Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


PATIENT INFO
Patient Name:
Medical Record #:
BD:        /        /              Sex:    F    M

PHYSICIAN INFO
Physician Name :
Address:
Ph: (        )        -              Fax: (        )        -              
Additional Report to:
Ph: (        )        -              Fax: (        )        -              

TESTS REQUESTED
Test Name: ICD9 Code: (required)
1. Bile Acids, Fractionated   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Bile Acids, Fractionated
CPT Code: 83789

Specimen Type: Blood

Tube Type/Collection Container: Red top (no anticoagulant) tube

Collection Volume: 2.5 mL (minimum 0.5 mL)

Storage: Refrigerated

Availability: Sent to reference lab

Methodology: Liquid Chromatography Tandem Mass Spectrometry

Special Instructions: Overnight fasting preferred.

TAT: 3-7 days

Panel Includes: Cholic Acid, Chenodeoxycholic Acid, Deoxycholic Acid, Urodeoxycholic Acid, Total Fractionated Bile Acids


Lab/Phone: 330-543-8418

Additional Info: Reference range: Cholic Acid: < or = 3.00 nmol/mL Deoxycholic Acid: < or = 2.20 nmol/mL Chenodeoxycholic Acid: < or = 5.00 nmol/mL Urodeoxycholic Acid: < or = 1.00 nmol/mL Total Fractionated Bile Acids: < or = 8.00 nmol/mL

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: