Stools, clay-colored
Pale, putty-colored stools usually result from hepatic, gallbladder, or pancreatic disorders. Normally, bile pigments give the stool its characteristic brown color. However, hepatocellular degeneration or biliary obstruction may interfere with the formation or release of these pigments into the intestine, resulting in clay-colored stools. These stools are commonly associated with jaundice and dark “cola-colored” urine.
History and physical examination
After documenting when the patient first noticed clay-colored stools, explore associated signs and symptoms, such as abdominal pain, nausea and vomiting, fatigue, anorexia, weight loss, and dark urine. Does the patient have trouble digesting fatty foods or heavy meals? Does he bruise easily?
Next, review the patient’s medical history for gallbladder, hepatic, or pancreatic disorders. Has he ever had biliary surgery? Has he recently undergone barium studies? (Barium lightens stool color for several days.) Also, ask about antacid use because large amounts may lighten stool color. Note a history of alcoholism or exposure to other hepatotoxic substances.
After assessing the patient’s general appearance, take his vital signs and check his skin and eyes for jaundice. Then examine the abdomen: inspect for distention and ascites, and auscultate for hypoactive bowel sounds. Percuss and palpate for masses and rebound tenderness. Finally, obtain urine and stool specimens for laboratory analysis.
Medical causes
Bile duct cancer
Commonly a presenting sign of bile duct cancer, clay-colored stools may be accompanied by jaundice, pruritus, anorexia and weight loss, upper abdominal pain, bleeding tendencies, and a palpable mass.
Biliary cirrhosis
Clay-colored stools typically follow unexplained pruritus that worsens at bedtime, weakness, fatigue, weight loss, and vague abdominal pain; these features may be present for years. Associated findings include jaundice, hyperpigmentation, and signs of malabsorption, such as nocturnal diarrhea, steatorrhea, purpura, and bone and back pain due to osteomalacia. The patient may also develop firm, nontender hepatomegaly; hematemesis; ascites; edema; and xanthomas on his palms, soles, and elbows.
Cholangitis (sclerosing)
Characterized by fibrosis of the bile ducts, cholangitis, a chronic inflammatory disorder, may cause clay-colored stools, chronic or intermittent jaundice, pruritus, right upper quadrant pain, chills, and a fever.
Cholelithiasis
Stones in the biliary tract may cause clay-colored stools when they obstruct the common bile duct (choledocholithiasis). However, if the obstruction is intermittent, the stools may alternate between normal and clay colored. Associated symptoms include dyspepsia and — in sudden, severe obstruction — characteristic biliary colic. This right upper quadrant pain intensifies over several hours, may radiate to the epigastrium or shoulder blades, and is unrelieved by antacids. The pain is accompanied by tachycardia, restlessness, nausea, intolerance to certain foods, vomiting, upper abdominal tenderness, a fever, chills, and jaundice.
Hepatic cancer
Before clay-colored stools develop, the patient usually experiences weight loss, weakness, and anorexia. Later, he may develop nodular, firm hepatomegaly, jaundice, right upper quadrant pain, ascites, dependent edema, and a fever. A bruit, hum, or rubbing sound may be heard on auscultation if the cancer involves a large part of the liver.
Hepatitis
With viral hepatitis, clay-colored stools signal the start of the icteric phase and are typically followed by jaundice within 1 to 5 days. Associated signs include mild weight loss and dark urine as well as continuation of some preicteric findings, such as anorexia and tender hepatomegaly. During the icteric phase, the patient may become irritable and develop right upper quadrant pain, splenomegaly, enlarged cervical lymph nodes, and severe pruritus. After jaundice disappears, the patient continues to experience fatigue, flatulence, abdominal pain or tenderness, and dyspepsia, although his appetite usually returns and hepatomegaly subsides. The posticteric phase generally lasts from 2 to 6 weeks, with full recovery in 6 months.
With cholestatic nonviral hepatitis, clay-colored stools occur with other signs of viral hepatitis.
Pancreatic cancer
Common bile duct obstruction associated with pancreatic cancer may cause clay-colored stools. Classic associated features include abdominal or back pain, jaundice, pruritus, nausea and vomiting, anorexia, weight loss, fatigue, weakness, and a fever. Other possible effects include diarrhea, skin lesions (especially on the legs), emotional lability, splenomegaly, and signs of GI bleeding. Auscultation may reveal a bruit in the periumbilical area and left upper quadrant.
Pancreatitis (acute)
Pancreatitis is an inflammatory disorder that may cause clay-colored stools, dark urine, and jaundice. Typically, it also causes severe epigastric pain that radiates to the back and is aggravated by lying down. Associated findings include nausea and vomiting, a fever, abdominal rigidity and tenderness, hypoactive bowel sounds, and crackles at the lung bases. With severe pancreatitis, findings include marked restlessness, tachycardia, mottled skin, and cold, sweaty extremities.
Other causes
Biliary surgery
Biliary surgery may cause bile duct stricture, resulting in clay-colored stools.
Special considerations
Prepare the patient for diagnostic tests, such as liver enzyme and serum bilirubin levels, hepatitis panels, sonograms, a computed tomography scan, endoscopy, retrograde cholangiopancreatography, and stool analysis.
Pediatric pointers
Clay-colored stools may occur in infants with biliary atresia.
Geriatric pointers
Because elderly patients with cholelithiasis have a greater risk of developing complications if the condition isn’t treated, surgery should be considered early on for treatment of persistent systems.
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Pale stool
» Next page: Constipation (A Pocket Manual of Differential Diagnosis)
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