STEATORRHEA

YL 1 – A2; GRP 11
 OUTLINE
1. Objectives
2. Steatorrhea
i. Symptoms of Steatorrhea
ii. Most Common Causes
3. Lipids
i. Functions of Lipids
ii. Fats
4. Digestion of Lipids
5. Absorption of Lipids
6. Normal Composition of Stool
6. Causation of Steatorrhea
i. Enzyme Defect
ii. Bile Deficiency
iii. Integrity of Intestinal Epithelium
7. Diseases/Conditions associated with Steatorrhea
8. Complications caused by Malabsorption & Maldigestion
of Fats: Malabsorption Syndrome
9. Diagnosis of Steatorrhea
10. Treatment of Steatorrhea
11. Conclusion
 OBJECTIVES
1. Define steatorrhea.
2. Discuss the normal digestion and absorption of
lipids.
3. Discuss the role of the following in the causation
of steatorrhea:
3.1 Enzyme defect
3.2. Bile deficiency
3.3. Integrity of the intestinal epithelium
4. Briefly discuss disease/ conditions that present with
steatorrhea and to point out the possible causes of fat
malabsorption or maldigestion
5. Identify the possible complications arise out from
malabsorption and maldigestion of fats
6. Discuss the different laboratory procedures, which can
help diagnose and determine the causes of steatorrhea
7. Discuss the treatment of steatorrhea
 STEATORRHEA
• “Fatty Stool”
• Presence of loose but bulky stool with globs of fat and
noticeable oil separation.
• It is the presence of excess fat in feces
• Presence of more than 5-7g of lipid in feces per 24 hours
• Increase in stool fat excretion to >6%
• Stools will be bulkier, pale, and foul-smelling. They tend to
float because of higher gas content.
 SYMPTOMS OF STEATORRHEA
• Foamy, frothy, or mucous-filled stool
• Foul-smelling stool
• Diarrhea or loose or runny stool that is bulkier than normal
• Light-colored stool, often a light brown, green, orange, or
yellow
• Stool that floats
• Stool that appears to be covered in a thick, greasy film
• Stool that is difficult to flush away
• Abdominal pain, cramping, bloating, and gassiness
• Heartburn and indigestion
• General exhaustion
• Minor muscle, bone, and joint ache
 MOST COMMON CAUSES
According to Rodrigues, 2010:
Three conditions account for most cases of malabsorption in
older individuals:
• Bacterial Overgrowth Syndrome
• Celiac Disease
• Chronic Pancreatitis (the latter is actually maldigestion
resulting in malabsorption).
 LIPIDS
• Important class of biological molecules
• Heterogenous group- insoluble in water but soluble in non-
polar organic solvents such as benzene, chloroform, and
ether
 FUNCTIONS OF LIPIDS
• FUEL
• INSULATOR
• PROTECTION
• BUILDING BLOCKS
• STRUCTURAL
 FATS
• Comprise 30-40% of the calories in typical diet
• Dietary fatty acids found in food are long-chain fatty acids
• Medium-chain fatty acids are rarely found in the food.
• Long Chain Fatty Acids – 12 to 24 carbons
• Medium Chain Fatty Acids – 8 to 10 carbons
• Short Chain Fatty Acids – < 6 carbons
• Digestion starts inside the mouth in the presence of an
acid-stable lingual lipase, secreted by glands at the
back of the tongue
• Target: TAG with short- and medium-chain fatty
acids (fewer than 12 C)
• The same TAGs
are broken down
by another acid-
stable lipase,
gastric lipase,
secreted by the
gastric mucosa
• Target: TAG
with short-
and medium-
chain fatty
acids (fewer
than 12 C)
• When fat
reaches the
duodenum,
secretin and
CCK are
produced,
triggering the
production
and release of
bile
• Fats are insoluble in aqueous phase; and therefore cannot
be reached easily by digestive enzymes.

