Intermittent acholic stools in an otherwise healthy patient.

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majahops

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My search of the literature leads me to believe that acholic (pale or white or gray or light yellow) stools can essentially ONLY reflect obstruction of the biliary [or some other related] duct.

However, I have met several patients who have reported acholic stools in the absence of jaundice or any other symptoms. Typically, they last just one or two days. I, myself, have had gray stools from time to time. Even as a fourth year medical student, it is essentially impossible for me to find anywhere in the medical literature that allows for this to be a normal variant. Can I ask why this might be?

In the absence of other symptoms or some obvious dietary abnormality or something (e.g. consuming nothing but bleached tapioca pudding for 2 weeks or something ridiculous like that), if a 35 year old patient comes to me with gray or light-yellow stools, should I be working them up? And for what?

Let's say they have had 2 days of a vague epigastric burning and acholic stools but no jaundice or other symptoms and a non-contributory history... does that change things?

Thanks so much in advance for your responses. I know people don't like to talk about stools... but look around on uptodate or gastroenterology books... it's easy to get the idea that acholic stools = obstruction every time... and that just doesn't jive with what I've seen clinically.

Thanks again.

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... didn't expect anybody would be able to answer that one.
 
I'd recommend having them collect the stools for your inspection next time, then reporting the bristol scale for each stool while carrying the bag of fun into your attending's office.

The stools weren't acholic. They were normal. The complaint of intermittent acholic stools is 100% specific for IBS in patients under the age of 50 and 100% specific for being old in patients over the age of 70.
 
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I do believe you and even suspected they weren't necessarily "acholic." But where in the literature does it say white/gray stools can be due to IBS?

Thanks again!

I'd recommend having them collect the stools for your inspection next time, then reporting the bristol scale for each stool while carrying the bag of fun into your attending's office.

The stools weren't acholic. They were normal. The complaint of intermittent acholic stools is 100% specific for IBS in patients under the age of 50 and 100% specific for being old in patients over the age of 70.
 
While I have immense respect for you, I believe your comment epitomizes the major weakness of gastroenterology as a field of medical science. I'm of the strong opinion that GI has many times been too quick to embrace the concept of "functional" deviations from clinical norms. To the extent that "functional" means "we just don't know what the hell is going on in there," I think it's a useful term... But it almost seems that it has evolved into meaning "the underlying pathology is either not understandable or not worth understanding." ... In addition, this latter concept often gets implicitly superimposed onto a background of "anxiety." As a result, by labeling something "functional," the GI scientist absolves him or herself of the responsibility of characterizing the underlying physiological mechanisms, because after all "it's partially a psych issue" - even if it were "understandable or worth understanding."

Of course many factors contribute to the activity of ones GI tract, and an anxious/hyper-sympathetic state can certainly have a profound influence on ones bowels.... That's not what I wanted to know, though. What I wanted to know was much simpler, and maybe I should have worded it as follows:

In the absence of hepatobiliary obstruction or pathology, hypermotility, dietary or medication changes - how can one's stools end up white?

... If you don't know, just say so. If there is a psychiatric mechanism, please detail it or refer me to an article explaining it... But to refer to the DSM is kind of insulting... Not just to me but to GI as a field of science.

I believe you'll find what gastrapathy was talking about in the DSM, Axis II section.
 
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First of all...I'm got a GI, I'm an oncologist who happens to focus on GI oncology. So getting your GI physiology from me is probably a mistake on your part. But here we go.

I don't want to speak for gastrapathy, but what i took from his statement was simply that, like most patients, with most conditions, they frankly don't know what the hell they're talking about. Lighter colored stools are a normal variant that can be influenced by diet, changes in intestinal transit time and other, non-biliary pathologies. Truly acholic stools aren't just light colored, they're gray/white, like this...
p3fig1.jpg

The likelihood that you, or your patients, had intermittent, truly acholic stools is, while not zero, pretty close to it. That was the "IBS/Axis II" thing I was getting at.

As to how you could get intermittent, truly acholic stools, it's not that difficult to explain from an anatomic perspective. A gallstone temporarily retained in the CBD or the ampulla could certainly cause it.
 
First of all, you can't insult the field of GI. We know what we are and are at peace with it.

Second, intermittent acholic stools is not a true phenomenon. Patients who have spent too much time on google (nice work gutonc, btw) may think they have it but they don't. Be sure you are the first new consult of the day when you role into GI because it would kill me to see you in the middle of a busy clinic.
 
Thanks so much for the thoughtful responses, guys.

It means a lot that you take the time to field questions and give advice on here.

There's no sense in my trying to convince you that these were legitimate cases of acholic stools. The transient / passing CBD stone explanation does make sense. I'd thought of it but just couldn't find it articulated in the literature... (Of course not everything is going to be)... But no biggie... not worth nagging you guys about it anymore.

Thanks so much again.
 
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There's no sense in my trying to convince you that these were legitimate cases of acholic stools. The transient / passing CBD stone explanation does make sense. I'd thought of it but just couldn't find it articulated in the literature... (Of course not everything is going to be)... But no biggie... not worth nagging you guys about it anymore.

You won't find it in the literature because it's hard to get a paper (even a review) that boils down to "well, no s*** Sherlock" published.

And no, I don't believe that you have encountered (and experienced) numerous cases of truly intermittent, truly acholic stools at this point in your career. So yes, you should probably give up on trying to convince me. Not that you should care what I think...but you did ask.
 
I propose we create a journal called "No sh** Sherlock." That documents evidence of the things we assume are true but haven't seen hard proof of.

You won't find it in the literature because it's hard to get a paper (even a review) that boils down to "well, no s*** Sherlock" published.

And no, I don't believe that you have encountered (and experienced) numerous cases of truly intermittent, truly acholic stools at this point in your career. So yes, you should probably give up on trying to convince me. Not that you should care what I think...but you did ask.
 
Sorry double post and can't seem to be able to delete one!
 
My search of the literature leads me to believe that acholic (pale or white or gray or light yellow) stools can essentially ONLY reflect obstruction of the biliary [or some other related] duct.

However, I have met several patients who have reported acholic stools in the absence of jaundice or any other symptoms. Typically, they last just one or two days. I, myself, have had gray stools from time to time. Even as a fourth year medical student, it is essentially impossible for me to find anywhere in the medical literature that allows for this to be a normal variant. Can I ask why this might be?



Thanks again.

I have had whitish grey stools from time to time for some years....and regularly yellow stools of which recently ( this whole week ) very light yellow. These are whithout stools being loose or any sign of it goint too fast trough the intestines. This time i'm a bit worried beacuse it is very light yellow.
Sometimes after drinking alcohol it can be grey for a day. The yellow version can last longer one week or a bit longer. It Always becomes brownish again.
Not sure if acholic , as someone here suggested, is referred only to white/ grey stools or also light yellow ( quite beautifull actually..pretty shiny lol )??
Most people have no idea and would not consult their doctors...soeme might do it and probably at first will get to hear they should wait a few days and come back. If i have it for some years i'm sure there are others.
Hopefully this time it will go away again, but i thought it might benefit someone to know that the person started this thread has a valid point.
 
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