Bristol stool scale

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Bristol stool scale
Bristol stool scale neutral.png
Bristol stool chart
Synonyms Bristol stool chart (BSC); [1] Bristol Stool Scale (BSS); Bristol Stool Form Scale (BSFS or BSF scale); [2]
Purposeclassify type of feces (diagnostic triad for irritable bowel syndrome) [3]

The Bristol stool scale is a diagnostic medical tool designed to classify the form of human faeces into seven categories. [4] It is used in both clinical and experimental fields. [5] [6] [7]

Contents

It was developed at the Bristol Royal Infirmary as a clinical assessment tool in 1997, [8] and is widely used as a research tool to evaluate the effectiveness of treatments for various diseases of the bowel, as well as a clinical communication aid; [9] [10] including being part of the diagnostic triad for irritable bowel syndrome. [11]

Interpretation

The seven types of stool are: [12]

Types 1 and 2 indicate constipation, with 3 and 4 being the ideal stools as they are easy to defecate while not containing excess liquid, and 6 and 7 indicate diarrhoea. [13]

In the initial study, in the population examined in this scale, the type 1 and 2 stools were more prevalent in females, while the type 5 and 6 stools were more prevalent in males; furthermore, 80% of subjects who reported rectal tenesmus (sensation of incomplete defecation) had type 7. These and other data have allowed the scale to be validated. [12] The initial research did not include a pictorial chart with this being developed at a later point. [8]

The Bristol stool scale is also very sensitive to changes in intestinal transit time caused by medications, such as antidiarrhoeal loperamide, senna, or anthraquinone with laxative effect. [14]

Uses

Diagnosis of irritable bowel syndrome

People with irritable bowel syndrome (IBS) typically report that they suffer with abdominal cramps and constipation. In some patients, chronic constipation is interspersed with brief episodes of diarrhoea; while a minority of patients with IBS have only diarrhoea. The presentation of symptoms is usually months or years and commonly patients consult different doctors, without great success, and doing various specialized investigations. It notices a strong correlation of the reported symptoms with stress; indeed diarrhoeal discharges are associated with emotional phenomena. IBS blood is present only if the disease is associated with haemorrhoids. [15]

Research conducted on irritable bowel syndrome in the 2000s, [16] [17] faecal incontinence [18] [19] [20] [21] and the gastrointestinal complications of HIV [22] have used the Bristol scale as a diagnostic tool easy to use, even in research which lasted for 77 months. [23]

Historically, this scale of assessment of the faeces has been recommended by the consensus group of Kaiser Permanente Medical Care Program (San Diego, California, US) for the collection of data on functional bowel disease (FBD). [15]

More recently, according to the latest revision of the Rome III Criteria, six clinical manifestations of IBS can be identified: [24] [25] [26] [27] [28]

Subtypes prevalent presentation of stool in IBS according to the Rome III Criteria [29]
1. IBS with constipation (IBS-C) – lumpy or hard stools * ≥ 25% and loose (soft) or watery stools † <25% of bowel movements. ‡
2. IBS with diarrhea (IBS-D) – loose (soft) or watery stools † ≥ 25% and lumpy or hard stools * <25% of bowel movements. ‡
3. Mixed IBS (IBS - M) – lumpy or hard stools * ≥ 25% and loose (soft) or watery stools † ≥ 25% of bowel movements. ‡
4. Untyped IBS (IBS - U) – insufficient stool abnormalities to be IBS-C, D or M ‡
* Bristol stool scale type 1–2 (Separate hard lumps like nuts or sausage-shaped);
† Bristol stool scale type 6–7 (fluffy pieces with ragged edges, soft or watery, no solid or completely liquid pieces);
‡ In the absence of the use of antidiarrhoeal or laxative.

These four identified subtypes correlate with the consistency of the stool, which can be determined by the Bristol stool scale. [15]

In 2007, the Mayo Clinic College of Medicine in Rochester, Minnesota, United States, reported a piece of epidemiological research conducted on a population of 4,196 people living in Olmsted County Minnesota, in which participants were asked to complete a questionnaire based on the Bristol stool scale. [30]

Distribution of risk factors in three groups classified according to the colonic transit and subgroups classified according to the type of feces model century [30]
Normal
colonic transit
(BSS 3–4)
(n=1662)		Slow
colonic transit
(BSS 1–2)
(n=411)		Fast
colonic transit
(BSS 5–7)
(n=197)
Age (mean ± s.d.; years)62 ± 1263 ± 1361 ± 12
Male (%)503843
BMI (mean ± s.d.)29.6 ± 7.528.2 ± 6.832.5 ± 9.9
SSC score (mean ± s.d.) (Somatic Symptom Checklist)1.6 ± 0,501.7 ± 0.531.8 ± 0.57
Smoking (%)8712
Alcohol (%)454841
Cholecystectomy (%)111219
Appendectomy (%)283135
Birth control pills (% women)353
Marital status
Married (%)807776
School level
Compulsory education (%)557
High school/some years (%)535258
Diploma or university (%)414236
Family history
Gastric cancer (%)161415
Bowel cancer (%)121115

