The definition of steatorrhea is an increase in fat excretion in the stools. Steatorrhea is one of the clinical features of fat malabsorption and noted in many conditions such as exocrine pancreatic insufficiency (EPI), celiac disease, and tropical sprue. An increase in the fat content of stools results in the production of pale, large volume, malodorous, loose stools. Screening for steatorrhea may be carried out by examining stool samples for the presence of fat by Sudan III staining. However, quantitative fecal fat estimation is required to confirm the diagnosis.
Among the macronutrients, digestion and absorption of fat involve a complex mechanism. Fat absorption requires bile acids, digestive enzymes, and a normally functioning small intestinal mucosa. Dietary lipids, mostly as triacylglycerols, are initially emulsified by bile acids and then hydrolyzed by the pancreatic lipases and colipases into free fatty acids and monoglycerides. In the proximal small bowel, these hydrolyzed lipids form micelles by the action of bile acids. The micelles are then absorbed across the intestinal villi and transported as chylomicrons via the intestinal lymphatics. Therefore, any defects in the availability or function of bile acids, pancreatic digestive enzymes or absorptive villi will lead to steatorrhea.
The causes of steatorrhea are numerous and subclassify under three broad categories: (1) conditions leading to EPI, (2) bile acid deficiency states, and (3) diseases affecting the small intestine. Most notable disorders in each category are given below:
Other rare causes of steatorrhea include lipase inhibitors such as orlistat, Zollinger-Ellison syndrome (increased production of gastric acid inactivates the pH-sensitive pancreatic lipases), and graft-versus-host disease.
In the early stages, steatorrhea may be unrecognized by many patients due to minimal or nonspecific presenting symptoms. Therefore, the exact prevalence and incidence of steatorrhea are challenging to estimate and often go underreported. Also, the epidemiology of steatorrhea depends on the epidemiology of various underlying causes which is a topic of discussion below.
In adults, chronic pancreatitis is the most common cause of EPI. Chronic pancreatitis has an annual incidence of approximately 4 per 100000 persons and a prevalence of about 42 per 100000 individuals in the U.S. In children, CF accounts for most cases of EPI. CF is the most common lethal autosomal recessive condition affecting the White population. The approximate prevalence of CF is 1 in 3000 births. About 85% of CF patients have pancreatic insufficiency.
The prevalence of celiac disease is on the rise, and a recent study reported a global seroprevalence of 1.4%. Also, there are differences in the prevalence depending on geographical location. Reports of biopsy-proven celiac disease show lower prevalence rates in South America and Africa and higher rates in Europe and Oceania. For example, in Europe, Germany has a lower prevalence of celiac disease, and the highest prevalence was in Sweden and Finland. Celiac disease has a higher prevalence in certain high-risk groups such as type 1 diabetes mellitus, Down syndrome, Turner syndrome, IgA deficiency, William's syndrome, and in first-degree relatives of celiac disease.
Based on a study from the Netherlands, PBC had an incidence of 1.1 per 100000 (male to female ratio was 1 to 6.3) and the point prevalence was 13.2 per 100000 individuals in 2008. Another study from the U.S. reported an overall incidence of PBC as 2.7 per 100000 person-years and age and sex-adjusted prevalence of 40 per 100000 with a similar female predilection. PSC has a prevalence rate depending on the geographical location. A systematic review reported the incidence and prevalence rates of PSC ranging from 0 to 1.3 per 100000 people per year and 0 to 16 per 100000 people, respectively. As there is no consensus on the definition of SIBO, its exact prevalence is unknown.
Patients with steatorrhea present with bulky, pale, foul-smelling oily stools. These fatty stools tend to float in the toilet bowl and often challenging to flush as well. In the early stages, steatorrhea may be asymptomatic and go unnoticed. Patients also have other nonspecific manifestations of fat malabsorption such as chronic diarrhea, abdominal discomfort, bloating sensation, and weight loss. Children may present with growth failure and delayed puberty. In severe cases, loss of subcutaneous fat and muscle wasting may be evident. Manifestations of fat-soluble vitamin (A, D, E, and K) deficiencies can accompany fat malabsorption. Celiac patients can present with a variety of extraintestinal signs such as anemia, oral ulcers, and dermatitis herpetiformis rash. Abdominal pain is a predominant symptom in patients with chronic pancreatitis but also reported in other conditions such as SIBO, inflammatory bowel disease, and celiac disease. CF patients have sinopulmonary manifestations. Jaundice, fatigue, and pruritis are suggestive of cholestatic liver diseases such as PBC or PSC. Signs for end-stage liver disease such as splenomegaly, ascites can be noted in PBC or PSC.
List of conditions which present with steatorrhea:
List of conditions which present with chronic diarrhea which can be mistaken for steatorrhea:
Untreated steatorrhea leads to malnutrition and other complications such as fat-soluble vitamin deficiencies (A, D, E, and K). Identifying the cause of steatorrhea is vital for proper management and prevention of these complications.
