When Persistent Floating Stools Become Concerning
In a patient with well-formed, normal-colored floating stools for four months and normal CBC, CMP, and liver enzymes, these symptoms are generally not concerning and do not require extensive investigation unless alarm features develop. 1
Key Reassuring Features in This Case
Your patient lacks the critical "red flag" features that would mandate aggressive workup:
- No fever, weight loss, blood in stools, or anemia 1
- Normal physical examination findings (implied by normal labs) 1
- Well-formed stools with normal color 1
- Normal inflammatory markers (normal CBC suggests no elevation in WBC) 1
Understanding Floating Stools
Floating stools alone are not pathological and commonly occur in healthy individuals due to:
- Increased gas content in stool 2
- Dietary fiber intake variations 2
- Normal variations in stool water-holding capacity 1
The Bristol Stool Chart defines diarrhea as type 5 and above, and your patient has well-formed stools, which suggests normal transit and consistency 1.
When to Escalate Investigation
Alarm features requiring immediate workup include: 1, 3
- Unintentional weight loss (>5% body weight)
- Rectal bleeding or positive fecal occult blood
- Nocturnal symptoms that wake the patient from sleep
- New onset after age 50 without prior similar symptoms
- Family history of inflammatory bowel disease or colorectal cancer
- Fever or systemic symptoms
- Anemia on CBC (which your patient does not have)
Recommended Next Steps for This Patient
If symptoms persist beyond 4 months with no alarm features:
Consider limited additional testing: 1, 3
- Fecal calprotectin to exclude subclinical inflammatory bowel disease (particularly if patient is under 45 years) 1
- Celiac serology (anti-tissue transglutaminase IgA with total IgA) as celiac disease can present with subtle symptoms 1, 3
- Stool for ova and parasites only if travel history or endemic area exposure 1, 3
If diarrhea-predominant symptoms develop:
- SeHCAT scanning or serum 7α-hydroxy-4-cholesten-3-one for bile acid malabsorption 1
- Lactose breath testing if patient consumes significant dairy 3
Common Pitfalls to Avoid
Do not over-investigate patients without alarm features. 1 The American Gastroenterological Association specifically warns against extensive workups in young patients with functional symptoms and normal initial investigations, as this leads to unnecessary costs and patient anxiety 1.
Do not assume floating stools equal malabsorption. 2 True malabsorption presents with additional features like weight loss, steatorrhea (greasy, foul-smelling stools), and nutritional deficiencies—none of which your patient demonstrates 1.
Do not order colonoscopy unless: 1, 3
- Patient is over age 50 and not up-to-date with colorectal cancer screening
- Alarm features are present
- Fecal calprotectin is significantly elevated (>250 μg/g) 1
Clinical Bottom Line
Your patient's four-month history of floating but well-formed, normal-colored stools with completely normal bloodwork represents a benign finding that does not warrant aggressive investigation at this time. 1 Reassure the patient, consider the limited additional tests mentioned above if symptoms are bothersome, and establish clear return precautions for alarm features 1. The absence of weight loss, blood, anemia, and abnormal physical findings makes serious pathology extremely unlikely 1.