Steatorrhea

What is Steatorrhea?

Steatorrhea is a condition where more fat is found in your stool than usual. This is usually a sign that your body is not absorbing fat properly and can be a symptom of many conditions like exocrine pancreatic insufficiency (EPI – a condition where the pancreas does not make enough enzymes), celiac disease, or tropical sprue (a condition that affects the absorption of nutrients from the intestines). When there is more fat in your stool, it might look pale, be larger than normal, smell bad, and be loose.

Doctors can check for steatorrhea by examining a stool sample to see if it has a lot of fat. They can do this by using a process called Sudan III staining. But to fully confirm the diagnosis, they have to measure the amount of fat in the stool.

The process your body uses to digest and absorb fat is complex and involves different steps and different parts of your body. Fat absorption needs bile acids (chemicals that help digest fat), digestive enzymes (proteins that help break down food into nutrients), and a normally working small intestine lining.

When you eat fat, most of it is in the form of triacylglycerols. These are first mixed with bile acids, which help break them down into fatty acids and monoglycerides with the help of pancreatic lipases and colipases. These broken down fats form tiny particles called micelles in the upper part of your small intestine, thanks to the action of bile acids. The micelles are then absorbed by the tiny, finger-like projections in your intestine, referred to as intestinal villi and transported as chylomicrons, a type of lipoprotein, via the intestinal lymphatics, channels that carry fluid and cells.

So, if anything affects the availability or function of bile acids, pancreatic digestive enzymes, or absorptive villi, it could result in steatorrhea.

What Causes Steatorrhea?

Steatorrhea, or excessively fatty stools, can be caused by a variety of health conditions. These conditions can be grouped into three main categories:

1. Conditions that lead to issues with the pancreas’s enzyme-producing function (known as exocrine pancreatic insufficiency, or EPI).
2. Conditions that cause a deficiency in bile acids, which help digest fat.
3. Diseases that affect the small intestine, which absorbs digested nutrients.

Some of the most common conditions in each category include:

1. EPI can be caused by chronic inflammation of the pancreas (chronic pancreatitis), a genetic disorder that causes sticky mucus to build up in the lungs and digestive tract (cystic fibrosis), or conditions that lead to blockage or removal of the pancreatic duct, such as pancreatic tumors.
2. Bile acid deficiency can result from many things, such as a slow or blocked flow of bile from the liver (cholestasis) caused by conditions like primary biliary cholangitis or primary sclerosing cholangitis, or an inability to absorb bile acids in the last part of the small intestine (ileum). This could be from a surgery that removes the ileum or Crohn’s disease affecting the ileum or an overgrowth of bacteria in the small intestine.
3. Diseases that affect the first part of the small intestine can also cause steatorrhea. These include celiac disease (an immune response to eating gluten), tropical sprue (a rare disease that affects absorption in the small intestine), giardiasis (an intestinal infection), Whipple disease (a rare bacterial infection), lymphoma (a type of cancer), amyloidosis (an abnormal protein build-up), an overgrowth of bacteria in the small intestine, and a digestive disorder caused by HIV.

Some less common causes of steatorrhea include medications that inhibit fat breakdown (like orlistat), Zollinger-Ellison syndrome that causes increased production of gastric acid (which inactivates the pH-sensitive enzymes produced by the pancreas that break down fat), and a complication from a bone marrow transplant called graft-versus-host disease.

Risk Factors and Frequency for Steatorrhea

Steatorrhea, or fatty stools, can be difficult to diagnose as its early stages often present minimal or nonspecific symptoms. As such, an exact count of how many people have this condition is hard to determine. Additionally, the rate of steatorrhea depends on the prevalence of various underlying causes.

In adults, chronic pancreatitis, long-term inflammation of the pancreas, is the most common cause of Exocrine Pancreatic Insufficiency (EPI), a condition where the pancreas can’t make enough enzymes to digest food. In children, cystic fibrosis (CF), a disease causing severe lung damage, often leads to EPI. CF is notably the most lethal inherited disease affecting the white population.

• Chronic pancreatitis has an annual occurence rate of approximately 4 per 100,000 people and a prevalence of about 42 per 100,000 people in the U.S.
• Approximately 1 in 3000 births is a case of CF, and about 85% of CF patients suffer from pancreatic insufficiency.

Celiac disease, a digestive disorder caused by an adverse reaction to gluten, is becoming more widespread, with different rates depending on geographical location. There are higher rates in Europe and Oceania, and lower rates in South America and Africa.

• Worldwide, about 1.4% of people have celiac disease.
• It’s more common in certain high-risk groups such as those with type 1 diabetes, Down syndrome, Turner syndrome, IgA deficiency, William syndrome, and in relatives of celiac disease patients.

Two other conditions, Primary Biliary Cirrhosis (PBC) and Primary Sclerosing Cholangitis (PSC), also have variation in their prevalence rates. PBC, a disease of the liver, has a greater incidence in women. The exact prevalence of a digestive condition called Small Intestinal Bacterial Overgrowth (SIBO) is hard to determine due to differing definitions of the condition.

