Steatorrhea

Specialty: Gastrointestinal.

• Fatty stools
• fat malabsorption
• oily stools
• steatorrheic diarrhea

Why it occurs

• Exocrine pancreatic insufficiency secondary to chronic pancreatitis or cystic fibrosis due to progressive acinar destruction
• Active celiac disease with severe duodenal villus atrophy that reduces the lipid absorption surface
• Crohn's disease of the terminal ileum with bile salt reabsorption dysfunction and decreased micellar pool
• Small intestinal bacterial overgrowth (SIBO) due to bacterial deconjugation of bile acids
• Chronic giardiasis or other invasive parasitic infections that damage the enterocyte mucosal absorptive barrier.

Initial workup

72-hour stool fat quantification (Van de Kamer method, gold standard) or steatocrit test | Determination of fecal elastase-1 (to evaluate pancreatic function) | General analysis: blood count, serum levels of fat-soluble vitamins (A, D, E, K), prothrombin time (INR), albumin and cholesterol | Anti-tissue transglutaminase IgA antibodies and endoscopy with duodenal biopsy | Abdominal ultrasound, abdominal CT with pancreatic protocol or cholangioresonance (MRCP).

Standard management

• Substitute pancreatic enzymes — lipase/amylase/protease in enteric-coated microspheres, initial dose of 25,000 to 50,000 units with each main meal, adjusted according to clinical response, ingested at the beginning and during the meal to avoid inactivation by gastric acid
• Supplementation of fat-soluble vitamins — vitamin A, cholecalciferol, alpha-tocopherol and phytomenadione according to the deficiencies documented by analysis
• Proton pump inhibitors (omeprazole 20 mg per day, to raise duodenal pH and enhance the activity of exogenous enzymes in refractory cases).