The research results (see table) indicate that about 1 in 5 people have a slow transit (type 1 and 2 stools), while 1 in 12 has an accelerated transit (type 5 and 6 stools). Moreover, the nature of the stool is affected by age, sex, body mass index, whether or not they had cholecystectomy and possible psychosomatic components (somatisation); there were no effects from factors such as smoking, alcohol, the level of education, a history of appendectomy or familiarity with gastrointestinal diseases, civil state, or the use of oral contraceptives.

Therapeutic evaluation

Several investigations correlate the Bristol stool scale in response to medications or therapies, in fact, in one study was also used to titrate the dose more finely than one drug (colestyramine) in subjects with diarrhoea and faecal incontinence. [31]

In a randomised controlled study, [32] the scale is used to study the response to two laxatives: Macrogol (polyethylene glycol) and psyllium ( Plantago psyllium and other species of the same genus) of 126 male and female patients for a period of 2 weeks of treatment; failing to show the most rapid response and increased efficiency of the former over the latter. In the study, they were measured as primary outcomes : the number weekly bowel movements, stool consistency according to the types of the Bristol stool scale, time to defecation, the overall effectiveness, the difficulty in defecating and stool consistency. [32]

From 2010, several studies have used the scale as a diagnostic tool validated for recognition and evaluation of response to various treatments, such as probiotics, [33] [34] moxicombustion, [35] laxatives in the elderly, [36] preparing Ayurvedic poly-phytotherapy filed TLPL/AY, [37] psyllium, [38] mesalazine, [39] methylnaltrexone, [40] and oxycodone/naloxone, [41] or to assess the response to physical activity in athletes. [42]

History

Developed and proposed for the first time in England by Stephen Lewis and Ken Heaton at the University Department of Medicine, Bristol Royal Infirmary, it was suggested by the authors as a clinical assessment tool in 1997 in the Scandinavian Journal of Gastroenterology [14] after a previous prospective study, conducted in 1992 on a sample of the population (838 men and 1,059 women), had shown an unexpected prevalence of defecation disorders related to the shape and type of stool. [43] The authors of the former paper concluded that the form of the stool is a useful surrogate measure of colon transit time. That conclusion has since been challenged as having limited validity for Types 1 and 2; [44] however, it remains in use as a research tool to evaluate the effectiveness of treatments for various diseases of the bowel, as well as a clinical communication aid. [9] [10]

Versions

The same scale has been validated in Spanish, [45] [20] Brazilian Portuguese, [46] and Polish versions. [47] A version has also been designed and validated for children. [48] [49] More recently, in September 2011, a modified version of the scale was validated using a criterion of self-assessment for ages six–eight years of age. [50] A modified version with extended descriptions for liquid fecal material was created for ostomates. [51]

A version of the scale was developed into a chart suitable for use on US television by Gary Kahan of NewYork–Presbyterian Hospital. [52]

Related Research Articles

<span class="mw-page-title-main">Defecation</span> Expulsion of feces from the digestive tract

Defecation follows digestion, and is a necessary process by which organisms eliminate a solid, semisolid, or liquid waste material known as feces from the digestive tract via the anus or cloaca. The act has a variety of names ranging from the common, like pooping or crapping, to the technical, e.g. bowel movement, to the obscene (shitting), to the euphemistic, to the juvenile. The topic, usually avoided in polite company, can become the basis for some potty humor.

<span class="mw-page-title-main">Constipation</span> Bowel dysfunction

Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement. Complications from constipation may include hemorrhoids, anal fissure or fecal impaction. The normal frequency of bowel movements in adults is between three per day and three per week. Babies often have three to four bowel movements per day while young children typically have two to three per day.

<span class="mw-page-title-main">Fecal incontinence</span> Inability to refrain from defecation

Fecal incontinence (FI), or in some forms, encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referred to as anal incontinence. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery, altered bowel habits. An estimated 2.2% of community-dwelling adults are affected. However, reported prevalence figures vary. A prevalence of 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.

<span class="mw-page-title-main">Irritable bowel syndrome</span> Functional gastrointestinal disorder

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by a group of symptoms that commonly include abdominal pain, abdominal bloating and changes in the consistency of bowel movements. These symptoms may occur over a long time, sometimes for years. IBS can negatively affect quality of life and may result in missed school or work or reduced productivity at work. Disorders such as anxiety, major depression, and chronic fatigue syndrome are common among people with IBS.

