Digestive Diseases and Sciences, l/oL 40, No. 9 (September 1995), pp.

1873-1882

Validation of a N e w Measure of Diarrhea

H O W A R D R. M E R T Z , MD, C. K E I T H BECK, MD, W I L D I X O N , PhD, M. A N N A E S Q U I V E L ,
R O N D. HAYS, PhD, and M A R T I N F. S H A P I R O , MD

Adequate measures of diarrheal disease are important to assess severity for clinical use and
outcomes research. We developed a questionnaire to assess diarrhea severity and complica-
tions, and administered it to 205 H I V positive patients with diarrhea, fever, or weight loss.
Noteworthy variations in stool form were reported by individuals and across subjects.
Self-reported diarrhea correlated with the occurrence of any stool pictured without form.
However, verbal descriptors "loose" and "semiformed" had little value in assessment of
diarrheal disease. Both verbal and pictorial stool descriptors correlated well with diarrhea
complications (pain, urgency, tenesmus, incontinence, and nocturnal diarrhea). By factor
analysis, discomfort and nondiscomfort diarrhea complications loaded on different factors,
consistent with clinical experience that discomfort is a distinct problem in diarrheal disease.
In summary we have developed an instrument to precisely characterize diarrhea severity that
correlates well with clinically important events such as incontinence and abdominal pain.

KEY WORDS: diarrhea; HIV; questionnaire; incontinence; pain.

Adequate measures of patient outcomes are critical
to patient care, clinical research, and assessment of
the performance of health care systems. Such tools
are particularly important in gastrointestinal diseases,
in which outcomes tend to be quite subjective. Diar-
rheal diseases present particular problems. Bowel
habits are a highly subjective concern, and terms to
characterize stools are quite vague and poorly stan-
dardized. Clinicians must interpret patient complaints
about altered stool habits and often have difficulty
deciding on the seriousness of the complaints. Col-
lection of stool is impractical, and most physicians ask
limited and unstructured questions about the number
of daily bowel movements and the appearance of the
stools. Physicians may not ask about pain with bowel
movements, nocturnal bowel movements, and incon-
tinence. An adequate measure of diarrheal status
should be reliable (ie, elicit consistent responses from
the same patients at different times when the condi-
tion is stable) and valid (ie, actually measure diar-
rheal status and not something else).
This paper summarizes the development of a self-
report measure of diarrhea. Included are a pictorial
representation of stool consistencies, specific ques-
tions about diarrhea complications and discomfort, as
well as standard questions about number of bowel
movements and consistency of stools. The measure
was administered to a sample of 204 patients with
H I V infection. Diarrheal disease is prevalent and a
range of severity is represented in this sample. There-
fore it presents a spectrum of bowel dysfunction ideal
for such an analysis.

Manuscript received February 24. 1995; accepted April 26. 1995.
From the Vanderbilt University School of Medicine. Gastroen-
tcrology C-2104 MCN, Nashville. Tennessee: Harbor/UCLA Med-
ical Center, Los Angeles, California; UCLA School of Medicine,
Los Angeles, California; and RAND, Santa Monica, California.
Support for this project was provided by the Agency for Health
Care Policy and Research, grant #R01-HS06775.
Address for reprint requests: Dr. Howard Mertz, Vanderbilt
University School of Medicine, Gastroenterology. C-2104 MCN,
Nasvhille, Tennessee 37232.
MATERIALS AND METHODS
Population. Outpatients and inpatients in the Harbor-
UCLA Medical Center (one of Los Angeles" county hospi-
tals) and West Los Angeles Veterans Administration Hos-
pital HIV clinics with symptomatic HIV infection were
asked to participate in a study evaluating symptoms, diag-
noses, and health-related quality of life (HRQOL). Subjects
enrolled met study criteria for diarrhea, fever, or weight

Digestive Diseases and Sciences. Vol. 40, No. 9 (September 19951 1873
111~3-2116,t~5i090t1-1873507.51)/0 ,.," 1~5 Plenum Publishing Corporation

TABLE 1. CIIAI{A',71"ERISTICSOF STUI)YSLIBJE(7S
Age (mean years _+ sD) 36 + S
Sex (G male) 91
HIV risk groups (e~)
Itomosexual 64
Intravenous drug usc 1I
Ethnicity/racc (%)
Black 26
Latino 28
White 39
Enrollment site (ci)
Municipal t4ospital 83
Veterans Administration Hospital 17
Enrollment symptom (%)
Diarrhea 5(1
Fever 43
Weight loss 7 statistical significance level of 0.05 was adopted.
CD4 count at entry (cclls/ml +- SD) 144 + I92
Time since HIV diagnosed (mean months _+ SD) 34 -+ 28
Time since symptom onset (mcan months + S D ) 24 _+ 23
loss. Diarrhea entry.' criteria were: (1) four or more loose
stools or one liquid stool per day five out of seven days in
each of the last two weeks: (2) four or more loose or one
liquid stool per day five out of the last seven days and fever
>100~ 10% weight loss over 3(1 days, 5c~ weightloss in thc
last seven days. orthostatic blood pressure changes > 10 mm
Hg or pulse >211: (3) three consecutive days of four loose or
one liquid stool per day occurring twice or more in the last
two months: (4) one or more loose stools pcr day for more
than two weeks while on antidiarrheal medication: or (5)
one or more loose stools per day for four or morc days
resulting in empiric antibiotic administration and either
fever >l(ll~ six or more stools per day, or orthostatic
changes.
Fever and weight loss entry criteria were, respectively.
temperature of 100.(FF on three days in the past 14 days
and involuntary weight loss of 1(}'7~:of body weight within 60
days or 2 Ib/week for four weeks. Many of the subjects who
entered the study for fever or weight loss also had diarrhe~,l
symptoms. For descriptive purposes, subjects were classified
into one symptom group and preference was given first to
fever, second to weight loss, and third to diarrhea. In
addition to the enrollment criteria stated above, to be
eligible for enrollment, we required that the patient's pri-
mary care clinician independently had to have decided that
the symptoms warranted a full evaluation.
Three hundred nineteen subjects were screened for the
study by study coordinators. One hundred fifteen subjects
(36~) were excluded: 55 refused the questionnaire, 12 were
unable to complete it, 13 refused evaluation, 16 felt too sick,
5 were felt to be unreliable by the stud}' coordinators, 2
,,','ere preterminal, and 12 were not competent to give con-
sent, as determined by their primary physician or the study
coordinators. Patient demographic characteristics, HIV risk
factors, reason for enrollment, and average CD4 count are
shown in Table 1.
Questionnaire. A 104-item questionnaire was adminis-
tered by study coordinators. The questionnaire included
three questions about stool form. two about the frequency
of stools, and six about potential morbidity due to diarrhea.
These 11 questions and how they were scored are listed in
1874
MERTZ ET AL
the Appendix. The interview took on average 75 minutes
and was conducted face to face in all cases.
A diarrhea severity scale was created by summing indi-
cators of tile stool form (item two) and tile change in
frequency of bowel movements (item four minus the
smaller of items 5a and 5b).
Analysis. Frequencies of responses to the diarrhea ques-
tionnaire items are reported. In addition, associations be-
tween different items are estimated using Pearson product-
moment correlation coefficients (r). Stool frequency (item
four) was found to have a Poisson distribution, so the
square root of frequency was used for correlation with
pictorial stool form. The frequency of incontinence for
subjects with a range of pictorial stool forms and stool
frequencies was compared using a chi-square analysis. A
To summarized the intercorrelations among nine indica-
tors of diarrhea form and diarrhea-associated symptoms, we
conducted an exploratory factor analysis. Several criteria
were examined to assess the appropriate number of factors
to rotate: Guttman's weakest lower bound (1), Cattell's
scree test (2), and parallel analysis (3). Common factor
analysis was conducted with squared multiple correlations
as eommunality estimates and factors were rotated to an
oblique solution using Promax (4).
RESULTS
Pictorial Stool F o r m E v a l u a t i o n . Of the 204 sub-
jects c o m p l e t i n g the q u e s t i o n n a i r e , 60% (N = 121)
selected either "all'" or "most of the time" for one of
the stool forms depicted in item 3 ( A p p e n d i x and
Figure 1 ). This subset of the sample was c o n s i d e r e d to
have selected a " p r e d o m i n a n t stool form," C o n s i s t e n t
with the fact that the sample included approximately
equal n u m b e r s of subjects e n t e r e d for diarrhea as for
o t h e r symptoms, the d i s t r i b u t i o n of p r e d o m i n a n t
stool forms selected was not symmetric. F o u r t e e n
percent indicated that their bowel m o v e m e n t s "all of
the time" or "most of time" looked like the stool form
in picture 1 (the most solid), 9% picture 2, 4% picture
3, 6% picture 4, 9% picture 5, and 17% picture 6 (the
most liquid).
O f subjects who experienced a p r e d o m i n a n t stool
form, T a b l e 2 shows the p e r c e n t a g e who also experi-
enced each of the other pictorial stool forms at least
"'some of the time" in the past seven days. T h e p a t t e r n
of o t h e r ( n o n p r e d o m i n a n t ) stool forms r e p o r t e d var-
ied by p r e d o m i n a n t stool form. Each n o n p r e d o m i -
nant stool form was reported at least some of the time
by at least 30% of the subjects for w h o m the p r e d o m -
inant form was i n t e r m e d i a t e (3 or 4). Subjects with
p r e d o m i n a n t l y liquid stool (forms 5 or 6) t e n d e d not
to have the most solid stool (form 1), but each n o n -
p r e d o m i n a n t stool form was reported by 20% of
them. Those with a p r e d o m i n a n t l y solid stool (form
0,~,,~,,,, Diseases and Sciences. |'o/. 40, No. 9 (September 19951
NEW MEASURE OF DIARRHEA

six forms "all" or "most of the time" (instead report-

1 2
6 liquid stools: of 17 diarrhea patients reporting only
JJ~
4 5
Fig 1. Pictorial stool representations used in the questionnaire.
Indicated below each picture is the corresponding stool form
number. (Pictures are also shown in questionnaire item 3 in the
Appendix.)
1) tended to have less of the other stool forms (each
of forms 4, 5, and 6 were reported by less than 15% of
these subjects).
Among the 40% of subjects who did not identify a
predominant stool form, 58% reported none of the
ing stool forms only "some" or "none" of the time),
35% had two stool forms "all" or "most of the time"
and 7% selected three or more forms "all" or "most
of the time."
Diarrhea Patients. Among subjects with diarrhea,
there was considerable variability in the number of
different stool forms selected (out of the possible six),
with over 40% of subjects experiencing four or more
different stool forms (see Figure 2A). The range of
stool forms reported (difference in score between the
3 most and least solid stool forms experienced at least
some of the time in the past seven days) was also
wide, with 56% having stool forms three or more
apart on the scale (see Figure 2B). Range in stool
forms experienced was smallest among those with
one stool type, 82% reported having the most liquid
stools (form 6).
Sixty-eight percent of the 105 patients who were
enrolled in the study for diarrhea experienced one
pictorial stool form "most" or "all of the time" in the
past seven days (41% had pictorial form 6, 24% form
5, 19% form 4, 7% form 3, 7% form 2, and 2% form
6 1). Eleven percent of diarrhea patients reported more
than one stool form "most" or "all of the time," while
21% reported none of the stool forms more than
some of the time.
Patient Definitions of Stool Form. A prior we de-
fined diarrhea as a patient report of completely un-
formed stool (pictures 4, 5, or 6) "all," "most," or
"some of the time" in the past seven days. We found
that subjects' report as to whether or not they had
diarrhea in the past seven days agreed very strongly
with our a priori definition (93%). Only eight of 153

TABLE 2. ALL PICTORIAL STOOL FORMS REPORTED BY PATIENTS WHO SELECTED A PREDOMINANT FORM
(N = 121)
Predommantpictonalstoolform se&cted (%)
Otherpictonal
stoolforms 1 2 3 4 5 6
reponed? (N = 29) (N = 18) (N = 9) (N = 13) ( N = 18) (N = 34)

1 50 44 31 6 6
2 45 67 46 28 21
3 24 50 69 33 21
4 14 17 56 56 21
5 t4 22 33 46 35
6 7 28 33 38 56

* Columns contain patients who selected that pictorial form (pictures 1-6, where form 1 is most solid and
form 6 is most liquid, see item 3, Appendix) as their predominant form (had that form "all" or "most
of the time" in the past seven days). Rows show the percent of persons with a particular predominant
stool form who experienced each other pictorial stool form (pictures 1-6) at least "some of the time" in
the past seven days.
1" Subjects frequently reported more than one "other" stool form.

Digestive Diseases a,,d Sciences, Vol. 40. No. 9 (September 1995) 1875
 MERTZ ET AL

TABLE 3. REL.VI'IONSHIP OF PATII/NT SELF-REPORTS OF DIARRHEA

A N u m b e r of S t o o l F o r m s R e p o r t e d AND PICTORIAl. STOOL FORM SEEEf_'I'ED*
By D i a r r h e a P a t i e n t s ( n = 1 0 5 )
25 Patient ever having
unformed stools depicted hy
pictures 4, 5, or 6?

co Yes No Total
20
O
(D Patient reports "'diarrhea" 135 6 141
Patient reports "no diarrhea" 8 50 58
Total 143 56 199
u]
*Five patients omitted due to missing data.
O

O
~D 10 descriptor, 82% of subjects reported having the most
liquid stool pictures (forms 5 and 6) and 14% ob-
served form 4. There was greater variability in picto-
rial stool type among those choosing the verbal terms
5
1 2 5 4 5 6 "loose" and "semiformed" to describe their stools in
Number of stool forms reported the past seven days. For neither descriptor was one
B picture form identified by more than 25%, and stools
Range in Stool Forms Reported
of all pictured forms were reported by at least some of
By D i a r r h e a P a t i e n t s ( n = 105)
25
the subjects (Figure 3B and C).
As expected, there was a progressive increase in the
bowel movement frequency (square root of move-
ments per day) as mean pictorial score (looser stool
ID
forms) increased (Figure 4). The linear association
9~ 20 between these two variables was highly statistically
Cr~ significant (r = 0.57, P < 0.001).
///
0
Diarrhea Morbidity. Incontinence was common in
"/// i////,
"/// the study population (N = 204): 32% of subjects had
./{/.. V///I
v/i/1
been incontinent at least once in the seven days prior
.~ , F///J
r)
h to entry and 42% had been incontinent in the four
VI//I
weeks prior to entry. Nocturnal diarrhea (stool forms
4, 5, and 6) in the week prior to entry occurred in 54%
of subjects.
0 1 2 5 4 5
Stool form (assessed by the verbal descriptors and
Range in reported stool form pictures pictorial score), change in number of stools per day
(highest form n u m b e r minus lowest) (difference between current stool frequency and fre-
Fig 2. Variety of stool forms reported by HIV patients with diar- quency prior to this), and diarrhea severity (a combi-
rhea. (A) Number of stool forms reported by diarrhea patients; (B) nation of the two, see Appendix) were significantly
range in stool forms reported by diarrhea patients.
correlated with frequency of incontinence and noc-
turnal diarrhea (Table 4). Incontinence was most
subjects who experienced unformed stools (pictures strongly correlated with stool form, with greater in-
4, 5, and 6) felt they did not have diarrhea in the past continence as stool became looser. The relative risk
seven days (94% sensitivity), and only six of 56 sub- of having frequent incontinence (defined as two or
jects who never observed unformed stools still felt more days with incontinence in the week prior to
they had diarrhea (89% specificity) (see Table 3). enrollment) was five times as great for patients with
When we compared self-reports for verbal (item 2) intermediate stool forms (defined as pictorial forms 3
and pictorial (item 3) descriptors, we found that and 4) as formed stool (pictorial forms 1 and 2) (P <
100% of those who selected the verbal descriptor 0.01), and 11.3 times a great for liquid stool (pictorial
"well-formed" stool also reported experiencing the forms 5 and 6) as formed stool (P < 0.0001). In
most solid pictorial stool (forms 1 and 2) "most" or contrast, the relative risk of frequent incontinence
"all of the time." For those selecting the "liquid" stool was only three times as great with more than six stools

1876 ~ige.~,i,.ePi~,.,,ses,,,,~ S,-i,.,,,..,-. rot.40. No. ~ ~Sep,,.,,,~,,,~ 1~')5~

NEW MEASURE OF DIARRHEA

70
STOOL FORM VS FREQUENCY
60 A Well-formed
I I I [ I I
50

40
% Reporting r=.57
3O 4 p<O.O01 o
20 .~ o
10 ~) o
o ~
1 1.5 2 2.5 3 3.5 4 4.5 5 5,5 6 ~ o o 8 8 8
PictorlalStoolFo~Scoro
o
70 o~ o ~ 8 o ~ ~
60 B Semi-formed q) ~ 2 0 COO CO Q3 GO

50 ... co o o

40
% Report~g
3O
~o o
20
o
10
0 I J I f I r
1 2 3 4 5 6
1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 most solid most liquid
Pictorial Stool Form Score
Pictorial Stool Form Score
70 84
Fig 4. Stool form vs frequency. Stool form (assessed by pictorial
60. Loose stool form score as described in item 3 of Appendix) and the square
50. root of stool frequency per day (item 4) are plotted for each
patient. Form and frequency were highly correlated (r = 0.57, P <
40
% Reporting
0.001) with increasing stool frequency as liquidity increased.
3O

20 per day as with less than three stools per day (P <
tO 0.02; Table 5).
O
Nocturnal diarrhea was strongly related to each of
1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 the measures of form and frequency, with the stron-
Pictorial Stool Form Score
gest correlation (r = 0.69, P < 0.05) with diarrhea
70
o
severity (the combined measure) (Table 4). In part
60 Liquid this strong correlation is due to the definition of
50 nocturnal diarrhea, which requires diarrhea to be
40'
present.
% Repo~ng Abdominal pain with bowel movements was mod-
3O
erately correlated with the measures of stool form
2O
and frequency. Correlations ranged from 0.33 to 0.41
10
(Table 4). Abdominal pain unrelated to bowel move-
O ments, tenesmus, and urgency correlated less strongly
1 1,5 2 2.5 3 3.5 4 4.5 5 5.5 6
Pictorial Stool Form Score than the other diarrhea symptoms with bowel habits.
For tenesmus and urgency, correlations with stool
frequency were greater than those with stool form.
Fig 3. Comparison of pictorial and verbal stool form assessments. Abdominal pain unrelated to bowel movements had a
For each verbal stool form designation (panel A, well-formed;
panel B, semiformed; panel C, loose; panel D, liquid) the distribu- lower correlation with stool form and frequency than
tion (in percent) of pictorial stool form scores are shown. The abdominal pain with bowel movements (P < 0.05).
pictorial stool form scores shown on the abscissa were derived by Correlations of form and frequency were generally
selecting the picture number the patient observed most frequently.
If multiple pictures were seen "all of the time" the corresponding weaker with the measures of discomfort (abdominal
numbers were averaged. If no picture was observed "all of the pain with or without bowel movements, tenesmus,
time," but multiples were observed "most of the time," they were and fecal urgency) than with the measures of com-
averaged. If no picture was selected "all" or "most of the time," the
"some of the time" picture numbers were averaged to give the plications (incontinence and nocturnal diarrhea)
pictorial stool form score. (Table 4).

Digestive Diseases and Sciences, Vol. 40. No. 9 (Septen, ber 1995) 1877
 MERTZ ET AL

TABLE 4. COMMON DIARRHEA-ASsOCIATEDSYMPTOMS AND CORRELATIONS WITH STOOl. FORM AND FREQUENCY*

Abdominal pain Abdominal pain

Nocturnal with bowel without bowel
Incontinence diarrhea movements Tenesmus Urgency movements

Form (verbal) 0.44 0.58 0.38 0.23 0.21 0.24

Form (pictorial) 0.47 0.59 0.34 0.19 0.23 0.19
Frequency (change in) 0.31 0.62 0.33 0.28 0.29 0.25
Diarrhea Severityt 0.42 0.69 0.41 0.30 0.29 0.27

*Pearson product-momcnt correlation coefficients are provided. All correlations are statistically significant (P < 0.05).
t Verbal ratings of stool form and the change in stool frequency wcre transformed to a 100-point scale and averaged to givc
a diarrhea scverity compositc score.

Guttman's weakest lower bound, parallel analysis,
and the scree test each suggested that two factors
were sufficient to account for the covariation among
the nine diarrhea measures. The Promax obliquely
rotated two-factor solution is presented in Table 6.
The first dimension is a bowel habits factor and the
second dimension represents a discomfort factor.
Loadings on the first factor ranged from 0.37 (incon-
tinence) to 0.89 (stool liquidity assessed by the picto-
rial stool form score). Loadings on the second factor
ranged from 0.41 (fecal urgency) to 0.66 (abdominal
pain). The estimated correlation between the bowel
habits and pain symptoms factor was 0.49.
DISCUSSION
Outcomes research requires precise quantification
of relevant measures in order to monitor changes that
may be subtle. This is important in the evaluation of
chronic illnesses, particularly gastroenterologic dis-
ease, in which symptoms are quite subjective and highly
variable. An accurate and precise measure of chronic
diarrhea is necessary to assess the impact of diarrhea on
quality of life, to track the course of disease over time,
and to evaluate the merits of treatment.
This study describes a system designed to charac-
terize diarrhea from the perspective of patients. Us-
ing pictorial representations of six different stool
forms varying from solid to completely liquid and a
battery of self-report items, we have documented in
detail the bowel habits of 204 symptomatic patients
with HIV-related illness.
The results of this study provide important infor-
mation about what patients mean when they use
verbal descriptors to describe their stool form. Spe-
cifically, we found that the meaning of verbal stool

TABLE 5. STOOL FORM AND FREOUENCY AND PREVALENCE OF FECAL INCONTINENCE*

Never
N or rare Occasional Frequent

Stool form (%)

Liquid (forms 5 + 6) 68 49 18 34 a
Intermediate (forms 3 + 4) 53 57 t' 28 b 15h
Formed (forms 1 + 2) 7"7 88 9 3c
Total 198
Stool frequency (%)
>6 per day 23 52 17 30
>3 to 6 per day 60 53 b 25 22
<3 per day 119 76 d 13 11d
Total 202

*Frequent incontinence was defined as two or more days with incontinence in the
previous week. Occasional incontinence was defined as one episode in the previous
week, or none in the previous week, but several times per week in the last month.
Rare incontinence was defined as none in the last week and once a week or less in the
last month. Liquid stool was defined as a pictorial form score 5 or greater (Appendix).
Unformed stool was defined as a pictorial form score of greater than 3 and less than
5. Formed stool was defined as a pictorial form of 3 or less. Differences in proportions
reporting incontinence were: a, P < 0.05 (liquid vs unformed); b, P < 0.01 (unformed
vs formed, and >3 and 6 bowel movements per day vs <3 bowel movements per day);
c, P < 0.001; d, P < 0.05 (formed vs liquid and < 3 bowel movements per day vs >6
bowel movements per day).

1878 Digestive Diseases and Sciences, Vol. 40, No. 9 (September 1995)
NEW MEASURE OF DIARRHEA
TABLE 6. FACq'OR ANALYSIS OF 8 DIARRrlEA MEASURES*
Bowel habits
Stool liquidity (pictorial form score)
Nocturnal diarrhea
Change in bowel frequency
Incontinence
Discomfort symptoms
Abdominal pain with bowel movements
Abdominal pain without bowel movements
Tenesmus
Fecal urgency
*The estimated correlation between the bowel habits and pain symptoms factor was 0.53.
descriptors varies across patients. Different patients
tended to select the same pictures when they reported
solid or liquid stools. However, when they described
their stools as semiformed or loose, there was wide
variation in the corresponding pictures selected. If
precise characterization of stool form is desired, the
verbal terms semiformed and loose should be avoided.
These results suggest that caution is needed in using
verbal descriptors and that they may be inadequate to
assess severity of illness and response to treatment in
medical practice and clinical investigations.
The pictorial stool form selected by patients was
found to correlate well with the occurrence of abdom-
inal pain, incontinence, and nocturnal diarrhea.
Moreover, 94% of patients who reported completely
unformed stools (pictured forms 4, 5, or 6) "some of
the time" or more in the past seven days also reported
that they had diarrhea during this time frame. There-
fore, the pictorial stool form is a reasonable index of
diarrhea status, since it correlates with symptoms,
complications, and both patient and physician defini-
tions of diarrhea. The pictorial form assessment was
easy to administer and was used successfully in a
population that included both English- and Spanish-
language patients. Because verbal stool characteriza-
tion is fraught with cultural and linguistic difficulties, it is
preferable to have a common vocabulary. Pictures are
most suited for that purpose (5, 6). Studies designed
specifically to examine the performance of this measure
across cultural or linguistic groups are needed.
Several observations on the nature of bowel habits
and diarrheal complications in patients with symp-
tomatic HIV disease are possible from this study.
Incontinence is extremely common in this population.
Forty-two percent of the patients in this study expe-
rienced loss of bowel control at least once in the
month prior to study enrollment. The risk of inconti-
nence increased dramatically as stool form became
Digestive Diseases and Sciences, Vol. 40, No. 9 (September 1995)
Bowel habits Discomfort symptoms
(factor I) (factor 2)
0.74 -0.03
0.78 -0.001
0,65 0.09
0.37 0,15
0.04 0.67
0.003 0.64
0.01 0.50
0,18 0.39
more liquid. Frequent incontinence occurred in only
3% of those with formed stools (pictures 1 and 2). In
contrast, 15% of those with intermediate stool forms
(pictures 3 and 4) had frequent incontinence as did
34% of those with liquid stools (pictures 5 and 6).
Therefore, reestablishing form to the stool of patients
with diarrhea and incontinence appears to be a rea-
sonable treatment goal. In non-HIV patients with
chronic diarrhea, fear of incontinence is a major
concern interfering with professional and social func-
tioning (3). In HIV patients, diarrhea is associated
with loss of social functioning and absenteeism from
work (4). Because patients are often too embarrassed
to complain of incontinence, and incontinence is
highly prevalent in HIV patients with diarrheal dis-
ease, physicians caring for these patients should in-
quire about loss of bowel control.
Although several factors affect frequency of bowel
movements [such as rectal inflammation (proctitis),
rectal sensitivity to distention and psychological fac-
tors], we have found a strong correlation between
more liquid form and increased bowel frequency (r =
0.57). Based on the strength of this correlation we
conclude that stool form may be a major contributor
to bowel frequency.
A factor analysis of the indicators of diarrheal
complications, pictorial stool form, and change in
bowel frequency revealed that incontinence, noc-
turnal diarrhea, stool form, and frequency loaded
together on the same factor. This bowel habits
factor encompasses two of the most troublesome
nonpainful complications of diarrhea, incontinence
and nocturnal diarrhea. Discomfort symptoms (pain
with and without bowel movements, urgency, and tenes-
mus), however, loaded on a different factor, consistent
with clinical experience that suggests that discomfort is a
distinct problem with a distinct pathophysiology from
alterations in stool form or frequency.
1879
 MERTZ ET AL

We have documented the pattern of different
types of stool forms in this sample of HIV patients.
Patients were asked to report each of the forms
that they experienced "all," "most," or "some of the
time" in the past seven days. There was consider-
able variation in the observed stool forms, particu-
larly among the diarrhea patients. Because of this
variation, and the fact that patients feel that they
have diarrhea if they experience any unformed stool,
it is important to ask about the frequency of a range
of stool forms as well as the most common one. For
example, a patient may report that he "still has diar-
rhea" despite a considerable improvement in stool
form,
In summary, the measures described here appear
promising for characterizing bowel habits in patients
with diarrhea. This characterization correlates with
clinically important events such as incontinence, noc-
turnal diarrhea and abdominal pain. These measures
(available without charge from the senior author)
should be useful for assessing bowel habits in both
clinical research and practice.

