the test strip enters the colorimetric tank of the urine dry chemistry analyzer, each reagent module is sequentially irradiated by the light source of the instrument and produces different reflected light. Processing, calculate the reflectance of each detection parameter, compare and correct with the standard curve, and finally output the result automatically in a qualitative or semi-quantitative way. Formula: R(%)=(Tm*Cs)/(Ts*Cm)
Common detection parameters: pH, SG (specific gravity), PRO (protein), GLU (glucose), BIL (bilirubin), URO (urobilinogen), KET (ketone body), NIT (nitrite), BLD ( occult blood or red blood cells), LEU (white blood cells), Vit C (vitamin C)
The multi-layer film structure of the multi-joint test strip: ①nylon film; ②velvet layer; ③water-absorbing layer; ④plastic bottom layer
【evaluate】
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Due to the limitations of the dry chemical method, microscopic review is essential: ①The microscope can truly display the shape of cells and other formed components, which is intuitive and reliable. ②Microscopic examination is time-consuming and not suitable for the screening of large quantities of specimens, especially when the test results are urgently needed in outpatient clinics.
When WBC, RBC, protein and nitrite are all negative in the dry chemical analyzer test results, microscopic re-examination may not be performed; however, if one of them is positive, microscopic re-examination must be performed at the same time.
Image-type urine formed component analyzer: Compared with microscopy, it has obvious advantages, but there are also disadvantages:
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Fully Automatic Urine Formed Components Analyzer: Compared with microscopy, it has obvious advantages, but there are also obvious deficiencies
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Therefore, the urine formed component analyzer cannot completely replace the microscope.
feces part
Stool color:
The feces of healthy adults should be yellowish brown, and golden yellow for babies. Caused by scrofula. Various physiological factors and pathological changes can change its color.
【Abnormal changes and clinical significance】
① bright red: seen in rectal cancer, anal fissure, hemorrhoids and other lower gastrointestinal bleeding.
②Black or asphalt: seen in upper gastrointestinal bleeding, taking iron supplements, eating pig blood, etc. Red blood cells are destroyed, and hemoglobin is decomposed under the action of bacteria, degraded into heme, iron, and porphyrin. Iron and hydrogen sulfide produced by intestinal decomposition form black iron sulfide.
③Kaolin color: seen in obstructive jaundice, biliary obstruction, excessive dietary fat, and after a barium meal.
④Green: found in infants with diarrhea, due to excessive intestinal peristalsis, biliverdin is formed by excretion of feces, or eating a lot of spinach, etc.
⑤ jam color: seen in amoebic dysentery, bacillary dysentery, etc.
Stool properties:
Healthy adults have formed soft stools, while those with constipation have spherical hard stools. Babies are mushy.
【Abnormal changes and clinical significance】
1. Mucus stool: Normal stool contains a small amount of mucus, which is not easy to see because it is evenly mixed with the stool. Increased mucus indicates intestinal inflammation or irritation, which is common in various enteritis, bacillary dysentery, amoebic dysentery, and acute schistosomiasis. When the small intestine is inflamed, the increased mucus is evenly mixed in the feces; when the large intestine is inflamed, the feces have gradually formed and adhere to the surface of the feces.
2. Pus and blood in the stool: seen in bacillary dysentery, amoebic dysentery, acute schistosomiasis, ulcerative colitis or rectal cancer. Among them, bacillary dysentery is mainly pus and mucus, with blood in the pus; amoebic dysentery is mainly blood, with pus in the blood, which is like jam.
3. Bloody stool: seen in colon cancer, rectal polyps, anal fissure and hemorrhoids.
4. Tarry stools: brown or black, soft and shiny, positive for occult blood test. Seen in upper gastrointestinal bleeding, when the amount of upper gastrointestinal bleeding exceeds 50ml, tarry stools can be seen.
