The Bristol stool scale is a diagnostic
medical
Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care practic ...
tool designed to classify the form of
human faeces
Human feces (or faeces in British English) is 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 ba ...
into seven categories. It is used in both clinical and
experimental
An experiment is a procedure carried out to support or refute a hypothesis, or determine the efficacy or likelihood of something previously untried. Experiments provide insight into cause-and-effect by demonstrating what outcome occurs when ...
fields.
It was developed at the
Bristol Royal Infirmary
The Bristol Royal Infirmary, also known as the BRI, is a large teaching hospital situated in the centre of Bristol, England. It has links with the nearby University of Bristol and the Faculty of Health and Social Care at the University of the Wes ...
as a clinical assessment tool in 1997,
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;
[Bristol scale stool form. A still valid help in medical practice and clinical research G Riegler, I Esposito – ''Techniques in coloproctology'', 2001 – Springer] including being part of the diagnostic triad for
irritable bowel syndrome
Irritable bowel syndrome (IBS) is a "disorder of gut-brain interaction" characterized by a group of symptoms that commonly include abdominal pain and or abdominal bloating and changes in the consistency of bowel movements. These symptoms may ...
.
Interpretation
The seven types of stool are:
* Type 1: Separate hard lumps, like nuts (difficult to pass)
* Type 2: Sausage-shaped, but lumpy
* Type 3: Like a sausage but with cracks on its surface
* Type 4: Like a sausage or snake, smooth and soft (average stool)
* Type 5: Soft blobs with clear cut edges
* Type 6: Fluffy pieces with ragged edges, a mushy stool (diarrhoea)
* Type 7: Watery, no solid pieces, entirely liquid (diarrhoea)
Types 1 and 2 indicate
constipation
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 ...
, with 3 and 4 being the ideal stools as they are easy to
defecate
Defecation (or defaecation) 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. The act has a variety of names ranging fro ...
while not containing excess liquid, 5 indicating lack of
dietary fiber
Dietary fiber (in British English fibre) or roughage is the portion of plant-derived food that cannot be completely broken down by human digestive enzymes. Dietary fibers are diverse in chemical composition, and can be grouped generally by the ...
, and 6 and 7 indicate diarrhoea.
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
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 ...
(sensation of incomplete defecation) had type 7. These and other data have allowed the scale to be validated.
The initial research did not include a pictorial chart with this being developed at a later point.
The Bristol stool scale is also very sensitive to changes in intestinal transit time caused by medications, such as
antidiarrhoeal
An anti-diarrhoeal drug (or anti-diarrheal drug in American English) is any medication which provides symptomatic relief for diarrhoea.
Types
* Electrolyte solutions, while not true antidiarrhoeals, are used to replace lost fluids and salts in ac ...
loperamide
Loperamide, sold under the brand name Imodium, among others,Drugs.co Page accessed September 4, 2015 is a medication used to decrease the frequency of diarrhea. It is often used for this purpose in inflammatory bowel disease and short bowel synd ...
,
senna, or
anthraquinone
Anthraquinone, also called anthracenedione or dioxoanthracene, is an aromatic organic compound with formula . Isomers include various quinone derivatives. The term anthraquinone however refers to the isomer, 9,10-anthraquinone (IUPAC: 9,10-dioxo ...
with
laxative
Laxatives, purgatives, or aperients are substances that loosen stools and increase bowel movements. They are used to treat and prevent constipation.
Laxatives vary as to how they work and the side effects they may have. Certain stimulant, lubri ...
effect.
Uses
Diagnosis of irritable bowel syndrome
People with irritable bowel syndrome (IBS) typically report that they suffer with abdominal
cramp
A cramp is a sudden, involuntary, painful skeletal muscle contraction or overshortening associated with electrical activity; while generally temporary and non-damaging, they can cause significant pain and a paralysis-like immobility of the aff ...
s and
constipation
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 ...
.
In some patients, chronic constipation is interspersed with brief episodes of
diarrhoea
Diarrhea, also spelled diarrhoea, is the condition of having at least three loose, liquid, or watery bowel movements each day. It often lasts for a few days and can result in dehydration due to fluid loss. Signs of dehydration often begin wi ...
