And Are You Telling Your Patients to Do the Same?

My interest in having my patients check for changes in their stool is quite personal. My brother-in-law Giles died of colon cancer in August last year. He was only 43. He left behind my sister and their 2 young children. He had been having blood in his stool for a few months but didn't think that it was important enough to report to his physician. He thought it was just a bleeding hemorrhoid and "would go away". It was only when the water in the toilet bowl was bright red after a bowel movement that he realized something was not right and took it seriously enough to go to the doctor. In a matter of days he was diagnosed with stage IV colon cancer that eventually took his life.

If you are not educating your patients to look at their stools I urge you to begin. I believe that Giles would still be with us if he had been educated by his physician to watch for changes in stool color. Here are some of the important things that I think you and your patients should pay attention to:

Blood on/in stool 
This is always an abnormal state. Blood streaked on outer surface usually indicates hemorrhoids or anal abnormalities; blood present in the stool usually comes from higher in the colon and may be the first sign of bowel cancer; if the bowel transit time is rapid, the blood can be from stomach or duodenum and will appear as bright or dark red. I urge you to take this sign seriously and evaluate for the cause of the bleed.

Undigested food
This may indicate insufficient HCL and/or pepsin production. An insufficiently acidic bolus of chyme moving into the intestines from the stomach may not trigger sufficient cholecystokinin release and a decrease in pancreatic enzyme production causing pancreatic insufficiency. Also consider that your patient is not chewing their food appropriately.

Mucous on stool
Mucous on the stool is usually due to gastrointestinal irritation (colitis, food sensitivity, pancreatitis). Translucent gelatinous mucus clinging to the surface of formed stool occurs in: spastic constipation; mucous colitis; emotionally disturbed patients; excessive straining at stool.

Loose stool 
Loose but not watery stool is associated with mild intestinal irritation and malabsorption.

Hard stool 
This is usually due to increased absorption of fluid as a result of prolonged contact of luminal contents with the mucosa of the colon because of delayed transit time (lack of fiber, dehydration, hypochlorhydria).

Floating stool
Consider malabsorption (esp. fats), reduced tract time due to anxiety or irritation, and a high fiber diet. The stool may also be described as slippery or greasy looking.

Ribbon-like shape 
A ribbon-like stool suggests a possibility of spastic bowel, rectal narrowing or stricture (pencil shaped), decreased elasticity, or partial obstruction (uterus malposition, prostatitis, polyp, tumor).

Small, round and hard 
A condition called scybala this is found with habitual or moderate constipation. Severe fecal retention can produce a large amount of impacted masses in the colon with a small, round and hard stool as overflow.

Brown
A brown colored stool is probably due to Sterobilin (urobilin), a bile pigment derivative resulting from the action of reducing bacteria in bilirubin. It is a normal finding.

Dark brown
A consistently dark brown stool is associated with an excessively alkaline colon that may indicate dysbiosis. A dark brown stool can be a normal finding indicating good bile flow and elimination of fat-soluble toxins.

Yellow
Usually seen with severe diarrhea, may be due to lack of intestinal flora and will also occur from antibiotic use. Consider excessive bile secretions due to over stimulation or irritation to the small intestine.

Black
This is usually a result of bleeding into upper GI tract (ulcer, Crohn's, Colitis, cancer); also the use of drugs, iron, bismuth, charcoal or a heavy meat diet.

Tan or clay colored 
This is associated with a blockage of the common bile duct (lack of bile pigments) as well as pancreatic insufficiency, which produces a pale, greasy acholic stool. Consider gall bladder insufficiency or hepatobiliary obstruction.

Offensive odor 
Indole and Skatole, intestinal toxins formed from intestinal putrefaction and fermentation by bacteria, are primarily responsible for odor. If the stool usually has an offensive odor then consider that it may be due to malabsorption, food decay, or dysbiosis If the stool is occasionally offensive then consider intermittent malabsorption with food decay and dysbiosis.

I hope you have found this useful and can begin to educate your patients on this sometimes embarrassing but I think essential topic!

All the best Dicken