• Bile aids in the digestion of lipids by emulsification to

increase surface area of the hydrophobic lipid droplets

• Bile salts coat lipid droplets, forming smaller micelles to

stabilize them and prevent them from coalescing with one
another
ABSORPTION OF LIPIDS
• Micelles transport cholesterol and the lipid soluble
vitamins A, D, E and K through the unstirred fluid layers.

• Uptake of lipids by intestinal epithelial cells occurs by

diffusion through the plasma membrane.

• 2-MAG and free fatty acids are readily absorbed by the

enterocytes of the jejunal mucosa via simple diffusion

• Recall that the cell membrane is made up of

phospholipids, which are also lipids
• Long chain fatty acid uptake is enhanced by a transporter
(FATP4 or SLC27A4)

• Cholesterol uptake is enhanced by a channel in the luminal

membrane

• Within the absorbing epithelial cells, the fate of absorbed

fatty acids depends on chain length.
NORMAL COMPOSITION OF STOOL
• 75% water
• 30% dead bacteria,
• 30% indigestible food matter,
• 10 – 20% cholesterol and other fats,
• 10 – 20% inorganic substances, and
• 2 – 3% protein.
• The color and odor are produced by bacterial action on chemical
constituents.
 CAUSES OF STEATORRHEA
•Enzyme Deficiency
•Bile Deficiency
•Integrity of Intestinal Epithelium
 ENZYME DEFECT
•High fat content in the feces maybe attributed to the defect
or lack on specific enzymes that hydrolyzes the lipids.

•Unabsorbed lipids add fatty content to the feces formed in

the large intestine (Davenport, 1982).

•When lipids are not hydrolyzed, the body will not be able to
absorb them. When they are not absorbed they are excreted.
BILE DEFICIENCY
BILE DEFICIENCY
•The bile micelles pass into the
duodenum. Here, the critical
process of emulsification
occurs.
•Emulsification increases the
surface area of the lipid droplets
BILE DEFICIENCY
•Bile salts stabilize the particles as
lipid particles tend to become
smaller, preventing them from
coalescing and finally assist the
final absorption of the products
of fat digestion.
 BILE DEFICIENCY
• Both bile and lipase are necessary for the proper
absorption of fats by the small intestine.

• Without one of these two:

• deficiency of the vital fat-soluble vitamins,
• fat malabsorption and fatty stools (steatorrhea)
• cause the feces to turn gray or pale.
INTEGRITY OF THE INTESTINAL EPITHELIUM
• When villi in the small intestines flatten the absorption
area of the intestines decreases. If this happens,
nutrient absorption will be impaired.
• This can occur occasionally in patients:
• severe and chronic disease of the small bowel
• extensive mucosal disease, the disease called Celiac
Sprue.
• inflammation of the small intestine, particularly disease
such as Crohn’s Disease.
CONDITIONS ASSOCIATED WITH STEATORRHEA

• Conditions affecting the pancreas

• Conditions affecting bile salts
• Conditions producing intestinal malabsorption
• Other causes. Drugs that can produce steatorrhea
include orlistat, a slimming pill, or as adverse effect of
octreotide or lanreotide, used to treat acromegaly or
other neuroendocrine tumors.
 CONDITIONS AFFECTING THE PANCREAS

• Exocrine pancreatic insufficiency can be caused by:

Chronic Pancreatitis
Cystic Fibrosis
Pancreatic Cancer (if it obstructs biliary outflow)
 CONDITIONS AFFECTING BILE SALTS

• Obstruction of the Bile Ducts by Gallstones

(Choledocholithiasis)
• Primary Sclerosing Cholangitis
• Liver Damage (Intrahepatic Cholestasis)
• Hypolipidemic Drugs
• Changes Following Gallbladder Removal
(Cholecystectomy)
CONDITIONS CAUSING INTESTINAL MALABSORPTION
• Celiac Disease
• Bacterial Overgrowth
• Tropical Sprue
• Giardiasis (A Protozoan Parasite Infection)
• Zollinger-Ellison Syndrome
• Short Bowel Syndrome
• Inflammatory Bowel Disease
• Abetalipoproteinemia
 OTHER CAUSES
• Drugs that can produce steatorrhea include

