Colin Kopes-Kerr, MD
6444 Timber Springs Drive
Santa Rosa CA 95409
E-mail: cpkerr@nni.com
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The Bowel Score & the Management of Chronic Fecal Retention:
While 'constipation' is common and usually considered a trivial diagnosis, the fact is that patients rarely see physicians for simple constipation. To be clear what we're talking about, consider 'simple' constipation to be what happens to a healthy adult who receives codeine for an ankle sprain for 3-5 days; this is a self-resolving problem that does not require medical attention. When patients come to a physician with a complaint of 'constipation,' it usually means a problem that has gone on for months, if not years. Then we are really talking about chronic fecal retention or fecal impaction, which is a mush more serious problem that can have serious consequences.
Chronic fecal retention is remarkably common. It happens in patients with risk factors, which include medications, immobility, older age, poor fluid intake, and other debilitating or immobilizing conditions. Among medications, the principal offenders are narcotics, tranquilizers, anti-depressants, other anticholinergic medications, and calcium-channel blockers. Among the elderly it occurs in those with lifetime poor bowel habits, multiple comorbid conditions, cancer, or immobility related to orthopedic problems. Whenever someone tells you that they've had 'constipation for years,' you should be thinking of chronic fecal retention.
The proper diagnosis is made by performing a bowel score based on the KUB x-ray. You have to actually look at the x-ray yourself because the radiologists do not know how to calculate this score and they have no objective system for evaluating the accumulation of stool in the bowel. The bowel score was first developed in the pediatric literature to assist in the management of encopresis in children. The original score defined an abnormal score as 10 in children. I have adapted the score for adults based on a series of over 100 patients and use a cut-off of > 13 for a diagnosis of chronic fecal retention/impaction in adults. The original publication of this system appeared in Clinical Pediatrics in 1979 (18 No. 11: 674-686; reproduced below), but appears to have been lost to the medical literature since then as evidenced by more than 20 major reviews of chronic constipation/fecal retention that make no mention of this tool since then.
The Bowel Score Evaluation of the KUB
The scoring process is simple. First, you have to realize that all stool is categorized into 2 types on x-ray: the typical "hard balls" (little rocks) of constipation and everything else which has a 'ground glass' or granular texture. Then all you're going to do is to note the distribution of either of these types of stool in the 4 regions of the bowel (ascending, transverse, descending, and rectum). To this you add a final assessment of global distribution of stool throughout the entire length of the colon. It takes a little practice, and different scorers will attain scores differing by 1-3 points. After about 6 scoring exercises, one will start to reach consistency.
I have put together an outline of this system, its use, and the treatment of scores > 13 in the link below titled "Bowel Score Poster." I have also placed a link to the full text of the original article.
For a concise introduction to an overview of the diagnosis and management of chronic fecal retention using the bowel score, click on the following link: Bowel.Score.Poster (which is a very large Word (doc) file.
For a link to a full-text copy of the original article, click on "Chronic and Occult Stool Retention" [Clinical Pediatrics, 1979]
To download a copy of the above instrument for your own use, click on "Bowel Score Instrument," which is an Adobe PDF file.