5、米泔样便：呈乳白色淘米水样，内含粘液片块，多见于霍乱、副霍乱。
6、溏便：粪便呈粥样但内含物粗糙，见于消化不良，慢性胃炎等。
7、胨状便：见于过敏性肠炎及慢性菌痢。病人常于腹部绞痛后排出粘胨状、膜状或纽带状粪便。
8、稀糊状或稀汁样便：见于各种感染性或非感染性腹泻，尤其是急性胃肠炎。若遇见大量黄绿色稀汁样便并伴有膜状物应考虑为假膜性肠炎。爱滋病并发隐孢子虫感染时也可排出大量稀汁样便。
9、乳凝块状便：粪便中有黄白色乳凝块或蛋花样便，见于消化不良，婴儿腹泻。
10、绿豆汤样便：见于沙门氏菌感染。
11、蛋青样便：白色念珠菌性肠道感染。
粪便的pH：
变化范围6.9-7.2。
细菌性痢疾、血吸虫病时碱性，8.0左右。阿米巴痢疾、病毒性肠炎为酸性，6.1~6.6左右。
粪便的量：
健康成人每日粪便为100-300g。
随食物种类、进食量和消化系统功能而变化。粗粮或纤维丰富的，粪便量多；细粮或肉类较多，粪便较少。
粪便的气味：
由于细菌作用的产物吲哚、硫化氢等等使得粪便有一定臭味。
消化吸收不良，胰腺疾病、消化道大出血时，为腐败臭味；脂肪或糖类消化不良，酸臭味；阿米巴痢疾时，鱼腥味。
粪便显微镜检查：手工盐水涂片镜检
操作方法：取一清洁玻片，滴加2滴生理盐水，用竹签挑取粪便中的异常部份，与盐水均匀混合制成薄涂片，盖上盖片，其涂抹厚度以透过标本看清字迹为宜。
先用低倍观察虫卵、原虫和其它异物，再用高倍镜仔细观察各种异常成分。细胞计数时，至少应检查10个以上的高倍视野。
结晶：正常粪便中可见到磷酸钙、草酸钙、胆固醇、碳酸钙等结晶，一般无临床意义。
病理性结晶有：
①夏科-莱登结晶：为菱形无色透明结晶，其两端尖长，大小不等，折光性强，是嗜酸粒细胞破裂后嗜酸性颗粒相互融合而成。见于阿米巴痢疾、钩虫病、过敏性肠炎粪便中，并常与嗜酸性粒细胞同时存在。
②血晶：为棕黄色斜方形结晶，不溶于氢氧化钾溶液，溶于酸，呈青色，见于胃肠道出血粪便中。
③脂肪酸结晶：见于阻塞性黄疸引起脂肪酸吸收不良时。
粪便隐血：是指消化道出血量少（每日出血量＜5ml），粪便中无可见的血液，且红细胞被消化破坏，显微镜下也见不到红细胞，这种肉眼及显微镜均不能证明，需用化学法、免疫法才能证实的微量出血称为隐血。隐血试验（OBT）是指用化学或免疫学的方法证实微量血液的试验。
【检测方法】
1）化学法：这类方法种类很多，根据色原物质不同分为：邻联甲苯胺法、邻甲苯胺法、联苯胺法、无色孔雀绿法、愈创木酯法、还原酚酞法等；根据反应试剂状态或试剂载体不同又分为湿化学和干化学试纸法。其实验设计原理基本相同，此类方法简便易行，成本低廉，目前实验室常用。
原理：血红蛋白中的含铁血红素有类似过氧化物酶的作用，将供氢体（色原）中的氢转移给H2O2生成水，供氢体脱氢（氧化）后形成发色基团而呈色。呈色深浅可反映血红蛋白（出血量）的多少。
灵敏度：
a、邻联甲苯胺、邻甲苯胺、还原酚酞法最灵敏，可检出0.2～1.0mg/L的血红蛋白，只要消化道有1～5ml出血就可检出。其中邻联甲苯胺法是在1983年中华医学会全国临床检验方法学学术讨论会推荐的方法，但易出现假阳性。
b、中度灵敏的试验有联苯胺法、匹拉抗米酮法及无色孔雀绿法，可检出1～5mg/L的血红蛋白，消化道有5～10ml出血即为阳性。为了减少假阳性和假阴性，临床上宜采用中度灵敏方法。
2）免疫学法：免疫学法常用的方法有ELISA和胶体金等方法，此类方法所使用的抗体为抗人血红蛋白单克隆抗体。免疫法操作简便、快速、灵敏度高（一般血红蛋白为0.2mg/L即可获阳性结果）、特异性强，饮食和药物等均对结果无影响，目前被认为是大肠癌普查最适用试验。
【参考区间】阴性
【临床意义】
1、对消化道出血有诊断价值：消化道溃疡、药物致胃粘膜损伤、肠结核、溃疡性结肠炎、结肠息肉、钩虫病、流行性出血热及消化道恶性肿瘤所致消化道出血时，隐血试验常呈阳性反应。
2. Provide evidence for the identification of gastrointestinal ulcers and tumor bleeding: patients with gastrointestinal tumors, because the tumor directly or indirectly invades and destroys blood vessels in the digestive organs, the occult blood test is persistently positive; patients with gastrointestinal ulcers only have bleeding at the time of onset The performance of bleeding, occult blood test results were intermittently positive.
3. It can be used as a screening index for the general screening of digestive tract malignant tumors: the positive rate of occult blood test for the diagnosis of digestive tract tumors can reach 95%, and the coincidence rate of early gastric cancer diagnosis is 20%, and the coincidence rate of late gastric cancer is 95%. For the above asymptomatic persons, a fecal occult blood test should be done once a year, which is of great value for early malignant tumors of the digestive tract. When the lesion of early colorectal cancer is limited to the mucosa or submucosa, it is often asymptomatic, and a small amount of bleeding in the stool is the only abnormal indicator that can be detected in the early diagnosis of colorectal cancer.
semen part
amount of semen
The semen volume is 2.0-6.0ml, with an average of 3.5ml, less than 1.5ml or greater than 8.0ml can be regarded as abnormal.
Azoospermia: The amount of semen is reduced to 1-2 drops, or even cannot be discharged, which is called anospermia.
Semen's appearance (color and clarity)
Grayish white or milky white, those who have not ejaculated for a long time can be light yellow, slightly turbid, translucent after liquefaction.
【Abnormal manifestations and clinical significance】
① Bloody semen: Semen that is bright red, light red, dark red or soy sauce-colored and contains a large number of red blood cells is called bloody semen. Commonly seen in non-specific inflammation of the prostate and seminal vesicles, tuberculosis of the reproductive system, tumors, stones, and also in reproductive system injuries; ② purulent semen: yellow or brown, common in seminal vesiculitis, prostatitis, etc.
Semen liquefaction time: The time required for semen to change from gel peptone state to fluid state is called semen liquefaction time. Semen liquefaction is mainly due to seminal proteolytic enzymes secreted by the prostate.