• PBC has an occurrence rate of 1.1 to 2.7 per 100,000 people, and a prevalence of 40 per 100,000 people, more commonly in females.
• The rate of PSC varies by location, from 0 to 1.3 cases per 100,000 people per year, and 0 to 16 per 100,000 people.

Signs and Symptoms of Steatorrhea

Steatorrhea is a medical condition that results in abnormal, oily stools. Patients with this condition produce stools that are bulky, pale, and have a strong, bad smell. These stools can float and are often hard to flush. Early on, steatorrhea might not show any symptoms and may go unnoticed. However, as the condition progresses, patients may experience other signs like:

• Frequent diarrhea
• Stomach discomfort
• A feeling of bloatedness
• Weight loss

In children, it could lead to delayed growth and slower puberty. Severe cases could result in loss of fat below the skin and muscle wasting. It might also cause deficiencies in fat-soluble vitamins like A, D, E, and K. If steatorrhea occurs because of celiac disease, patients may have symptoms outside the intestines like anemia, mouth ulcers, and a type of skin rash called dermatitis herpetiformis.

Abdominal pain is often a major symptom, especially in conditions like chronic pancreatitis, Small Intestine Bacterial Overgrowth (SIBO), inflammatory bowel disease, and celiac disease. Patients with the Cystic Fibrosis (CF) disease can have symptoms related to the sinus and lungs. If steatorrhea is caused by liver diseases like Primary Biliary Cholangitis (PBC) or Primary Sclerosing Cholangitis (PSC), patients may experience yellowing of the skin or eyes (jaundice), fatigue, itchiness, and in the late stages, an enlarged spleen or fluid in the abdomen.

Testing for Steatorrhea

The process of diagnosing steatorrhea, a condition characterized by excess fat in stool, involves examining clinical symptoms, running lab tests, and gathering images from scans. In some cases, a doctor may need to perform procedures like a small intestinal biopsy or liver biopsy to determine the exact cause.

The first step usually takes the form of a test to estimate the amount of fat in your stool. If more than 7 grams of fat are detected in a 24-hour period, this is indicative of steatorrhea. The test involves following a strict diet which includes 100 grams of fat daily for five days. After this, you would need to provide a stool sample from the last 72 hours. This method, oftentimes deemed cumbersome and unpleasant by patients, is very accurate. An alternative test can be used to evaluate specific pancreatic conditions, requiring only a single stool sample. It may be less accurate in the early stages of a condition though, and a solid stool sample is necessary to avoid any false low results.

To evaluate chronic pancreatitis, a typical X-ray can show if there are any calcifications in your pancreas. Additionally, CT or MRI scans can reveal pancreatic damage and ductal dilatation, which shows if the ducts carrying digestive fluids have been expanded. More specialized imaging tests can give an even more thorough evaluation – these include magnetic resonance cholangiopancreatography (MRCP), or endoscopic retrograde cholangiopancreatography (ERCP). The same tests also play a vital role in assessing pancreatic tumors.

To check for celiac disease, a blood test can be taken to identify certain antibodies. These are substances that your body produces in response to specific triggers, and their presence can indicate an immune response to certain elements in the diet, like gluten. If the results show you may have the disease, duodenal biopsies can be done to confirm the diagnosis.

In cases where chronic liver disease is suspected, blood tests can reveal abnormal levels of liver enzymes, suggestive of liver cell damage. Less commonly, a liver biopsy might be done to reveal destruction of small tubes in the liver and changes suggestive of cirrhosis, a late stage of scarring of the liver.”

For another liver disease called PSC, preferred diagnostic practice is a screening test called magnetic resonance cholangiography (MRC). Through this, any narrowing and enlargement of the ducts (tubes) within and outside the liver can be revealed. A biopsy might be done in certain situations but is not a routine test.

Lastly, to evaluate condition called SIBO, breath tests utilizing either glucose or lactulose are commonly used. These are used to measure the amount of certain gases, which are produced by bacterial fermentation.

Treatment Options for Steatorrhea

Treatment for steatorrhea, a condition where the body excretes too much fat through the stools, depends on what caused it in the first place. Here are some examples:

If someone has exocrine pancreatic insufficiency (EPI), where the pancreas doesn’t produce enough enzymes to break down food, the primary treatment is pancreatic enzyme replacement therapy (PERT). This treatment uses medicines to replace the missing enzymes. Along with this therapy, people with EPI are typically advised to eat a normal to high-fat diet, and they may also need to have supplements of vitamins that dissolve in fat. While eating a diet low in fat could reduce symptoms associated with steatorrhea, it might worsen their overall nutritional status, so it’s not usually recommended.

For people with small intestinal bacterial overgrowth (SIBO), where there are too many bacteria in the small intestine, treatment often involves a trial of antibiotics. One commonly used antibiotic is rifaximin, but other options might be used depending on the decisions of the doctors and the individual patient’s needs.

