BSI: Bowel Scene Investigation

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The subject was a 43-year old male with Crohn's disease.  A "Crohnie," they call him.  After a particularly good week, he entered a favorite Mexican establishment by the name of Chipotle.  He ordered a burrito bowl:  rice, beans, chicken, a little salsa and guacamole, but no cheese or sour cream.  Nothing big.  He had eaten that the week before with no reactions.  However, this time the meal had a decidedly stronger kick.  And, instead of merely drinking water as was his usual, the Crohnie decided to wash the meal down with a diet Coke.  Coke Zero, actually.  Usually, he tolerates such an extravagance.  However, before he left, he refilled the cup and downed another 16 ounces or so of the carbonated, caffeinated beverage.  About five hours later he was found on the toilet.  His stools were loose.  Real loose.  Telltale signs of undigested food filled the bowl.  The Crohnie had pushed too far.   And now he was paying the price.  But what was the cause?  It was time for a BSI.



Bowel Scene Investigation.  Before coming down with Crohn's, I rarely thought about or paid any attention to my daily (or sometimes, every other day) trip to the throne room.  I can't remember a time before Crohn's when I actually took a close look into the bowl to examine what recently came out of my body.  In-out was my philosophy. I was never one of those guys to sit for a long time on the toilet.  Unlike some people I know, it was not my preferred reading spot.  There was this guy in college who lived in my apartment complex junior year.  He would sit for an hour or so on the toilet, reading a magazine.  He liked to not only keep the door to the bathroom open, but also the door to the apartment open so that he could see what was going on in the courtyard.  Consequently, everyone could see him as well.  He liked to smile and wave at people when they made eye-contact.  That was never me.

Bowel examination is a very important component of the lifestyle of a Crohn's patient.  In fact, doctors say that it should be something that everyone does as the stool can give one clues about general health. But, again, this is not something that most people do.  There is a taboo-like stigma we place on the process of moving our bowels.   In fact, just saying "bowel movement" sanitizes the whole process.  It's not like we are actually moving our bowels.  Let's face it: we're excreting feces.  It's an excretion process that occurs after your body has absorbed the nutrients from the food.  But it is a process that's essential to our well-being.  It is essential to our survival.  The process itself is very complex and when things aren't going right you know it.  All you have to do is look in the bowl.

The day I ate Chipotle, I had a feeling something was going to happen.  I started having loose stools and more gas by the afternoon.  The previous day, I had only made one trip to the bathroom.  Not that day; I had already gone three times as much.  In the bowl, I saw chunks of tomato.  This would suggest the salsa I had on my burrito bowl.  However, I also had spaghetti the night before and there were chunks of tomato in that meal as well.  The question: was the tomato from lunch or the dinner from the previous night? 

According to the Mayo Clinic, the process of digestion can take several days.  The food moves through the stomach after a couple of hours, then into the small intestine.  That takes a total of six hours or so to complete.  Then the journey through the large intestine usually concludes after a twenty-four hour period.

In Crohn's patients, this process is faster.  The food moves, sometimes in its undigested state, from the body to the bowl in a matter of hours.  This can be due to a flare-up or some other reaction to the food in question.  Caffeine can also contribute to the quick bowel and the loose stools as well.

The only way to determine the cause is to examine the stool.  Sometimes you have to get down on all fours and look directly into that bowel.  Don't think of it as a toilet but a window to you body.  The closest most people come to this is probably when they are about to vomit.  Not for a Crohn's patient.

Bowl examination becomes an art form for a Crohn's patient.  We've learned how to take toilet paper and swirl it in the water to move the particles around.  If needed, we can even pick pieces out of the water with the toilet paper in order to get a closer look.  And not once get our hands dirty.
 
What I was seeing was definitely tomato. But it was difficult to tell if it was from the salsa or the spaghetti sauce.   I swirled the water a bit and thought for a moment what my family would think if they barged in at that time.  I could just hear my son, "Dad, are you playing with your poo?"

And then I saw it:  a small green leaf.  It was cilantro.  What I was looking at was the meal that I had just five hours earlier. 

But what was it that was causing this reaction?  After all, I had had this same meal last week with no problems whatsoever.  Except this time around I had the Coke Zero.  And the salsa seemed to be a bit on the "hot" side this time around.

It was probably one of those things or a combination of both; spice and caffeine.  The bane of a Crohnie. 

Caffeine has always been a trigger for me, but I can usually have a little bit before it affects my digestive system.  Over the last several weeks, I have almost completely given up caffeine, except for the occasional half-decaf coffee I treat myself to on weekends.  At Chipotle, I think I pushed the caffeine too far.  One soda probably would have been fine.  But two pushed me over the line.

Stool examination can be an important diagnostic tool for anyone, not just Crohnies.  Even Dr. Oz recommends it.  "At the end of the day," he says, "you can analyze your body really effectively by looking at what comes out of your body."  In 1997, doctors at the University of Bristol developed a scale to help diagnosis problems in the colon by looking at the stool.  It is called the "Bristol Stool Scale."  There are even apps available to track your movements.  Ah, technology.

Next time I go to Chipotle, I will drink only water and see if I have the same reaction to the food.  I doubt I will.

If there is a reaction, I know just what to do.