; 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
Stress may refer to:
Science and medicine
* Stress (biology), an organism's response to a stressor such as an environmental condition
* Stress (linguistics), relative emphasis or prominence given to a syllable in a word, or to a word in a phrase ...
; indeed diarrhoeal discharges are associated with
emotional phenomena.
IBS blood is present only if the disease is associated with
haemorrhoid
Hemorrhoids (or haemorrhoids), also known as piles, are vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become a disease when swollen or inflamed; the unqualified term ''hemo ...
s.
Research conducted on irritable bowel syndrome in the 2000s,
faecal incontinence
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 referre ...
and the gastrointestinal complications of
HIV
The human immunodeficiency viruses (HIV) are two species of ''Lentivirus'' (a subgroup of retrovirus) that infect humans. Over time, they cause acquired immunodeficiency syndrome (AIDS), a condition in which progressive failure of the immune ...
have used the Bristol scale as a diagnostic tool easy to use, even in research which lasted for 77 months.
Historically, this scale of assessment of the faeces has been recommended by the
consensus group of
Kaiser Permanente
Kaiser Permanente (; KP), commonly known simply as Kaiser, is an American integrated managed care consortium, based in Oakland, California, United States, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney Garfield. Kaiser P ...
Medical Care Program (
San Diego
San Diego ( , ; ) is a city on the Pacific Ocean coast of Southern California located immediately adjacent to the Mexico–United States border. With a 2020 population of 1,386,932, it is the List of United States cities by population, eigh ...
, California, US) for the collection of data on functional bowel disease (FBD).
More recently, according to the latest revision of the
Rome III Criteria, six clinical manifestations of IBS can be identified:
These four identified subtypes correlate with the consistency of the stool, which can be determined by the Bristol stool scale.
In 2007, the ''
Mayo Clinic College of Medicine
The Mayo Clinic College of Medicine and Science (MCCMS), formerly known as Mayo Clinic College of Medicine (MCCM), is a private graduate-only research university based in Rochester, Minnesota that trains physicians, scientists, and allied health ...
'' in
Rochester, Minnesota
Rochester is a city in the U.S. state of Minnesota and the county seat of Olmsted County. Located on rolling bluffs on the Zumbro River's south fork in Southeast Minnesota, the city is the home and birthplace of the renowned Mayo Clinic.
Acco ...
, United States, reported a piece of
epidemiological research
Epidemiology is the study and analysis of the distribution (who, when, and where), patterns and determinants of health and disease conditions in a defined population.
It is a cornerstone of public health, and shapes policy decisions and evidenc ...
conducted on a population of 4,196 people living in
Olmsted County Minnesota
Minnesota () is a state in the upper midwestern region of the United States. It is the 12th largest U.S. state in area and the 22nd most populous, with over 5.75 million residents. Minnesota is home to western prairies, now given over to ...
, in which participants were asked to complete a questionnaire based on the ''Bristol stool scale''.
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
Body mass index (BMI) is a value derived from the mass (weight) and height of a person. The BMI is defined as the body mass divided by the square of the body height, and is expressed in units of kg/m2, resulting from mass in kilograms and he ...
, whether or not they had
cholecystectomy
Cholecystectomy is the surgical removal of the gallbladder. Cholecystectomy is a common treatment of symptomatic gallstones and other gallbladder conditions. In 2011, cholecystectomy was the eighth most common operating room procedure performed i ...
and possible
psychosomatic
A somatic symptom disorder, formerly known as a somatoform disorder,(2013) somatisation
Somatization is a tendency to experience and communicate psychological distress in the form of bodily and organic symptoms and to seek medical help for them. More commonly expressed, it is the generation of physical symptoms of a psychiatric cond ...
); there were no effects from factors such as
smoking
Smoking is a practice in which a substance is burned and the resulting smoke is typically breathed in to be tasted and absorbed into the bloodstream. Most commonly, the substance used is the dried leaves of the tobacco plant, which have bee ...
,
alcohol
Alcohol most commonly refers to:
* Alcohol (chemistry), an organic compound in which a hydroxyl group is bound to a carbon atom
* Alcohol (drug), an intoxicant found in alcoholic drinks
Alcohol may also refer to:
Chemicals
* Ethanol, one of sev ...
