Acholic Stool

Acholic Stool, Pale StoolThere are many interesting complaints that we encounter in the Emergency Department. Many make you scratch your head (how did they get that FB in the Ear?) and others will challenge you (how do I get this fish hook out of the kid’s face?), but one thing is always true; the guardians of neonates worry about A LOT!! This, I believe, is appropriate. I would rather a new parent be more careful rather than careless and cavalier. Plus, you can never trust a neonate! In addition to the numerous concerns about formula and development, many parents will get worried about the color of the child’s stool. (How delightful. Now we have to talk about poop.) Unfortunately, you can’t just dismiss this concern, as it could be a problem. Let us QUICKLY discuss one of the colors that should grab your attention – Acholic Stool:


Acholic Stool: Colors of the Rainbow

  • Stool color can vary drastically with patient age and diet.
    • Stools of healthy breastfed infants are often “daffodil” yellow.
    • Stools of healthy formula-fed infants are often “mustard” yellow.
  • Certainly, medications and other ingested chemicals / dyes can also affect the stool color.
  • Most often the exact color is inconsequential, but we should be mindful of:
    • Black and sticky (aka, melena)
    • Red and/or maroon (ill-appearing infants with bloody stool warrant concern!)
    • Acholic (aka, pale)
      • One or two pale stools should not lead to massive freak out!… but persistent acholic stools do warrant evaluation.
      • Does not represent one color, but is a spectrum. [Bakshi, 2012]
      • “Cream cheese”
      • “Uncooked pastry”
      • “Manila envelope” (yes, we can describe things in terms that aren’t food related!)
      • Dark urine can obscure the stool’s true pale coloration (just to complicate things more). [Bakshi, 2012]


Acholic Stool in Neonate: The Concern

  • Biliary Atresia or other cholestatic disease is the biggest concern with acholic stools.
    • There are many potential conditions, like neonatal hepatitis that require evaluation.
    • Don’t forget other metabolic conditions that stress the body like Sepsis, Hypothyroidism, Galactosemia, and panhypopituitarism.
  • Biliary Atresia:
    • Most common cause of neonatal cholestasis that requires surgery [Agin, 2016; Bakshi, 2012]
    • Characterized by destruction of the hepatic biliary system leading to biliary cirrhosis.
    • The condition can be overlooked initially as the infants are generally well appearing.
    • Early detection is critical!
      • A Kasai procedure has good success rates if performed early.
      • Later referral, after cirrhosis has develop, will often lead to liver transplantation.


Acholic Stool: A Significant Clue!

  • Traditionally, biliary atresia is thought of when jaundice lasts longer than 2 weeks of life or with acholic stool and/or dark urine.
  • After evaluating many potential clues to differentiate patients with biliary atresia from other cholestatic disease:
    • Early development jaundice is more commonly seen in biliary atresia. [Agin, 2016]
    • The presence of acholic stools was the most sensitive characteristic. [Agin, 2016]


Acholic Stool: Not as Easy as You Think

  • So why are we doing a Morsel on Acholic Stool… seems easy… if stool is super pale, than check for biliary congestion…
  • But, experienced providers’ (RN and MD) ability to discern acholic stool is not good enough to rely on our unaided visual inspection alone. [Bakshi, 2012]
  • There are several tools that exist that can be helpful:
    • Stool Cards / Charts have been found to be useful.
    • iPhone App (PoopMD) uses RGB hexcodes to discern the acholic stool. [Franciscovich, 2015]
    • iPhone App (Baby unchi) [Hoshino, 2017]
      • “Baby Poop” app – only available in Japan right now
      • Uses machine learning processes to recognize concerning stool colors (if we are using artificial intelligence for this… you know it is serious!).


Moral of the Morsel

  • Most colors are fine… but not all! Pay attention to the acholic stool complaint.
  • Don’t rely on your eyes… even if you have “perfect vision!” Use a stool card/chart!
  • If it is acholic, don’t miss the opportunity to save a liver! Check urinalysis, fractionated bilirubin, and LFTs.



Hoshino E1, Hayashi K2, Suzuki M3, Obatake M4, Urayama KY2,5, Nakano S3, Taura Y6, Nio M7, Takahashi O2. An iPhone application using a novel stool color detection algorithm for biliary atresia screening. Pediatr Surg Int. 2017 Oct;33(10):1115-1121. PMID: 28819683. [PubMed] [Read by QxMD]

Ağın M1, Tümgör G, Alkan M, Özden Ö, Satar M, Tuncer R. Clues to the diagnosis of biliary atresia in neonatal cholestasis. Turk J Gastroenterol. 2016 Jan;27(1):37-41. PMID: 26728861. [PubMed] [Read by QxMD]

Jain M1, Adkar S1, Waghmare C1, Jain J2, Jain S2, Jain K2, Passi GR2, Vinay RS2, Soni MK3. Neonatal Cholestasis – Single Centre Experience in Central India. Indian J Community Med. 2016 Oct-Dec;41(4):299-301. PMID: 27890981. [PubMed] [Read by QxMD]

Shen Z1, Zheng S2, Dong R2, Chen G2. Saturation of stool color in HSV color model is a promising objective parameter for screening biliary atresia. J Pediatr Surg. 2016 Dec;51(12):2091-2094. PMID: 27692864. [PubMed] [Read by QxMD]

Franciscovich A1, Vaidya D2, Doyle J3, Bolinger J3, Capdevila M4, Rice M3, Hancock L3, Mahr T3, Mogul DB1. PoopMD, a Mobile Health Application, Accurately Identifies Infant Acholic Stools. PLoS One. 2015 Jul 29;10(7):e0132270. PMID: 26221719. [PubMed] [Read by QxMD]

Schreiber RA1, Masucci L2, Kaczorowski J3, Collet JP4, Lutley P5, Espinosa V6, Bryan S7. Home-based screening for biliary atresia using infant stool colour cards: a large-scale prospective cohort study and cost-effectiveness analysis. J Med Screen. 2014 Sep;21(3):126-32. PMID: 25009198. [PubMed] [Read by QxMD]

Bakshi B1, Sutcliffe A, Akindolie M, Vadamalayan B, John S, Arkley C, Griffin LD, Baker A. How reliably can paediatric professionals identify pale stool from cholestatic newborns? Arch Dis Child Fetal Neonatal Ed. 2012 Sep;97(5):F385-7. PMID: 22933100. [PubMed] [Read by QxMD]

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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  1. why kasai surgery are so complex and dangerous and it was never enhanced since original invention 70 year ago maybe engineer could assist surgeon to enhance the procedure as the surgeon lacks creative thinking

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