The freshly ejaculated semen is highly viscous, and the liquefaction time is <30min.
Delayed liquefaction of semen: fresh semen specimens do not liquefy at room temperature for more than 60 minutes, known as ~, common in prostatitis.
Sperm motility: Refers to the number of viable sperm, expressed as the ratio of "live" sperm.
1. Wet film method: observe 100 sperm under a high-power microscope, and count the ratio of motile sperm to immotile sperm to indicate the motility rate of sperm. This method is simple, fast, and widely used, but it is subjective and has many influencing factors, resulting in large error and poor repeatability.
2、活体染色法（也称为精子存活率）：检测正常活动的精子数，是测定活精子和死精子的定量方法。用染料对精子染色。该法操作较为复杂，费时，但较客观反映死活精子比例，结果准确、可靠、重复性好，试剂易配制，易保存，是检测精子功能简便方法。
【参考值】
①湿片法：＞70%（精液离体30～60min内）。
②伊红染色法：＞75%（精液离体30～60min内）
【临床意义】
精子活率检查主要用于男性不育症的诊断。正常精液排出后60min内，精子活动率为80%～90%，至少＞60%，
曾认为精子数在60×10^9/L以上才能受孕，现认为只要有活动力的精子达45%，即使精子数＜0.5×10^9/L，仍能受孕。
精子活动力：指精子向前运动的能力，是直接反映精子质量的一项指标。
WHO将活力分4级（书上分为三级），用百分率表示。
a：快速前向运动 ，精子活动力良好
b：慢或呆滞的前向 ，精子活动力较好
c：非前向，在原地打转或抖动，精子活动力不良
d：不动 ，死精子
【检测方法】：
显微镜检查：取液化后精液1d 于玻片上，在高倍镜下观察5-10个视野，计数100个精子并进行活动分级用百分率来表示。
连续摄影法：将液化的精液直接充入记数池当中，在显微镜下200倍视野下，调节精子浓度大约每视野10-15个，然后显微摄影，在同一张胶片上对同一个视野的精子进行6次暴光摄影，1s/次，可以得到精子的运动轨迹，死精子位置则始终不变。
精子质量分析仪测定：利用光束通过少量精液，检测精子运动带来的光密度变化。简单迅速，重复性好。
【参考值】
射精60min内，a级精子应＞25%；或a和b级精子之和＞50%。
精子活动力与受精的关系十分密切，若连续检查，精子活率不足40%，且以c级活动力精子为主，则可能为男性不育的原因之一。
精子活动力下降见于：①精索静脉曲张。②生殖系统非特异性感染以及使用某些药物（抗代谢药、抗疟药、雌激素）等。
精子计数
【方法】
1、血细胞计数板检测；
2、Makler精子计数板检测：专门用于精子检验，池深为10um，不影响精子的正常运动，但是只使用于相差显微镜和暗视野显微镜；
3、Macro计数板检测：可以用于普通显微镜检测。
【参考值】
①精子浓度：（50～100）×10^9/L；WHO：＞20×109/L。②精子总数：≥40×10^6/次
一般认为＜20×10^9/L为不正常，连续3次检查皆低下者可确定为少精症，多次未查到精子为无精症。
但临床上亦可见到精子浓度＜20×10^9/L仍能生育，因此估计一个男性的生育能力应将精子浓度与精液其他参数结果综合考虑分析。
精子浓度减低见于：①先天性或后天性睾丸疾病如睾丸畸形、萎缩、结核、炎症、肿瘤等。②精索静脉曲张。③输精管阻塞、精囊缺陷。④重金属或放射线损害。⑤某些药物如抗癌药或长期服用棉酚。⑥50岁以上老年人等。
正常精子形态：
正常精子外形似蝌蚪状，由头、体（颈、中段）、尾（主、末段）构成。头部正面观呈卵圆形，侧面观呈扁平梨形，长约4.0～5.0μm，头部轮廓规则，顶体覆盖头部表面的1/3以上。体部轮廓直而规则，长约5～7μm。尾部细长，弯而不卷曲呈鞭毛状，长约50～60μm。
异常精子形态包括：①头部异常：常见有大头、小头、锥形头、无定形头、空泡样头、双头、无顶体头等。②体部异常：常见有体部肿胀、不规则、弯曲中段、异常薄中段。③尾部异常：常见有无尾、短尾、长尾、双尾、卷尾等。④联合缺陷体：精子头、体、尾均有或其中两者有不同程度异常。
检查方法
涂片染色：HE染色、Giemsa染色，相差显微镜检查
【参考值】 正常精液中异常精子数＜20%。
精子形态检查是反映男性生育能力的1项重要指标。如正常形态精子<30%，称为畸形精子症（WHO），
畸形精子>40%，即会影响精液质量，>50%常可致不育。精子形态异常与睾丸、附睾的功能异常密切相关，增多常见于生殖系统感染，精索静脉曲张，雄性激素水平异常时；某些化学因素、物理因素、药物因素、生物因素及遗传因素也可影响睾丸生精功能，导致畸形精子增多。
未成熟生殖细胞
Refers to the incompletely developed spermatogenic cells at various stages, including spermatogonia, primary spermatocytes, secondary spermatocytes and incompletely developed spermatids. Normal semen immature germ cells <1%,
【Clinical Significance】
According to the type of spermatogenic cells, the spermatogenic function of the testis can be further measured, the etiology of the testis can be analyzed, and a scientific basis can be provided for the etiology analysis of azoospermia and oligospermia. At the same time, dynamic observation of the changes of spermatogenic cells in semen can be used as one of the indicators to observe the curative effect and judge the prognosis of male infertility. When the basement membrane of the testicular varicose seminiferous tubules is abnormal and the development of spermatogenic cells causes azoospermia, there are no spermatogenic cells in the semen; when the spermatogenic function of the seminiferous tubules is damaged, more pathological immature cells can appear in the semen .