, the level of education, a history of
appendectomy
An appendectomy, also termed appendicectomy, is a Surgery, surgical operation in which the vermiform appendix (a portion of the intestine) is removed. Appendectomy is normally performed as an urgent or emergency procedure to treat complicated acu ...
or familiarity with gastrointestinal diseases, civil state, or the use of
oral contraceptive Oral contraceptives, abbreviated OCPs, also known as birth control pills, are medications taken by mouth for the purpose of birth control.
Female
Two types of female oral contraceptive pill, taken once per day, are widely available:
* The combin ...
s.
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
Colestyramine (INN) or cholestyramine (USAN) (trade names Questran, Questran Light, Cholybar, Olestyr) is a bile acid sequestrant, which binds bile in the gastrointestinal tract to prevent its reabsorption. It is a strong ion exchange resin, w ...
) in subjects with
diarrhoea
Diarrhea, also spelled diarrhoea, is the condition of having at least three loose, liquid, or watery bowel movements each day. It often lasts for a few days and can result in dehydration due to fluid loss. Signs of dehydration often begin wi ...
and faecal incontinence.
In a
randomised controlled study,
the scale is used to study the response to two laxatives:
Macrogol
Macrogol, also known as polyethylene glycol (PEG), is used as a medication to treat constipation in children and adults. It is also used to empty the bowels before a colonoscopy. It is taken by mouth. Benefits usually occur within three days. ...
(
polyethylene glycol
Polyethylene glycol (PEG; ) is a polyether compound derived from petroleum with many applications, from industrial manufacturing to medicine. PEG is also known as polyethylene oxide (PEO) or polyoxyethylene (POE), depending on its molecular we ...
) and
psyllium
Psyllium , or ispaghula , is the common name used for several members of the plant genus ''Plantago'' whose seeds are used commercially for the production of mucilage. Psyllium is mainly used as a dietary fiber to relieve symptoms of both constip ...
(''
Plantago psyllium
''Plantago indica'', commonly known as branched plantain, sand plantain, or black psyllium, is a flowering plant in the plantain family Plantaginaceae, and is one of a few species in the ''Plantago'' genus under the common name psyllium. The pla ...
'' and other
species
In biology, a species is the basic unit of classification and a taxonomic rank of an organism, as well as a unit of biodiversity. A species is often defined as the largest group of organisms in which any two individuals of the appropriate s ...
of the same
genus
Genus ( plural genera ) is a taxonomic rank used in the biological classification of extant taxon, living and fossil organisms as well as Virus classification#ICTV classification, viruses. In the hierarchy of biological classification, genus com ...
) 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.
From 2010, several studies have used the scale as a diagnostic tool validated for recognition and evaluation of response to various treatments, such as
probiotic
Probiotics are live microorganisms promoted with claims that they provide health benefits when consumed, generally by improving or restoring the gut microbiota. Probiotics are considered generally safe to consume, but may cause bacteria-host i ...
s,
moxicombustion, laxatives in the elderly,
preparing
Ayurvedic
Ayurveda () is an alternative medicine system with historical roots in the Indian subcontinent. The theory and practice of Ayurveda is pseudoscientific. Ayurveda is heavily practiced in India and Nepal, where around 80% of the population rep ...
poly-phytotherapy filed TLPL/AY,
psyllium,
mesalazine
Mesalazine, also known as mesalamine or 5-aminosalicylic acid (5-ASA), is a medication used to treat inflammatory bowel disease, including ulcerative colitis and Crohn's disease. It is generally used for mildly to moderately severe disease. It ...
,
methylnaltrexone
Methylnaltrexone (MNTX, brand name Relistor), used in form of methylnaltrexone bromide (INN, USAN, BAN), is a medication that acts as a peripherally acting μ-opioid receptor antagonist that acts to reverse some of the side effects of opioid dr ...
,
and
oxycodone
Oxycodone, sold under various brand names such as Roxicodone and OxyContin (which is the extended release form), is a strong, semi-synthetic opioid used medically for treatment of moderate to severe pain. It is highly addictive and a commonly ...