<span class="mw-page-title-main">Rectal prolapse</span> Medical condition

A rectal prolapse occurs when walls of the rectum have prolapsed to such a degree that they protrude out of the anus and are visible outside the body. However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on whether the prolapsed section is visible externally, and whether the full or only partial thickness of the rectal wall is involved.

Functional gastrointestinal disorders (FGID), also known as disorders of gut–brain interaction, include a number of separate idiopathic disorders which affect different parts of the gastrointestinal tract and involve visceral hypersensitivity and motility disturbances.

Functional constipation, known as chronic idiopathic constipation (CIC), is constipation that does not have a physical (anatomical) or physiological cause. It may have a neurological, psychological or psychosomatic cause. A person with functional constipation may be healthy, yet has difficulty defecating.

Rectal tenesmus is a feeling of incomplete defecation. It is the sensation of inability or difficulty to empty the bowel at defecation, even if the bowel contents have already been evacuated. Tenesmus indicates the feeling of a residue, and is not always correlated with the actual presence of residual fecal matter in the rectum. It is frequently painful and may be accompanied by involuntary straining and other gastrointestinal symptoms. Tenesmus has both a nociceptive and a neuropathic component.

<span class="mw-page-title-main">Fecal impaction</span> Medical condition

A fecal impaction or an impacted bowel is a solid, immobile bulk of feces that can develop in the rectum as a result of chronic constipation. Fecal impaction is a common result of neurogenic bowel dysfunction and causes immense discomfort and pain. Its treatment includes laxatives, enemas, and pulsed irrigation evacuation (PIE) as well as digital removal. It is not a condition that resolves without direct treatment.

<span class="mw-page-title-main">Renzapride</span> Chemical compound

Renzapride is a prokinetic agent and antiemetic which acts as a full 5-HT4 agonist and partial 5-HT3 antagonist. It also functions as a 5-HT2B antagonist and has some affinity for the 5-HT2A and 5-HT2C receptors.

The Rome process and Rome criteria are an international effort to create scientific data to help in the diagnosis and treatment of functional gastrointestinal disorders, such as irritable bowel syndrome, functional dyspepsia and rumination syndrome. The Rome diagnostic criteria are set forth by Rome Foundation, a not for profit 501(c)(3) organization based in Raleigh, North Carolina, United States.

<span class="mw-page-title-main">Lubiprostone</span> Medication used for constipation

Lubiprostone, sold under the brand name Amitiza among others, is a medication used in the management of chronic idiopathic constipation, predominantly irritable bowel syndrome-associated constipation in women and opioid-induced constipation. The drug is owned by Mallinckrodt and is marketed by Takeda Pharmaceutical Company.

<span class="mw-page-title-main">Human feces</span> Metabolic waste of the human digestive system

Human feces are the solid or semisolid remains of food that could not be digested or absorbed in the small intestine of humans, but has been further broken down by bacteria in the large intestine. It also contains bacteria and a relatively small amount of metabolic waste products such as bacterially altered bilirubin, and the dead epithelial cells from the lining of the gut. It is discharged through the anus during a process called defecation.

Bowel management is the process which a person with a bowel disability uses to manage fecal incontinence or constipation. People who have a medical condition which impairs control of their defecation use bowel management techniques to choose a predictable time and place to evacuate. A simple bowel management technique might include diet control and establishing a toilet routine. As a more involved practice a person might use an enema to relieve themselves. Without bowel management, the person might either suffer from the feeling of not getting relief, or they might soil themselves.

Bile acid malabsorption (BAM), known also as bile acid diarrhea, is a cause of several gut-related problems, the main one being chronic diarrhea. It has also been called bile acid-induced diarrhea, cholerheic or choleretic enteropathy, bile salt diarrhea or bile salt malabsorption. It can result from malabsorption secondary to gastrointestinal disease, or be a primary disorder, associated with excessive bile acid production. Treatment with bile acid sequestrants is often effective. It is recognised as a disability in the United Kingdom under the Equality Act 2010

<span class="mw-page-title-main">Anismus</span> Medical condition

Anismus or dyssynergic defecation is the failure of normal relaxation of pelvic floor muscles during attempted defecation. It can occur in both children and adults, and in both men and women. It can be caused by physical defects or it can occur for other reasons or unknown reasons. Anismus that has a behavioral cause could be viewed as having similarities with parcopresis, or psychogenic fecal retention.

Obstructed defecation syndrome is a major cause of functional constipation, of which it is considered a subtype. It is characterized by difficult and/or incomplete emptying of the rectum with or without an actual reduction in the number of bowel movements per week. Normal definitions of functional constipation include infrequent bowel movements and hard stools. In contrast, ODS may occur with frequent bowel movements and even with soft stools, and the colonic transit time may be normal, but delayed in the rectum and sigmoid colon.