A. The common clinical cause of testicular infertility is stagnation of spermatogenic cell maturation, which refers to the stagnation of sperm production at a certain stage, the sudden stop of sperm production, azoospermia and oligospermia.
B. Many drugs can act on the testis, such as nitroimidazoles, which mainly inhibit primary spermatocytes and early sperm cells, but have no effect on quiescent spermatocytes. Gossypol mainly acts on the metamorphic spermatids and middle and late spermatids.
C. The analysis of germ cells is beneficial to the analysis of etiology and judgment of curative effect.
D. Reproductive system infection leads to the rise of pointed sperm, amorphous sperm and sperm cells, as well as spermatic cord and varicose veins.
Normal semen has a small amount of WBC (<5/HP) and epithelial cells, occasionally RBC.
【Clinical Significance】
Semen RBC, WBC increase can be seen in reproductive system inflammation, tuberculosis, malignant tumors and so on.
Patients with leukocytes > 1×10^9/L in semen are called leukospermia, indicating the presence of infection, such as seminal vesiculitis, prostatitis, epididymitis, etc.; erythrocytosis is seen in tumors, etc.
Antispermatozoon antibody (AsAb): When the reproductive system is inflamed, blocked, and the immune system is destroyed and other pathological changes, sperm as a unique antigen contacts the body’s immune system to produce its own or the same antisperm antibody (AsAb) ). AsAb in blood or genital secretions can cause immune infertility. AsAbs are divided into three categories according to their effects on sperm: agglutination, immobilization and binding.
[Related] seminal plasma immunoglobulin:
Mainly IgA, IgG, equivalent to 1% to 2% in serum. The IgG in the seminal plasma comes from the serum infiltrating the prostate, and the IgA in the seminal plasma mainly comes from the prostate.
【Reference value】①IgG: 28.6±16.7mg/L. ②IgA: 90.3±57.7mg/L. ③IgM: 2.3±1.9 mg/L.
AsAb positive, IgG, IgM increased; normal seminal plasma secretory IgA content is very low, reproductive tract inflammation, secretory IgA increased; reproductive tract infection early IgM increased.
vaginal discharge
Vaginal discharge: It is the liquid secreted by the female reproductive tract, which is mainly composed of secretions from cervical glands, Bartholin glands, endometrium and vaginal mucosa, commonly known as "leucorrhea".
general traits
Normal vaginal discharge is a white, flocculent, viscous liquid, odorless, with varying amounts, and its properties are related to estrogen levels and genital congestion. 1. When ovulation is approaching, the amount is large, clear and transparent, thin like egg white; 2. After 2-3 days of ovulation, the amount decreases and becomes cloudy and sticky; 3. The amount increases before menstruation; during pregnancy, the amount of leucorrhea is more.
【Abnormal traits and clinical significance】
① Purulent leucorrhea: yellow or yellow-green, smelly, seen in trichomonas or purulent bacterial infection. Foamy purulent leucorrhea is common in trichomonal vaginitis.
②Tofu-like leucorrhea: Thick tofu-like or curd-like small pieces, common in fungal vaginitis, patients often accompanied by genital itching.
③Bloody leucorrhea: There is blood mixed in the leucorrhea, which has a special odor. It can be found in cervical polyps, uterine submucosal tumors, senile vaginitis, chronic cervicitis, and cervical cancer (often with a special odor).
④ Yellow watery leucorrhea: It is often caused by degeneration and necrosis of lesion tissue, such as uterine submucosal fibroids, cervical cancer, uterine body cancer and fallopian tube cancer. ⑤ creamy leucorrhea: seen in vaginal Gardnerella infection.
cleanliness check
Examination methods include wet film method and smear staining method. The wet sheet method is simple, fast and commonly used in clinical practice, but the results of bacterial observation are poor. The smear staining examination can clearly observe the cell structure and bacteria, and the result is accurate and objective, but it is complicated, time-consuming and rarely used.
[Reference value] Degree I～II.
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[Clinical Significance] The cleanliness of vaginal secretions is an index for judging vaginal inflammation and ovarian gonad secretion function in women of childbearing age. Grades III to IV are abnormal, more common in vaginitis, and pathogens can often be found at the same time. When the simple cleanliness is abnormal and no pathogens are found, it is non-specific vaginitis; when ovarian function is insufficient and estrogen levels are reduced, vaginal epithelial cell proliferation is poor, glycogen is reduced, vaginal bacillus is reduced, and it is easy to be infected with miscellaneous bacteria, resulting in vaginal insufficiency. Cleansing, such as before menstruation and after menopause.
Trichomonas vaginalis: It is a flagellate that parasitizes the female vagina and urethra and the male urethra and prostate
Inspection methods include wet film method, smear staining method, latex agglutination test and in vitro culture method.
The wet film method is simple and fast, and is a commonly used method in clinical laboratories. The disadvantage is that it is affected by the time, temperature, thickness of the smear and the level of the examiner, and the positive rate is low.