/
naloxone
Naloxone, sold under the brand names Narcan (4 mg) and Kloxxado (8 mg) among others, is a medication used to reverse or reduce the effects of opioids. It is commonly used to counter decreased breathing in opioid overdose. Effects begin within ...
,
or to assess the response to physical activity in athletes.
History
Developed and proposed for the first time in
England
England is a country that is part of the United Kingdom. It shares land borders with Wales to its west and Scotland to its north. The Irish Sea lies northwest and the Celtic Sea to the southwest. It is separated from continental Europe b ...
by Stephen Lewis and Ken Heaton at the University Department of Medicine,
Bristol Royal Infirmary
The Bristol Royal Infirmary, also known as the BRI, is a large teaching hospital situated in the centre of Bristol, England. It has links with the nearby University of Bristol and the Faculty of Health and Social Care at the University of the Wes ...
, it was suggested by the authors as a clinical assessment tool in 1997 in the ''
Scandinavian Journal of Gastroenterology
The ''Scandinavian Journal of Gastroenterology'' is a monthly peer-reviewed medical journal covering the field of gastroenterology. It is published by Informa and was established in 1966. The editor in chief is Helge Waldum. According to the '' ...
''
after a previous
prospective study
A prospective cohort study is a longitudinal cohort study that follows over time a group of similar individuals (cohorts) who differ with respect to certain factors under study, to determine how these factors affect rates of a certain outcome. F ...
, conducted in 1992 on a
sample
Sample or samples may refer to:
Base meaning
* Sample (statistics), a subset of a population – complete data set
* Sample (signal), a digital discrete sample of a continuous analog signal
* Sample (material), a specimen or small quantity of s ...
of the population (838 men and 1,059 women), had shown an unexpected
prevalence
In epidemiology, prevalence is the proportion of a particular population found to be affected by a medical condition (typically a disease or a risk factor such as smoking or seatbelt use) at a specific time. It is derived by comparing the number o ...
of
defecation
Defecation (or defaecation) 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. The act has a variety of names ranging f ...
disorders related to the shape and type of stool.
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;
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.
Versions
The same scale has been validated in
Spanish
Spanish might refer to:
* Items from or related to Spain:
**Spaniards are a nation and ethnic group indigenous to Spain
**Spanish language, spoken in Spain and many Latin American countries
**Spanish cuisine
Other places
* Spanish, Ontario, Cana ...
,
Brazilian Portuguese
Brazilian Portuguese (' ), also Portuguese of Brazil (', ) or South American Portuguese (') is the set of varieties of the Portuguese language native to Brazil and the most influential form of Portuguese worldwide. It is spoken by almost all of ...
,
and
Polish
Polish may refer to:
* Anything from or related to Poland, a country in Europe
* Polish language
* Poles, people from Poland or of Polish descent
* Polish chicken
*Polish brothers (Mark Polish and Michael Polish, born 1970), American twin screenwr ...
versions.
[Fig. 1: Polish BSFS]
(CC BY-NC-SA 4.0) A version has also been designed and validated for children.
More recently, in September 2011, a modified version of the scale was validated using a criterion of self-assessment for ages 6–8 years of age.
A version of the scale was developed into a chart suitable for use on US television by Gary Kahan of
NewYork–Presbyterian Hospital The NewYork-Presbyterian Hospital is a nonprofit academic medical center in New York City affiliated with two Ivy League medical schools, Cornell University and Columbia University. The hospital comprises seven distinct campuses located in the New Y ...
.
References
Bibliography
*
*
*
*
*
*
* {{cite book, first1=Stephen, last1=Zderic, first2=Natalie, last2=Platcher, first3=Jennifer, last3=Kirk, title=Pediatric Urology for the Primary Care Provider, url=https://books.google.com/books?id=n6OjaL7OgYcC&pg=PA22, date=15 September 2008, editor=SLACK Incorporated, isbn=978-1-55642-785-5, pages=22–
Feces
Gastroenterology
Medical assessment and evaluation instruments
Medical scales
Physiology
Stool tests
Bristol stool scale
The Bristol stool scale is a diagnostic medical tool designed to classify the form of human faeces into seven categories. It is used in both clinical and experimental fields.
It was developed at the Bristol Royal Infirmary as a clinical asse ...