acholic stool

Q: 58 years old male is admitted to ICU from free standing Emergency Room (ER) in the community with severe dehydration and abdominal pain. CT scan of abdomen could not be performed as the machine was broken in ER. Patient required fluid resuscitation, pressors, and placement of an Arterial line. Patient reported loss of weight in the last six months and acholic stool. What could be the first concern?

Answer: Pancreatic cancer

Acholic (not alcoholic) stool is a clay-colored or pale stool, i.e., stool without a normal yellow-brown color. This shows a lack of bilirubin. The breakdown products of bilirubin, urobilin, and stercobilin give stool its brown color. Although it sounds simple, many clinicians have failed to identify it. In modern digital days, mobile phone applications using a phone camera are available to identify this important clinical sign. In pediatric populations, biliary atresia is a common cause, and early proper identification can be helpful.

The two major causes of symptomatic acholic stool, particularly in adults, are:

1. viral hepatitis 

2. Pancreatic cancer

With prolonged abdominal pain and loss of weight, pancreatic cancer is on top of the list of differential diagnoses. This is due to near-complete common bile duct obstruction from cancer of pancreatic head or the duodenal ampulla. Many times, it can be a presenting symptom.

The acholic stool can be transient in normal people due to diet or different intakes, such as large amounts of the active ingredient in antacids, which can cause pale stools.

#hepatology

#GI

#oncology

References:

1. De La Cruz MS, Young AP, Ruffin MT. Diagnosis and management of pancreatic cancer. Am Fam Physician. 2014 Apr 15;89(8):626-32. PMID: 24784121.

2. Franciscovich A, Vaidya D, Doyle J, Bolinger J, Capdevila M, Rice M, Hancock L, Mahr T, Mogul DB. PoopMD, a Mobile Health Application, Accurately Identifies Infant Acholic Stools. PLoS One. 2015 Jul 29;10(7):e0132270. doi: 10.1371/journal.pone.0132270. PMID: 26221719; PMCID: PMC4519295.