The smear staining inspection can use the oil lens to observe the parasite structure, which can improve the detection rate. However, affected by various factors such as smear and staining, for example, the worm body may be atypical and the size varies greatly, and the examiner is required to have rich experience.
Latex agglutination test is available in kits. It is easy to operate, fast, and has high sensitivity and specificity. It is better than wet sheet method and culture method, and is suitable for routine clinical applications. However, non-specific reactions may occur when vaginal secretions are viscous.
The positive rate of the culture method is high, but the operation is complicated. It is mainly used for the inspection of carriers with mild symptoms or chronic patients and as a basis for diagnosis and treatment observation.
Gardnerella vaginalis (GV)
Under normal circumstances, there is no or a little in the vagina, and the inspection of Lactobacillus and Gardnerella can be used as a reference for the diagnosis of bacterial vaginosis. Under normal circumstances, the number of lactobacilli is 6~30 or more than 30/HPF.
1. Non-bacterial vaginosis: Lactobacillus > 5/HPF, only a few Gardnerella vaginalis.
2. Bacterial vaginosis: Lactobacillus <5/HPF or none, but Gardnerella vaginalis and other small G+/G- bacteria increased in large numbers.
Clue cells: It is one of the important indicators for the diagnosis of Gardnerella vaginitis. Its main features: Vaginal squamous epithelial cells adhere to a large number of Gardnerella and other small bacillus, forming a huge cell mass, the surface of the epithelial cells is rough, with spots and a large number of fine particles.
cerebrospinal fluid
Cerebrospinal fluid (CSF): is a colorless, clear fluid that exists in the ventricles, subarachnoid space, and central canal of the spinal cord. It is mainly secreted actively by the choroid plexus of the ventricle.
color
【Reference range】Colorless transparent or light yellow
Newborns may be yellow due to migration of bilirubin. When there is inflammation, injury, tumor or obstruction in the central system, the blood-brain barrier is destroyed, the composition changes, and its color changes.
【Clinical Significance】
(1) Red: common in bleeding of various causes, especially bleeding from puncture injury, subarachnoid space or ventricle hemorrhage.
In addition, when the yellow pigment, carotene, melanin, and lipid pigment in the cerebrospinal fluid increase, the cerebrospinal fluid can also turn yellow.
(2) Yellow: Yellow cerebrospinal fluid is called jaundice, which can be caused by hemorrhage, jaundice, stasis, obstruction, etc.
①Hemorrhagic jaundice: seen in old subarachnoid hemorrhage or cerebral hemorrhage, due to the release of hemoglobin from red blood cells, bilirubin increases. The cerebrospinal fluid can turn yellow after 4-8 hours of bleeding, the color is the darkest at 48 hours, and can last for about 21 days.
②Icteric jaundice: seen in severe icteric hepatitis, liver cirrhosis, leptospirosis, bile duct obstruction, neonatal hemolytic disease, etc., due to the increase of bilirubin in the cerebrospinal fluid, it turns yellow.
③ Stasis jaundice: When the intracranial veins and cerebrospinal fluid are stagnant, red blood cells leak from the capillaries, resulting in increased bilirubin in the cerebrospinal fluid, which makes the cerebrospinal fluid yellow.
④ Obstructive jaundice: seen in spinal canal obstruction caused by extramedullary tumors, etc., leading to a significant increase in protein content in cerebrospinal fluid. When the protein exceeds 1.5g/L, the cerebrospinal fluid can turn yellow. The degree of yellow is directly proportional to the protein content of cerebrospinal fluid, and the lower the obstruction site, the more obvious the yellow.
(3) White: mostly caused by leukocytosis in cerebrospinal fluid, common in suppurative meningitis caused by Neisseria meningitidis, Streptococcus pneumoniae, and hemolytic streptococcus.
(4) Green: more common in Pseudomonas aeruginosa and acute pneumococcal meningitis.
(5) Brown or black: more common in meningeal melanosarcoma or melanoma.
(6) Colorless: In addition to normal cerebrospinal fluid, it can also be seen in viral encephalitis, mild tuberculous meningitis, poliomyelitis, neurosyphilis, etc.
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transparency
[Reference interval] Normal cerebrospinal fluid is clear and transparent.
【Clinical Significance】
The turbidity of cerebrospinal fluid is related to the number of cells and bacteria contained in it. When the leukocytes in cerebrospinal fluid exceed 300×10^6/L, it can be turbid; when the protein in cerebrospinal fluid is significantly increased or contains a large number of bacteria and fungi, cerebrospinal fluid can also become turbid. turbid.
The cerebrospinal fluid of tuberculous meningitis may be ground-glass turbid, the cerebrospinal fluid of suppurative meningitis may be purulent or blocky turbid, and the cerebrospinal fluid of puncture injury may be slightly red turbid. The cerebrospinal fluid of viral encephalitis and neurosyphilis can be transparent.
Generally divided into three levels: clear and transparent, slightly cloudy, cloudy
Coagulation
[Reference interval] Normal cerebrospinal fluid will not form a film, clot or precipitate after being placed for 12-24 hours.
