Bristol stool chart (BSC);[1] Bristol Stool Scale (BSS); Bristol Stool Form Scale (BSFS or BSF scale);[2]
Purpose
classify 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]
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]
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 (diarrhea)
Type 7: Watery, no solid pieces, entirely liquid (diarrhea)
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]
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]
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]
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]
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]
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]
References
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10.1016/j.purol.2014.06.008.
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^Gut Sense What Exactly Are Normal Stools?, Konstantin Monastyrsky. Accessed July 2015
^What to know about the Bristol Stool Chart or Bristol Stool Scale.. N.p.: Dr.Hakim Saboowala, 2022.
^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.
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^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.
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^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.
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^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.
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abAckley BJ, Ladwig GB (2013). Nursing Diagnosis Handbook, An Evidence-Based Guide to Planning Care, 10: Nursing Diagnosis Handbook. Elsevier Health Sciences. p. 240.
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abBristol scale stool form. A still valid help in medical practice and clinical research G Riegler, I Esposito – Techniques in coloproctology, 2001 – Springer
^Adibi P, Behzad E, Pirzadeh S, Mohseni M (August 2007). "Bowel habit reference values and abnormalities in young Iranian healthy adults". Dig Dis Sci. 52 (8): 1810–3.
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^El-Gazzaz G, Zutshi M, Salcedo L, Hammel J, Rackley R, Hull T (December 2009). "Sacral neuromodulation for the treatment of fecal incontinence and urinary incontinence in female patients: long-term follow-up". Int J Colorectal Dis. 24 (12): 1377–81.
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^Tinmouth J, Tomlinson G, Kandel G, Walmsley S, Steinhart H, Glazier R (2007). "Evaluation of Stool frequency and stool form as measures of HIV-related diarrhea". HIV Clin Trials. 8 (6): 421–8.
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^Zutshi M, Tracey T, Bast J, Halverson A, Na J (June 2009). "Ten-year outcome after anal sphincter repair for fecal incontinence". Dis Colon Rectum. 52 (6): 1089–94.
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^Remes-Troche J, Ozturk R, Philips C, Stessman M, Rao S (February 2008). "Cholestyramine--a useful adjunct for the treatment of patients with fecal incontinence". Int J Colorectal Dis. 23 (2): 189–94.
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^Sakai T, Makino H, Ishikawa E, Oishi K, Kushiro A (June 2011). "Fermented milk containing Lactobacillus casei strain Shirota reduces incidence of hard or lumpy stools in healthy population". Int J Food Sci Nutr. 62 (4): 423–30.
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^Michna E, Blonsky E, Schulman S, Tzanis E, Manley A, Zhang H, Iyer S, Randazzo B (May 2011). "Subcutaneous methylnaltrexone for treatment of opioid-induced constipation in patients with chronic, nonmalignant pain: a randomized controlled study". J Pain. 12 (5): 554–62.
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