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 a ...

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 moveme ...

, 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 t ...

, 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

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 syn ...

, 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-dioxoan ...

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

. 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 w ...

; 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 ''hem ...

s. Research conducted on irritable bowel syndrome in the 2000s, faecal incontinence and the gastrointestinal complications of HIV 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 Per ...

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 eighth most populous city in the United States ...

, 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'' 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. Ac ...

, United States, reported a piece of epidemiological research 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 t ...

, 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 ...

, 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) dsm5.org. Retrieved April 8, 2014. is any mental disorder that manifests as physical symptoms that suggest illness or injury, but cannot be explained fully by a general ...

components (

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 con ...

); 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 b ...

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 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 acute appe ...

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 combi ...

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, whic ...

) in subjects with

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 const ...

(''

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 appropriat ...

of the same

genus Genus ( plural genera ) is a taxonomic rank used in the biological classification of living and fossil organisms as well as viruses. In the hierarchy of biological classification, genus comes above species and below family. In binomial nom ...

) 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 repo ...

poly-phytotherapy filed TLPL/AY, psyllium, mesalazine,

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 dru ...

, 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 withi ...

, 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 ...

by Stephen Lewis and Ken Heaton at the University Department of Medicine,

, it was suggested by the authors as a clinical assessment tool in 1997 in the '' Scandinavian Journal of Gastroenterology'' 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. ...

, 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 ...

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 ...

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, Can ...

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 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