【Clinical Significance】
The formation of cerebrospinal fluid film is related to the protein contained in it, especially the content of fibrinogen. When the protein content in cerebrospinal fluid exceeds 10g/L, film, clot or precipitation may appear. The cerebrospinal fluid of suppurative meningitis can form clots or sediments after standing for 1-2 hours. After the cerebrospinal fluid of tuberculous meningitis is left to stand for 12-24 hours, a thin omentum is formed on the surface of the specimen, and a high positive rate can be obtained by taking this omentum for tuberculosis examination. When the subarachnoid space is obstructed, the protein content of the cerebrospinal fluid can reach 15 g/L due to the obstruction of the cerebrospinal fluid circulation, and the cerebrospinal fluid can be yellow gelatinous.
Frion-Nonne syndrome: colloidal coagulation, yellowing, and protein-cell separation in cerebrospinal fluid (the protein content is obviously ↑, and the cells are normal or slightly increased), which is called ~.
protein
The protein content in cerebrospinal fluid is lower than that in plasma, about 0.5% of plasma. There are two methods of qualitative and quantitative examination of cerebrospinal fluid protein.
Qualitative methods: Pandy test, ammonium sulfate test and Leevinson test.
① pandy test: protein and phenol are combined to form an insoluble protein salt. The required sample volume is small, the sensitivity is high, the operation is simple, and the result is easy to observe. However, this test is too sensitive, and some normal people may appear weakly positive. ② Ammonium sulfate test: The use of globulin can produce precipitation or turbidity in saturated ammonium sulfate. The operation is more complicated, and the sensitivity is not as good as the pandy test, but the specificity is high. ③ Leevinson test: time-consuming operation, low specificity.
【Reference interval】
① Qualitative: Negative or weakly positive. ②Quantitative: lumbar puncture: 0.2~0.4g/L; cisterna magna puncture: 0.1~0.25g/L; lateral ventricle puncture: 0.05~0.15g/L.
【Clinical Significance】
Strong positive cerebrospinal fluid protein is common in brain tissue and meningeal inflammatory lesions, such as suppurative meningitis, tuberculous meningitis, polio, and meningitis. Strong positivity is seen in cerebral hemorrhage, traumatic brain injury, etc. (blood mixed into cerebrospinal fluid).
glucose
The glucose content in the cerebrospinal fluid of healthy people is only 50% to 80% of the blood sugar. The glucose content of premature infants/newborns is slightly higher than that of adults due to the imperfect development of the blood-brain barrier (BBB).
The detection methods include glucose oxidase method and hexokinase method (the accuracy and specificity of the latter are higher than the former)
【Reference interval】
Lumbar puncture: 2.5~4.4mmol/L; cisterna magna puncture: 2.8~4.2mmol/L; ventricle puncture: 3.0~4.4g/L.
【Clinical Significance】
Reduce: ① acute suppurative meningitis, tuberculous meningitis, fungal meningitis, the lower the glucose content, the worse the prognosis. ② Brain tumors, especially malignant tumors. ③ neurosyphilis. ④ hypoglycemia.
Elevation: ① full meal or intravenous glucose (blood sugar ↑). ② Cerebral hemorrhage. ③ Acute/severe trauma affecting the brainstem. ④ Diabetes.
chloride
The content of chloride in CSF is related to blood chloride concentration, pH, blood-brain barrier permeability and protein content.
Detection principle: Commonly used are mercury nitrate titration method, mercury thiocyanate colorimetric method, ion selective electrode method, galvanometric method, etc.
【Reference interval】
120~130mmol/L for adults; 111~123mmol/L for children.
【Clinical Significance】
Reduced seen in: ① bacterial meningitis and fungal meningitis early, tuberculous meningitis (the reduction in chloride earlier than glucose decreased), ② vomiting, adrenal insufficiency and kidney disease. ③ Viral encephalitis, poliomyelitis, and brain tumors (slightly lower or not lower).
Increased seen in: uremia, dehydration, heart failure and serous meningitis.
microscopic examination
1. Total cell count check: For clear or slightly mixed cerebrospinal fluid samples, the total cell count can be directly counted. If there are too many cells in the sample, dilute the sample with normal saline or red blood cell diluent, then use the direct counting method to count the total number of cells, and multiply the result by the dilution factor.
2. White blood cell count: direct counting method can be used. If there are too many white blood cells, it can be diluted with white blood cell diluent, and then the white blood cells are counted by direct counting method, and the result is multiplied by the dilution factor.
3. Differential counting of white blood cells: After direct counting of white blood cells, the classification and counting of white blood cells and the morphological characteristics of the nucleus are carried out under a high-power microscope. Wright staining can also be used to classify and count under the oil immersion microscope.
[Reference value] ①No red blood cells. ② Very few white blood cells, adults: (0-8)×10^6/L, children: (1-15)×10^6/L, mainly mononuclear cells, the ratio of lymphocytes to monocytes is 7: 3. Endothelial cells are occasionally seen.
[Clinical Significance] Cerebrospinal fluid leukocytes of (10-50)×10^6/L are mildly increased, (50-100)×10^6/L are moderately increased, and greater than 200×10^6/L are significantly increased .
Significantly increased: mainly seen in suppurative meningitis, mainly increased neutrophils.
Mild or moderate increase: common in tuberculous meningitis, neutrophils dominate in the early stage of the disease, lymphocytes dominate in the later stage, and neutrophils, lymphocytes, and plasma cells co-exist.
Normal or slightly increased: mainly seen in serous meningitis, viral meningitis, cerebral edema, and mainly lymphocytes.
Parasitic infection: increased eosinophils.
Subarachnoid hemorrhage or cerebral hemorrhage: red blood cells significantly increased.
