OBJECTIVES The aims of this study were: (1) to investigate translation difficulties encountered during linguistic validation of the Bristol Stool Scale; (2) to discover whether certain items consistently posed problems across different languages; and (3) to analyse how solutions were reached and what types of solutions were appropriate.  METHODS The investigation was made up of the following stages: (1) collation of back translation reviews of the Bristol Stool Scale for 30 European and Asia-Pacific languages; (2) identification of problematic words and phrases, based on written discussion between lead translators and project managers; (3) investigation of patterns that became apparent across different languages; (4) review of methods used to overcome the translation difficulties. RESULTS For more than a third of the languages reviewed (2 European and 9 Asia-Pacific, including 7 Indian), difficulties were experienced when attempting to translate certain items word-for-word. The majority of these difficulties centred on the food-related similes used in the scale to describe the different stool types. In all of the Indian languages in this study, alternative food-related similes were deemed necessary (e.g. ‘banana’ replacing ‘sausage’) in order to ensure that the wording was culturally relevant. Of the other languages, Thai and Romanian preferred similes that did not relate to food (‘bullets’ and ‘beads/little round bits’ respectively, instead of ‘nuts’), while for Singapore Chinese and Polish it was decided to remove certain similes altogether (‘like nuts’/‘like a sausage’). CONCLUSIONS Certain items in the Bristol Stool Scale, in particular the two food-related similes, cause translation difficulties for some languages. For such items, it may not be appropriate to produce a word-for-word translation. In these cases, alternative solutions must be sought, taking into account cultural considerations, in order to achieve conceptual equivalence.