Oralistat, a slimming pill

Adverse effect of octreotide or lanreotide, used to treat
acromegaly or other neuroendocrine tumors.
• Intestinal Malabsorption can be due to:
• mucosal damage (enteropathy)
• congenital or acquired reduction in absorptive
surface
• Defects of specific hydrolysis
• Defects of ion transport
• pancreatic insufficiency
• impaired enterohepatic circulation
Symptoms of Malabsorption:
• Anemia, with weakness and fatigue
• Diarrhea, steatorrhea, and abdominal distention
with cramps, bloating, and gas
• Edema
• Malnutrition and weight loss
• Muscle cramping
• Muscle wasting and atrophy
• Perianal skin burning, itching, or soreness
 GUIDELINES FOR DIAGNOSING STEATORRHEA

• How frequent are stools?

• How long have symptoms been present?
• Any recent travel or pancreatitis (ask about level of alcohol
intake)? Weight loss?
• Are there food intolerances or family history of similar
problems?
 GUIDELINES FOR DIAGNOSING
STEATORRHEA
A careful history and physical examination provide clues to
probable diagnoses and guides the astute clinician to tests
most likely to provide a definitive diagnosis regarding
steatorrhea
A. Liver disease
B. Medications
C. GI problems
D. Foods
DIFFERENT LABORATORY PROCEDURES
Tests For Fat Malabsorption:
• Sudan Staining,
• Van De Kamer Method
• Acid Steatocrit
• Sudan Staining, acetic
acid and Sudan III stain
are added to the stool
sample to determine the
number and size of the
fat globules present in
the stool (Drummey et
al., 1961).
• Steatocrit is a quantitative
measure of fat as a proportion
of a whole centrifuged
homogenized stool sample
(Sugai et al., 1994).
• Van De Kamer Method or
The 72-hour Fat Chemical
Analysis is considered to
be the most accurate test
for fecal fat assessment
however this method is
apparently time
consuming.
• Blood tests can also be
used as screening tools if
the cause is not apparent.
Results of the blood tests
may be used in diagnosis
and can be helpful in
tracking the cause of fat
malabsorption.
 DETERMINATION OF THE TYPE OF
STEATORRHEA
• Pancreatic exocrine insufficiency can be screened by:
• measuring fecal elastase-1, a simple noninvasive test for
pancreatic exocrine insufficiency.
• aspiration of pancreatic contents after secretin or
secretin-cholecystokinin administration, the 14C-triolein
breath test, and the cholesteryl-[1-13C] octanoate breath
test (Chowdhury & Forsmark, 2003).
• Measurement of elastase and chymotrypsin in the stool
 DETERMINATION OF THE TYPE OF
STEATORRHEA
More specific diagnostic tests:
• Upper Endoscopy
• Colonoscopy
• Barium X-rays
-Merck Manual of Geriatrics (2000),
 TREATMENT OF STEATORRHEA

• Main Goal: Identify and treat the underlying causes of the

disease and this involves correcting deficiencies of
nutrients, vitamins, and trace minerals.
 CAUSES TREATMENT
Iron Deficiency Ferrous Sulfate Tablets

Folate Deficiency Oral Folic Acid

Intramuscular Vitamin B12

Cobalamin Deficiency
Injections can be given
monthly
• Patients with marked steatorrhea require:

• fat-soluble vitamin and calcium supplementation.

• A high-protein, low-fat diet and high-calorie dietary
supplementation
• Medium-chain triglycerides, given as a dietary
supplement
• Parenteral nutrition
• pancreatic enzyme replacement supplements
 CONCLUSION
• All fats, including saturated fatty acids, have important
roles in the body.

• However, the most important fats are those that the

body cannot make and thus must come from the food we
eat.

• Normal digestion AND absorption of fats are necessary to

maintain normal physiological functions of the human
body.
• Additionally, studies have shown that increasing the intake
of certain essential fatty acids, either alone or in
combination with other fats and compounds, can increase
health, help in treating certain diseases, and even improve
body composition, mental and physical performance.