Clinical Application of Cerebrospinal Fluid Examination
Clinically, cerebrospinal fluid inspection items can be divided into two categories: routine inspection items and special inspection items
1. Routine examination: measurement of cerebrospinal fluid pressure, total cell count (WBC+RBC), cell differential count, cerebrospinal fluid/plasma glucose ratio, total protein determination, etc.
The clinical application of routine inspection items is as follows.
(1) Application in the diagnosis and treatment of central nervous system infectious diseases
Viral meningitis, tuberculous meningitis, fungal meningitis
(2) Application in the diagnosis and treatment of central nervous system tumors
Cerebrospinal fluid examination finds tumor cells, which is helpful for the diagnosis of central nervous system tumors. However, the positive rate of primary tumors (except medulloblastoma) is low, and the positive rate of brain metastases and meningeal cancer can reach about 80%.
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2. Special inspection:
Culture, including bacteria (also M. tuberculosis), fungi, viruses, etc.; Gram/acid-fast stain, bacterial/fungal antigens, enzymes (LD, ADA, CK-BB), lactic acid, PCR for M. tuberculosis and Virus, protein electrophoresis, special protein determination (CRP, TRF), syphilis test, etc.
serous cavity effusion
The thoracic cavity, abdominal cavity, and pericardial cavity of the human body are collectively referred to as the serous cavity. Under normal circumstances, there is only a small amount of liquid, which mainly acts as a lubricant. A small amount of fluid in the serosa of normal people comes from plasma filtration in the parietal serosa capillaries and is reabsorbed through the lymphatic vessels and venules of the visceral serosa.
[Normal value] Pleural fluid <20ml, peritoneal fluid <50ml, pericardial fluid about 10-30ml, joint cavity fluid 0.1-0.2ml.
Serosal cavity effusion: When the serosa has inflammation, circulation disorder, malignant tumor and other lesions, the serosal cavity fluid will increase and accumulate in the serosal cavity, and its properties will also change, which is called ~ at this time.
1. Transudate: Generally, it is non-inflammatory effusion. The reasons for the formation of transudate are:
1. Capillary blood pressure increases; 2. Intravascular colloid osmotic pressure decreases; 3. Lymphatic return is blocked; 4. Water and sodium retention:
2. Exudate: Most of them are inflammatory effusions. During inflammation, due to the toxins of pathogenic microorganisms, hypoxia, and inflammatory mediators, the vascular endothelial cells are damaged, and the vascular permeability increases, resulting in liquid and intravascular macromolecular substances (such as Albumin, globulin, fibrin, etc.) and various cell components leak from the blood vessel to the outside of the blood vessel, the interstitial space and the serous cavity, forming a effusion. See below for the reasons:
1. Infectiousness: such as suppurative bacteria, mycobacteria, viruses or mycoplasma, etc.
2. Malignant tumors: produce vasoactive substances, increase the permeability of serosal capillaries
3. Others: such as trauma, chemical stimulation (blood, urine, bile and gastric juice), rheumatic diseases, etc. can also cause effusion.
[Precautions] If the specimen has been confirmed to be a transudate through general inspection, bacterial testing is not required; if it has been confirmed to be an exudate, bacterial testing should be done.
collection of specimens
It is usually obtained by a clinician through serosal cavity puncture; the collected specimens are divided into 4 tubes,
Tube 1 for bacteriology; tube 2 for chemistry and immunology; tube 3 for cytology and tube 4 for observation of coagulation.
EDTA-K2 anticoagulation should be used for routine and cytological examination, and heparin anticoagulation should be used for chemical examination.
Note: The inspection and testing must be timely; if the inspection cannot be done, absolute ethanol should be added and stored in the refrigerator.
The color of the serous effusion
Normal pleural fluid, peritoneal fluid, and pericardial fluid are clear, pale yellow fluids, and different color changes may occur under pathological conditions. Generally, the exudate is dark in color and the transudate is light in color.
【Abnormal color and clinical significance】
①Red: bloody. It can be caused by puncture injury, tuberculosis, tumor, visceral injury, bleeding disorder, etc. ② Purulent pale yellow: purulent infection milky white: caused by a large number of leukocytes and bacteria in purulent infection, true chylus when the thoracic duct is blocked or ruptured, or pseudochylous when it contains a large number of fatty degeneration cells. Purulent effusions with a foul smell are mostly caused by infections caused by anaerobic bacteria. ③Green: caused by Pseudomonas aeruginosa infection; brown: mostly caused by amoebic abscess ruptured into the chest cavity or abdominal cavity; ④yellow or light yellow: jaundice due to various causes; ⑤black: caused by Aspergillus Caused by infection; ⑥ straw yellow: more common in pericardial effusion caused by uremia.
Volume of Serous Effusion
Normally, there is a small amount of fluid in the thoracic cavity, abdominal cavity, and pericardial cavity, but under pathological conditions, the fluid increases, and the degree of increase is related to the location of the lesion and the severity of the disease. It can range from a few milliliters to thousands of milliliters.
Transparency (clear, slightly cloudy, cloudy)
Normal pleural fluid, peritoneal fluid, and pericardial fluid are clear and transparent fluids. The transparency of the effusion is often related to the degree of cells, bacteria, and proteins contained in it.
The exudate is turbid to varying degrees, and the chyle is also turbid because it contains a lot of fat; the transudate is generally clear and transparent.