<span class="mw-page-title-main">Neurogenic bowel dysfunction</span> Human disease involving inability to control defecation

Neurogenic bowel dysfunction (NBD) is the inability to control defecation due to a deterioration of or injury to the nervous system, resulting in faecal incontinence or constipation. It is common in people with spinal cord injury (SCI), multiple sclerosis (MS) or spina bifida.

<span class="mw-page-title-main">Satish SC Rao</span>

Satish Sanku Chander Rao is the J.Harold Harrison Distinguished University Chair in Gastroenterology at the Medical College of Georgia, Augusta University. He served as the former President of the American Neurogastroenterology and Motility Society and as Chair of the American Gastroenterological Association (AGA) Institute Council, Neurogastroenterology/Motility Section.

Low anterior resection syndrome is a complication of lower anterior resection, a type of surgery performed to remove the rectum, typically for rectal cancer. It is characterized by changes to bowel function that affect quality of life, and includes symptoms such as fecal incontinence, incomplete defecation or the sensation of incomplete defecation, changes in stool frequency or consistency, unpredictable bowel function, and painful defecation (dyschezia). Treatment options include symptom management, such as use of enemas, or surgical management, such as creation of a colostomy.

References

  1. ↑ Amarenco G (2014). "Bristol Stool Chart: étude prospective et monocentrique de "l'introspection fécale" chez des sujets volontaires" [Bristol Stool Chart: Prospective and monocentric study of 'stools introspection' in healthy subjects]. Progrès en Urologie (in French). 24 (11): 708–13. doi:10.1016/j.purol.2014.06.008. PMID   25214452.
  2. ↑ Gut Sense What Exactly Are Normal Stools?, Konstantin Monastyrsky. Accessed July 2015
  3. ↑ What to know about the Bristol Stool Chart or Bristol Stool Scale.. N.p.: Dr.Hakim Saboowala, 2022.
  4. ↑ Harvey S, Matthai S, King DA (27 September 2022). "How to use the Bristol Stool Chart in childhood constipation". Archives of Disease in Childhood: Education and Practice Edition. 108 (5): 335–339. doi:10.1136/archdischild-2022-324513. PMID   36167665. S2CID   252567021.
  5. ↑ Koh H, Lee MJ, Kim MJ, Shin JI, Chung KS (February 2010). "Simple diagnostic approach to childhood fecal retention using the Leech score and Bristol stool form scale in medical practice". J Gastroenterol Hepatol. 25 (2): 334–8. doi:10.1111/j.1440-1746.2009.06015.x. PMID   19817956. S2CID   46258249.
  6. ↑ Corsetti M, De Nardi P, Di Pietro S, Passaretti S, Testoni P, Staudacher C (December 2009). "Rectal distensibility and symptoms after stapled and Milligan-Morgan operation for hemorrhoids". J Gastrointest Surg. 13 (12): 2245–51. doi:10.1007/s11605-009-0983-7. PMID   19672663. S2CID   30157677.
  7. ↑ Wang HJ, Liang XM, Yu ZL, Zhou LY, Lin SR, Geraint M (2004). "A Randomised, Controlled Comparison of Low-Dose Polyethylene Glycol 3350 plus Electrolytes with Ispaghula Husk in the Treatment of Adults with Chronic Functional Constipation". Clin Drug Investig. 24 (10): 569–76. doi:10.2165/00044011-200424100-00002. PMID   17523718. S2CID   29204976.
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  32. 1 2 Wang H, Liang X, Yu Z, Zhou L, Lin S, Geraint M (2004). "A Randomised, Controlled Comparison of Low-Dose Polyethylene Glycol 3350 plus Electrolytes with Ispaghula Husk in the Treatment of Adults with Chronic Functional Constipation". Clin Drug Investig. 24 (10): 569–76. doi:10.2165/00044011-200424100-00002. PMID   17523718. S2CID   29204976.
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  37. ↑ Munshi R, Bhalerao S, Rathi P, Kuber V, Nipanikar S, Kadbhane K (July 2011). "An open-label, prospective clinical study to evaluate the efficacy and safety of TLPL/AY/01/2008 in the management of functional constipation". J Ayurveda Integr Med. 2 (3): 144–52. doi: 10.4103/0975-9476.85554 . PMC   3193686 . PMID   22022157.
  38. ↑ Pucciani F, Raggioli M, Ringressi M (December 2011). "Usefulness of psyllium in rehabilitation of obstructed defecation". Tech Coloproctol. 15 (4): 377–83. doi:10.1007/s10151-011-0722-4. hdl: 2158/596461 . PMID   21779973. S2CID   7425517.
  39. ↑ Bafutto M, Almeida J, Leite N, Oliveira E, Gabriel-Neto S, Rezende-Filho J (2011). "Treatment of postinfectious irritable bowel syndrome and noninfective irritable bowel syndrome with mesalazine". Arq Gastroenterol. 48 (1): 36–40. doi: 10.1590/s0004-28032011000100008 . PMID   21537540.
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