Intended for healthcare professionals

Rapid response to:

Clinical Review

Chronic constipation in adults

BMJ 2009; 338 doi: (Published 20 March 2009) Cite this as: BMJ 2009;338:b831

Rapid Response:

Bristol Stool Chart and Bristol Stool Form Scale

In their review of constipation, McCallum et al commend the Bristol
Stool Chart for monitoring the progress of treatment and attribute the
Chart to myself and SJ Lewis1. This attribution is incorrect. The mistake
is understandable since it appears in Wikipedia, where I have tried and
failed to amend the entry. In fact, the Chart was developed by me alone
(but named as such by others) as a visual equivalent to the well-
established Bristol Stool Form Scale, a transit time-sensitive list of
seven verbal descriptors which colleagues and I had published in 19902.

The first 'proper' publication of the visual Chart (accompanied by
the verbal Scale) was in 1999 in a booklet for the general public3. In
the same year, it appeared in a book for GPs4. I am not aware of the Chart
having been published in an academic journal.

All published validations are based on the verbal Scale, not on the
visual Chart, and one of these was indeed a paper by SJ Lewis and myself5.
It so happens that this study is relevant to the review of McCallum et al
because it demonstrated the responsiveness of the Bristol Scale to
laxatives and constipating agents.

I am glad to say that a paper validating the Chart against the Scale
is now in press -in English - in Revista Espanola de Enfermedades
Digestivas (D Parés et al, Barcelona University Hospital Colorectal
Surgery Unit).

1 McCallum IJD, Ong S, Mercer-Jones M, Chronic constipation in
adults. BMJ 2009;338:b831 (28 March 2009).
2. O’Donnell LJD, Virjee J, Heaton KW, Detection of pseudodiarrhoea by
simple clinical assessment of intestinal transit rate. BMJ 1990;300:439-
3 Heaton KW, Understanding Your Bowels, 3rd edn. Banbury: Family Doctor
Publications, 1999.
4 Heaton KW, Thompson WG, Irritable Bowel Syndrome, Oxford: Health Press,
5 Lewis SJ, Heaton KW, Stool form scale as a useful guide to intestinal
transit timeScand J Gastroent 1997;32:920-4.

Competing interests:
None declared

Competing interests: No competing interests

04 April 2009
Kenneth W Heaton
Retired physician
Claverham House, Claverham, Bristol BS49 4QD