Coagulation
The transudate generally does not coagulate, and the exudate often coagulates by itself or clots appear.
Reason: The role of fibrinogen, which can degrade fibrin when the exudate contains plasmin.
proportion
Depending on protein content, transudates are less than 1.015 and exudates are greater than 1.018.
The pH of the serous cavity effusion: need to isolate the air and send it for inspection in time
[Reference interval] transudate: 7.455-7.465; exudate: 6.87-7.39
【Clinical Significance】
1. Pleural effusion: pH < 7.4, inflammatory effusion; pH < 7.3, accompanied by decreased glucose, suggesting complications; pH < 6.0, mostly due to gastric juice entering the pleural cavity, seen in esophageal rupture and severe empyema.
2. Peritoneal effusion: When accompanied by infection, the acidic substances produced by bacterial metabolism increase, reducing the pH. A pH less than 7.3 has a sensitivity and specificity of 90% for the diagnosis of spontaneous bacterial peritonitis.
3. Pericardial effusion: Significant reduction can be seen in rheumatic, tuberculosis, suppurative, malignant tumor, uremic pericarditis, etc. Among them, the reduction of malignant and tuberculous effusion is more obvious.
protein check
1. Qualitative-Rivalta test
Serosa epithelial cells increase mucin secretion under inflammatory stimuli. Pleural and ascites were added dropwise to dilute acetic acid to see if there was protein precipitation.
Negative: clear, no mist; Positive: white mist, which sinks to the bottom of the tube and does not disappear.
Negative below 30g/L, positive above 40g/L, about 80% positive between the two.
2. Quantitative-biuret method for protein determination
Total protein, globulin, fibrin, etc.,
The exudate is greater than 30g/L, and the transudate is less than 25g/L.
3. Serum-ascites albumin gradient (SAAG)
In recent years, it has been considered that the ratio of effusion/serum protein is more accurate. Generally, a ratio greater than 0.5 is a transudate, and a ratio less than 0.5 is a transudate. Pleural effusion is generally identified by this. Ascites is generally identified using a serum-ascites albumin gradient (SAAG). One of the most basic causes of portal hypertension is the pressure differential between the portal vessels and the ascites.
SAAG = serum albumin concentration - ascites albumin concentration (g/L)
①, SAAG ≥ 11g/L, mostly portal hypertension, transudate.
②, SAAG<11g/L means no portal hypertension, mostly exudate. 97% accuracy.
Glucose determination
The glucose content in the transudate is similar to the blood sugar content, which is 3.9-6.1mmol/L,
The glucose in the exudate can be decomposed by some bacteria and reduced. The glucose content in the pleural effusion of patients with suppurative pleurisy is significantly reduced, usually lower than 1.12mmol/L; the glucose content in the effusion of patients with tuberculous pleurisy is also significantly reduced. About half of the cases can be lower than 3.30mol/L; the glucose content in cancerous pleural effusion is not significantly reduced, but when the cancer cells infiltrate the pleura extensively, the glucose content in pleural effusion can be reduced to 1.68-3.30mmol/L.
Serous cavity effusion cell count (microscopic examination)
All nucleated cells, including mesothelial cells, are included in the cell count.
Bloody effusions caused by malignant tumors account for 50%-85%. When the red blood cells in the effusion are greater than 0.1×10^12/L, malignant tumors, pulmonary embolism, puncture loss, trauma, etc. should be considered.
1. Check the total number of cells: clear or slightly mixed samples can be counted directly. If there are too many cells in the sample, dilute the sample with normal saline or red blood cell diluent and count it.
2. White blood cell count: direct counting method can be used. If there are too many white blood cells, count the white blood cells after diluting with white blood cell diluent.
3. Differential counting of white blood cells: After direct counting of white blood cells, the classification and counting of white blood cells is carried out under a high-power microscope according to the morphological characteristics of white blood cells and nuclei. Wright staining can also be used to classify and count under the oil immersion microscope.
【Reference】
1. The number of white blood cells in the transudate does not exceed 100×10^6/L, mainly mesothelial cells and lymphocytes.
2. The number of white blood cells in the exudate is more than 500×10^6/L.
【Clinical Significance】
①Mainly neutrophils: more common in acute suppurative infection or early stage of tuberculosis infection; ②Mainly lymphocytes: seen in various chronic infections of tuberculosis and syphilitic; ③Eosinophilia: more common in allergic diseases or Parasitic diseases ④ Tumor cells: The detection of tumor cells is an important basis for the diagnosis of primary or metastatic tumors.
① Mesothelial cells: abundant cytoplasm, pale blue, containing a few vacuoles, 1-3 large nucleoli, all purple, large nuclei, located in the center or offset, cells are relatively large, about 15-30um , round or oval, the shape may be very irregular in the exudate, and the nucleolus may not be seen in the naive type, and sometimes it is even indistinguishable from malignant cells. ② Histiocytes: generally slightly larger than white blood cells, with a diameter generally not exceeding 16um, the cells are lightly stained, the nuclei are kidney-shaped or irregular, deviated, the nuclei are dense, and the cytoplasm is mostly foamy. Seen in congestion, malignant tumors, etc. ③Plasma cells: the cytoplasm is foamy blue, and the nucleus is car-spoke, which is seen in hyperplastic myeloma.
Distinguishing between transudate and exudate
PART1
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part2
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Differentiation of benign/malignant ascites
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Differentiation of tuberculous and malignant pleural effusion
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