Report Viewer

NINDS CDE Notice of Copyright
Bristol Stool Form Scale (BSFS)
Please visit this website for more information about the Bristol Stool Form Scale
Supplemental: Spinal Cord Injury (SCI)
Short Description of Instrument
The Bristol Stool Form Scale (BSFS) is an ordinal scale of stool types (consistency, shape) that range from Type 1 (the hardest) to Type 7 (the softest). (Blake et al., 1996) Types 1 and 2 are abnormally hard stools indicative of constipation. Types 3, 4 and 5 are considered to be most 'normal' stool form and Types 6 and 7 are abnormally loose/liquid stools, indicative of diarrhea. (Blake et al. 1996; Lewis and Heaton 1997; O'Donnell et al., 1990) It is also referred to as the Bristol Stool Scale or the Bristol Stool Chart. (Tate et al., 2020)
Scoring and Psychometric Properties
Single 7-point ordinal scale
Type 1: Separate hard lumps, like nuts.
Type 2: Sausage-shaped but lumpy.
Type 3: Like a sausage or snake but with cracks on its surface.
Type 4: Like a sausage or snake, smooth and soft.
Type 5: Soft blobs with clear cut edges.
Type 6: Fluffy pieces with ragged edges, a mushy stool.
Type 7: Watery, no solid pieces. (O'Donnell et al., 1990; Lewis & Heaton, 1997)
Psychometric Properties:
Reliability: "The Bristol Stool Form Scale has excellent reliability and agreement when used to rate individual stool type by raters. However, BSFS reliability and agreement decreases when determining Rome III stool form categories." (Chumpitazi et al., 2016) "The mBSFS-C is reliable and valid for use by children, with age 6 years being the lower limit for scale use with descriptors read and age 8 years being the lower limit without descriptors read. We anticipate that the mBSFS-C can be effectively used in pediatric clinical and research settings." (Lane et al., 2011) No reliability studies have been reported in SCI. (Tate et al., 2020)
Validity: Face validity as ordinal rating of stool form. (Tate et al., 2020) No association with Whole Gut Transit Time (WGTT) (Park et al., 2013); significant association with Neurogenic Bowel Dysfunction score (Previnaire et al., 2016)
Responsiveness: Two SCI trials showed significant change of BSFS scores (Kim et al., 2016; Mehrotra et al., 2017)
Strengths/Weaknesses:  The Bristol Stool Form Scale is a quick and easy to use observational measure for the outcome of bowel management (Tate et al., 2020). It has been extensively used in various diagnostic groups and general population and has demonstrated utility in clinical practice and research. (Tate et al., 2020)  Given it is an observational measure, it does require a person present (e.g., person with SCI, caregiver) to observe the results. (Tate et al., 2020),
Key References:
Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol. 1997;32(9):920-924.
O'Donnell LJ, Virjee J, Heaton KW. Detection of pseudodiarrhoea by simple clinical assessment of intestinal transit rate. BMJ. 1990;300(6722):439-440.
Additional References:
Blake MR, Raker JM, Whelan  K. Validity and reliability of the Bristol Stool Form Scale in healthy adults and patients with diarrhoea-predominant irritable bowel syndrome. Aliment Pharmacol Ther. 2016;44(7):693-703.
Chumpitazi BP, Self MM, Czyzewski DI, Cejka S, Swank PR, Shulman RJ. Bristol Stool Form Scale reliability and agreement decreases when determining Rome III stool form designations. Neurogastroenterol Motil. 2016;28(3):443-448.
Kim JH, Lee SK, Joo MC. Effects and safety of aqueous extract of Poncirus fructus in spinal cord injury with neurogenic bowel. Evidence-Based Complementary Altern Med 2016;2016:7154616.
Lane MM, Czyzewski DI, Chumpitazi BP, Shulman RJ. Reliability and validity of a modified Bristol Stool Form Scale for children. J Pediatr. 2011;159(3):437-441.e1.
Mehrotra A, Jamdar J, Sharma P, Godbole C, Singh S, Das KK, et al. Constipation in degenerative cervico-thoracic spine myelopathy: a simple co-existence or a complex inter-relationship? Europ Spine J 2017;26:2318-2323.
Park HJ, Noh SE, Kim GD, Joo MC. Plain abdominal radiograph as an evaluation method of bowel dysfunction in patients with spinal cord injury. Ann Rehabil Med 2013;37:547-555.
Previnaire J-G, Soler J-M, Mortier P-E, Bordji H, Fiolet M-C, Navaux M-A. Assessment of severity of neurogenic bowel dysfunction in chronic patients with a simple 1-item questionnaire (PGI-S). Ann Phys Rehabil Med 2016;59:e128.
Tate DG, Wheeler T, Lane GI, Forchheimer M, Anderson KD, Biering-Sorensen F, Cameron AP, Santacruz BG, Jakeman LB, Kennelly MJ, Kirshblum S, Krassioukov A, Krogh K, Mulcahey MJ, Noonan VK, Rodriguez GM, Spungen AM, Tulsky D, Post MW. Recommendations for evaluation of neurogenic bladder and bowel dysfunction after spinal cord injury and/or disease. J Spinal Cord Med. 2020;43(2):141-164.
Document last updated November 2021