“The Bristol Stool Scale was developed by some researchers in Bristol, England. It’s a numerical scale from 1 to 7, going from 1 small, hard, pebbly stool to 7 liquid, very watery stool. Ideal is sort of a 3 to 4. I actually think it would be fantastic to have a dating service based on this, because if you're a 7 and you're running to the bathroom, well, obviously you want to try and get to a 3 or 4. You want to try to uncover the root cause of why you're a 7. But that's not going to work if you're dating somebody who's a 1 who's having a small, hard stool once a week. In all seriousness, it can be helpful. For example, the definition of diarrhea really has to do with frequency and amount of stool, not consistency. So one person's loose is another person's mushy is another person's not quite formed.
When I'm in my office with patients, I always try to use the food comparison. I know some people might find that sort of off-putting or even gross if you say, ‘Is it oatmeal consistency? Is it tiramisu?’ If you use that, people know what that is. I can't tell you how many times someone has said it's not formed. And then when I look at a picture of their stool, it's perfectly formed, but it may be a little shaggy around the edges. So the Bristol Stool Scale helps us to quantify that with a chart. And similarly, using food examples can be helpful for people. People know what oatmeal consistency is versus grain.
When I talk about stool nirvana there are really 5 things: color, cut, clarity, consistency, and clean-up, sort of riffing on the diamond industry. But the 3 most important are probably color, consistency, and clean-up.
“When I talk about stool nirvana there are really 5 things: color, cut, clarity, consistency, and clean-up, sort of riffing on the diamond industry.”
So if we go through that with color, red is always worrisome for me as a gastroenterologist because I want to make sure there isn’t blood in the stool. Keep in mind that eating beets can make your stool red, food coloring can turn things a little bit red. So red isn't always dangerous, but ideally, the color is a nice chocolatey brown color. If your stool is too pale and chalky, it can be for a number of reasons. It can be that you're not eating enough green vegetables. It could be a sign of liver disease where the bile isn't getting into the stool, the biopigment. So it can be dietary. It can be a sign of a more concerning illness, since certain infections can cause greenish stool.
I tell my patients to eat enough vegetables so that when you have a bowel movement and wipe, the toilet paper has a little green tint, like that grass residue. That's how you really know you're eating enough plants. But if you have an infection, you can have green stool. A lot of this is dependent on context, but color is ideally chocolatey brown. Dark stool, like a dark, dark brown tending towards black can be a sign of blood in the stool higher up in the GI tract, where the blood is mixed in with stool, with the dead bacteria, the cellulose, et cetera, and produces a darker color. We call that melena. That's also problematic.
For consistency, it should be firm, but it's okay if it's shaggy or shredded. When it hits the bowl, if it falls apart a little bit, that can be assigned to having lots of plant matter in it. So shredded isn't such a big deal. If it's so shredded that it literally disintegrates into pieces, that might suggest it doesn't have enough form. And there are lots of causes for that, too.
Clean-up is the last one I want to talk about because it's so important. If you find that you're going and you're wiping and wiping and wiping and having a hard time getting everything all clean (in the sense of no more stool), that can be a really important sign of something called tenesmus, which means incomplete evacuation. So that can be a sign that all the stool is not evacuating. To me, as a gastroenterologist, it's a trigger for me to help that person bulk the stool with, for example, more fiber in the morning, maybe a little osmotic cathartic at night, plus the fiber. They need more bulk if they're having that incomplete evacuation. Or again, it can be a sign of a more worrisome condition like diverticulosis. So it’s really reading tea leaves. My goal is that I want people to understand what their poo is telling them so that they don't have to come and see me so that they can read their own tea leaves.”
Want more? This is an excerpt from a longer convo with Robynne Chutkan, MD — listen or watch here!