Episode 55: The Poop Episode. 

Dr Civelli and Dr Lundquist describe the Bristol Stool Scale. What is the ideal shape of stools? What is normal vs. abnormal stools? Intro about antibody medicine.

Today is June 9, 2021. 

Antibody Medicine. 

Have you ever heard of antibody medicine? Human biologic targets can be linked to a multitude of diseases onset, progression or even prevention. The role of antibody therapy is to identify those targets, conduct industry-grade research trials to validate and then develop highly specific therapies. Some examples are: Dupixent (dupilumab) for asthma, atopic dermatitis, and chronic sinusitis; rituximab for Non-Hodgkin Lymphoma and pemphigus vulgaris, or other “mabs.” These are a few such examples of antibody medications.  

 

Antibody medicines typically mimic the natural pathways of the body’s immune system. These antibody medicines are derived from living organisms, not from chemical processes like most pills.  And because they are designed so specifically, they are designed to avoid unwanted effects on other cells in the body.  

 

Antibody medicines have been proven to change lives and have altered the course of the treatment of serious diseases like asthma, cancer, heart disease, rheumatoid arthritis, and severe eczema over the past several decades. I wonder what this means for accessibility and who will this benefit?  I know many of the “mabs” like dupixent are available and there are assistance programs to help with coverage. I love that we are in the era of innovation and discovery! 

 

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it is sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

 

The Poop Episode. 
By Valerie Civelli, MD, and Arianna Lundquist, MD. 

 

What is brown, smells really bad and may attract flies? I will be honest with you, there’s no clever joke. It was exactly what you are thinking.  That is right, it is Poop. Everyone does it. I do, you do. We all do Doo Doo. 

As physicians, we are here to give you the scoop on the poop. Let’s start with a few rhetorical questions: 

1. What is normal stool?
2. How do you describe it? 
3. Do most patients know the difference b/w normal and abnormal? 
4. Is it easy for patients to describe and talk about?

Normal stool has an alkaline pH. Sodium and potassium salts are the primary stool solutes. The sodium plus potassium concentration in stool usually ranges between 130 and 150 mEq/L. Other cations, such as calcium and magnesium, are present at much lower concentrations. The main inorganic stool anions are bicarbonate (approximately 30 mEq/L), chloride (approximately 10 to 20 mEq/L), and a small amount of phosphate and sulfate. Changes from these baselines may lead us to a variety of diagnoses. 

Let’s take this discussion into clinical practice.  Poop is a tough topic for patients according to multiple sources and extracting pertinent patient history is challenging: Because it is embarrassing, because patients are often unaware of what is normal vs. abnormal bowel movements. 

I have asked patients if they have any constipation. They report bowel movements daily only to find out these are small, hard pellet-like stools daily.  Unless you are a bunny, you are constipated if having pellet-like stool.  

The good news is Ken Heaton, MD, from the University of Bristol, developed the Bristol Chart in 1997 to improve our ability to assess patient bowel movements. The Bristol chart categorizes the 5 different types of stool and shows normal versus abnormal.  The Bristol Stool Scale is also known as the Meyer’s Scale and is still used to today as a great tool to help patient describe the shapes and types of stool. Let’s go over this together: 

Type 1 – Separate Hard lumps, like nuts (hard to pass)

Type 2 – Sausage-shaped, but lumpy

Type 3 – Sausage-shaped, but with cracks on surface

Type 4 – Sausage- or snake-like, smooth, and soft

Type 5 – Soft blobs with clear-cut edges (easy to pass)

Type 6 – Fluffy pieces with ragged edges, mushy

Type 7 – Watery, no solid pieces (entirely liquid) 

The ideal stool is generally type 3 or 4, easy to pass, without being too watery. If yours is like type 1 or 2, you're probably constipated. If your is more like types 5, 6, and 7, you probably have diarrhea. The most important thing to look for in your stool: Well first you must look at it.  Some patients have admittedly avoided this step but encourage them to look every time. "Blood should be the first thing to look for in your stool," according toDr. Mark Pimentel, a gastroenterologist atCedars-Sinai. Blood may be dark black or bright red. It may be a marker of colon cancer, Crohn's disease,or colitis. Can you think of any other differentials? 

Would you recognize the difference between human poop vs. dog poop? True story, I have a doctor friend whose son was obsessed with video games. He played for hours, skipped meals, peed in his pants more than once. One day, my friend came home after working a long shift at the hospital to find large human feces on the living room floor. Naturally, she yelled out his full name and asked why he pooped in the living room. His response? It was the dog!

I preface with this story because 1. I will never let my future kids play video games for hours and 2. typically, unless you’re a doctor or in medicine at some level, most people aren’t going around checking each other’s poop. As studies showed by Dr. Pimentel of gastroenterology at Cedars Sinai, "We often don't realize what's normal vs. abnormal.”  So, educate patients on normal stools and encourage them to talk about it.

Three key features to ask patients to keep in mind as they assess their stool health which is consistency, color, and smell.

It is recommended to have a mainly solid, not loose, consistency. "If someone tells me that their stool looks like soup, gravy or mashed potatoes, and it's been like that for a long time, their stool is not normal," says Dr. Pimentel. Generally, a healthy color is brown, but the color can range from a very light brown to an almost greenish brown. Those colors are all perfectly normal and may vary based on diet. 

Black poop is never normal! Black can mean decomposed blood into heme, so this can be serious. However, keep in mind stool could also turn black with intake of iron pills or certain over-the-counter stomach aids, such as Pepto-Bismol. Blood sausage can give you black stools as well. 

As far as smell is concerned, if your poop is "extremely foul," this can be a sign of maldigestion or malabsorption. 3 primary causes of changes to stool color, consistency or smell are irritable bowel syndrome (IBS),celiac diseaseor alactose intolerance. These differentials should be considered. 

Don’t neglect the basics to a healthy gut meaning: Have a balanced diet, plenty of fiber, adequate hydration, "You can't overdrink water to treat constipation.”  EXERCISE is a must! Regular physical activity keeps your stools moving.

Conclusion.

Now we conclude our episode number 55 “The Poop Episode”. Dr Civelli, Dr Lundquist, and Dr Arreaza had a candid conversation about normal stools. The Bristol or Meyer Scale can help you identify more precisely the type of stools your patients are having. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Valerie Civelli, and Arianna Lundquist. Audio edition: Suraj Amrutia. See you next week! 

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References:

1. Antibody Medicine and Regeneron Technology, Regeneron, https://www.regeneron.com/science/antibodies, accessed on June 2, 2021. 

 

1. Emmet, Michael, et al, Acid-base and electrolyte abnormalities with diarrhea, Up to Date, last updated: Jul 01, 2020. https://www.uptodate.com/contents/acid-base-and-electrolyte-abnormalities-with-diarrhea?search=normal%20stool&source=search_result&selectedTitle=6~150&usage_type=default&display_rank=6.

 

1. DerSarkissian, Carol, MD, What Kind of Poop Do I Have? WebMD, January 16, 2020, https://www.webmd.com/digestive-disorders/poop-chart-bristol-stool-scale, accessed on June 9, 2021.

 

1. Healthy Bowel Movements: Why You Should Pay Attention to Your Poop, Jul 08, 2020, Cedars Sinai Staff (California), https://www.cedars-sinai.org/blog/healthy-bowel-movements.html.

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