APPENDIX. DIARRHEA QUESTIONNAIRE

A. Stool Form Assessment

1. Have you been having diarrhea in the past 7 days?

Yes
No
2. In the past 7 days have your stools typically been:
well-formed
semi-formed (very soft but retains some form)
loose (no form, breaks apart)
Liquid (mushy like applesauce or watery.)
3. How often have your bowel movements looked like
each of the following pictures in the past 7 days?
All of the time Most of the time Some of the time None of the time
picture 1
picture 2
picture 3
picture 4
picture 5
picture 6

1 2 3 4 5 6

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NEW MEASURE OF DIARRHEA

B. Stool Frequency Assessment

4. On a typical day in the past 7 days, about how many bowel movements did you have?
_ _ p e r day
5a. How many bowel movements per day did you have before you started the pattern and appearance of
stools that you indicated above?
_ _ p e r day
5b. How many bowel movements per day did you have 6 months ago?
_ _ p e r day

C. Diarrhea Morbidity Assessment

6a. During the past 7 days did you have pain or cramping in your abdomen with your bowel movements?
0 never
1 <half
2 >half
3 all
6b. How would you rate the pain or cramping?
a mild
b moderate
c severe
d very severe
7a. During the past 7 days, did you have pain or cramping in your a b d o m e n without aassing stool?
0 never
1 one day
2 2-3 days
3 4 - 6 days
4 once-twice every day
5 ->twice every day
7b. How would you rate the pain or cramping?
a mild
b moderate
c severe
d very severe
8. During the past 7 days, did you have pains or spasms in your rectum without pass,rig stool?
0 never
1 one day
2 2-3 days
3 >3 days, -<2/day
4 >2/day
9. During the past 7 days, have you had urgency (felt like you had to pass a stool) without passing stool?
0 never
1 one day
2 2-3 days
3 >3 days, <-2/day
4 >2/day
10. During the past 7 days, on how many days did you lose control of your bowels or not make it to the bathroom for a bowel
movement? If never, did you lose control of your bowels in the past 4 weeks?
0 none
1 none in last week and -<l/week in last month
2 once in last week or none in last week and several/wk last m o n t h
3 2-3 days in last week
4 4 - 7 days in last week
11. During the past 7 days after bedtime, how many nights did you have stools that looked like pictures 4, 5, or 6?
0 -< 1 night
1 2-3 nights
2 4 - 6 nights
3 every night

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 MERTZ ET AL

Scoring of Questionnaire
S c o r i n g for i t e m 3:
P i c t o r i a l stool f o r m score was d e t e r m i n e d by t h e n u m b e r o f t h e p i c t u r e ( 1 - 6 ) e x p e r i e n c e d m o s t f r e q u e n t l y
by t h e p a t i e n t (all o f t h e t i m e > m o s t o f t h e t i m e > s o m e o f t h e t i m e ) . If m u l t i p l e p i c t u r e s w e r e s e e n "all o f
t h e t i m e " t h e c o r r e s p o n d i n g p i c t u r e n u m b e r s w e r e a v e r a g e d . If n o p i c t u r e was o b s e r v e d "all o f the t i m e , " but
m u l t i p l e w e r e o b s e r v e d " m o s t o f t h e t i m e " t h e y w e r e a v e r a g e d . If n o p i c t u r e was o b s e r v e d " a l l " o r " m o s t o f t h e
t i m e , " t h e p i c t u r e n u m b e r s s e l e c t e d " s o m e o f the t i m e " w e r e a v e r a g e d to give t h e p i c t o r i a l s t o o l f o r m score.
Scoring for change in stool frequency:
Current frequency (item 4) minus prior (item 5a or 5b, whichever smaller*):
0 <0
1 >0, <3
2 :>3, <5
3 :>5, <7
4 :>7, <9
5 :>9, <12
6 >-12
Scoring for item 6:
0 0
1 a
2 lb
3 lc
4 ld, 2b-d, 3b-d
Scoring for item 7:
0 0
1 l-3a, lb, 2b
2 4a, 5a, 3b, lc, ld, 2c, 2d
3 4b, 5b. 3c, 3d
4 4e, 4d, 5c, 5d
* Note: the smaller prior stool frequency number was selected to compare the new frequency to the most normal premorbid frequency.

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