A person with celiac disease, a disorder in which the body reacts negatively to a protein in wheat called gluten, treatment usually involves a strict, life-long diet without gluten. It’s also important for them to learn about the disease, manage any nutritional deficiencies they may have, join a support group, and consult with a dietitian who has experience in this condition.

If someone is suffering from primary biliary cholangitis (PBC), a disease where the body’s immune system attacks its own liver, the first-line treatment is usually ursodeoxycholic acid. This medication helps to reduce the amount of bile in the liver, preventing further damage. However, this treatment doesn’t work for around 40% of patients, who may eventually require a liver transplant.

For patients with primary sclerosing cholangitis (PSC), a condition where the bile ducts inside and outside of the liver become inflamed and scarred, medical therapy with ursodeoxycholic acid is often used, but it isn’t always effective at stopping the disease from progressing. Another treatment called ERCP with stent dilation, a type of procedure where a tube is inserted into the bile ducts to widen them, can provide symptomatic relief. However, the definitive cure is a liver transplant. Even with a transplant, the disease might return.

What else can Steatorrhea be?

When a patient comes in with steatorrhea (fatty stools), doctors will need to investigate the following possibilities to ensure the correct diagnosis:

• Alcoholic pancreatitis
• Hereditary pancreatitis caused by gene mutations
• Pancreatic insufficiency due to genetic conditions e.g., cystic fibrosis or Pearson’s syndrome
• Celiac disease
• Tropical sprue
• Chronic liver diseases such as primary biliary cirrhosis (PBC) or primary sclerosing cholangitis (PSC)
• Advanced pancreatic cancer
• Disease or surgery affecting the final part of the small intestine (ileum) e.g., Crohn’s disease
• Giardiasis
• Whipple’s disease
• Small intestinal bacterial overgrowth (SIBO)

Doctors also need to be mindful of conditions that lead to chronic diarrhea – these can be easily confused with steatorrhea:

• Irritable bowel syndrome
• Problems breaking down certain sugars, such as lactose or fructose
• Long-term use of laxatives
• Repeated gut infections
• Coming off of opioids
• Conditions linked to your hormone levels, such as overactive thyroid, Addison’s disease or neuroendocrine tumors

What to expect with Steatorrhea

The chances of getting better from steatorrhea, or excess fat in the stool, depends on what’s causing it. If it’s due to a shortage of enzymes in your pancreas (exocrine pancreatic insufficiency) or conditions like celiac disease (where your body reacts to gluten), tropical sprue (a condition that affects nutrient absorption), or giardiasis (an infection in your small intestine), then the outlook is generally good.

However, if your steatorrhea is caused by cystic fibrosis (a disease affecting your lungs and digestion) or lacks enough bile salts like in primary sclerosing cholangitis (a liver disease that causes inflammation and blockage of bile ducts) and primary biliary cirrhosis (a slow damage to the bile ducts in your liver), the outlook isn’t as good. These conditions tend to get worse over time.

Possible Complications When Diagnosed with Steatorrhea

Steatorrhea, or excessive fat in the stool, can lead to various complications. Here are some potential issues that could arise from this condition:

• A significant loss of weight in adults and increased vulnerability to infections. Malnutrition could additionally lead to more serious disease complications and possibly death. In children, it can result in failed growth and poor neurological development.
• A deficiency in fat-soluble vitamins (A, D, E, and K) may happen.
• Conditions such as osteopenia, osteoporosis, and possible fractures might arise due to poor bone health.
• Patients may also experience iron deficiency anemia, zinc deficiency.
• Dermatitis herpetiformis, non-Hodgkin lymphoma, and cancers of the upper digestive tract may occur.
• Patients risk developing megaloblastic anemia due to a deficiency in vitamin B12.
• Among those with consistently inflamed pancreas, complications may include pancreatic pseudocyst, ascites, splenic vein thrombosis, diabetes, and pancreatic cancer.
• For those with celiac disease, complications may include seizures, osteopenia, unsteady movements, easy bruising, headaches, decreased spleen functioning, and muscle twitching.
• Those with certain liver diseases may progress to cirrhosis, end-stage liver disease, and cancers such as cholangiocarcinoma and colon cancer.

Preventing Steatorrhea

It’s crucial for patients suffering from steatorrhea, a condition characterized by excess fat in the stool, to be properly educated about the condition. A nutritionist should guide them about their diet, particularly their intake of fats and vitamins that dissolve in fats, known as fat-soluble vitamins.

In the past, patients with an insufficient amount of digestive enzymes from the pancreas, a condition called exocrine pancreatic insufficiency, were advised to consume less fat. While this decreased the volume of their stool, it also created the risk of not getting enough nutrients, leading to malnutrition. Because of this, the new recommendation is to have a diet with normal to high amounts of fat, along with supplements to replace the missing pancreatic enzymes.

Diet advice from a nutritionist is also key for patients with celiac disease, a condition where the body can’t tolerate gluten, a protein found in some grains.