The diagnosis of steatorrhea is usually delayed for months to years due to non-specific or minimal presenting symptoms during the early stages. A multidisciplinary team approach is often necessary for diagnosis, treatment, and follow-up. If steatorrhea is suspected clinically, the general physician and nurse practitioner should refer the patient to a gastroenterologist for consultation. As numerous conditions could contribute to steatorrhea, a systematic evaluation is required to expedite the diagnosis and to prevent further complications. The team should also include specialty-trained nurses and pharmacists. The involvement of a skilled dietician is indispensable for enhancing the nutritional status and limiting further malnutrition related adverse outcomes. [(Level V]
We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.
This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.
Click Your Answer Below
Would you like to access teaching points and more information on this topic?
Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.
Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.
|Di Sabatino A,Lenti MV,Corazza GR, Malabsorption and malabsorption tests: do they still matter? Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver. 2014 May; [PubMed]|
|Li BR,Pan J,Du TT,Liao Z,Ye B,Zou WB,Chen H,Ji JT,Zheng ZH,Wang D,Lin JH,Ning SB,Hu LH,Li ZS, Risk Factors for Steatorrhea in Chronic Pancreatitis: A Cohort of 2,153 Patients. Scientific reports. 2016 Feb 15; [PubMed]|
|Uchiyama K,Kishi H,Komatsu W,Nagao M,Ohhira S,Kobashi G, Lipid and Bile Acid Dysmetabolism in Crohn's Disease. Journal of immunology research. 2018; [PubMed]|
|Lebwohl B,Sanders DS,Green PHR, Coeliac disease. Lancet (London, England). 2018 Jan 6; [PubMed]|
|Boonstra K,Kunst AE,Stadhouders PH,Tuynman HA,Poen AC,van Nieuwkerk KM,Witteman EM,Hamann D,Witteman BJ,Beuers U,Ponsioen CY, Rising incidence and prevalence of primary biliary cirrhosis: a large population-based study. Liver international : official journal of the International Association for the Study of the Liver. 2014 Jul; [PubMed]|
|Kleeff J,Whitcomb DC,Shimosegawa T,Esposito I,Lerch MM,Gress T,Mayerle J,Drewes AM,Rebours V,Akisik F,Muñoz JED,Neoptolemos JP, Chronic pancreatitis. Nature reviews. Disease primers. 2017 Sep 7; [PubMed]|
|Mattner J, Impact of Microbes on the Pathogenesis of Primary Biliary Cirrhosis (PBC) and Primary Sclerosing Cholangitis (PSC). International journal of molecular sciences. 2016 Nov 9; [PubMed]|
|Ghoshal UC,Ghoshal U, Small Intestinal Bacterial Overgrowth and Other Intestinal Disorders. Gastroenterology clinics of North America. 2017 Mar; [PubMed]|
|Conwell DL,Lee LS,Yadav D,Longnecker DS,Miller FH,Mortele KJ,Levy MJ,Kwon R,Lieb JG,Stevens T,Toskes PP,Gardner TB,Gelrud A,Wu BU,Forsmark CE,Vege SS, American Pancreatic Association Practice Guidelines in Chronic Pancreatitis: evidence-based report on diagnostic guidelines. Pancreas. 2014 Nov; [PubMed]|
|Lindfors K,Ciacci C,Kurppa K,Lundin KEA,Makharia GK,Mearin ML,Murray JA,Verdu EF,Kaukinen K, Coeliac disease. Nature reviews. Disease primers. 2019 Jan 10; [PubMed]|
|Durie P,Baillargeon JD,Bouchard S,Donnellan F,Zepeda-Gomez S,Teshima C, Diagnosis and management of pancreatic exocrine insufficiency (PEI) in primary care: consensus guidance of a Canadian expert panel. Current medical research and opinion. 2018 Jan; [PubMed]|
|Burden S,Langley-Evans S,Talley N, Coeliac disease: pathogenesis, prognosis and management. Journal of human nutrition and dietetics : the official journal of the British Dietetic Association. 2014 Jun; [PubMed]|
|Bader TR,Beavers KL,Semelka RC, MR imaging features of primary sclerosing cholangitis: patterns of cirrhosis in relationship to clinical severity of disease. Radiology. 2003 Mar; [PubMed]|
|Clark R,Johnson R, Malabsorption Syndromes. The Nursing clinics of North America. 2018 Sep; [PubMed]|
|Ramos AT,Figueirêdo MM,Aguiar AP,Almeida Cde G,Mendes PS,Souza EL, Celiac Disease and Cystic Fibrosis: Challenges to Differential Diagnosis. Folia medica. 2016 Apr-Jun; [PubMed]|
|van Gils T,Brand HS,de Boer NK,Mulder CJ,Bouma G, Gastrointestinal diseases and their oro-dental manifestations: Part 3: Coeliac disease. British dental journal. 2017 Jan 27; [PubMed]|
|Shandro BM,Nagarajah R,Poullis A, Challenges in the management of pancreatic exocrine insufficiency. World journal of gastrointestinal pharmacology and therapeutics. 2018 Oct 25 [PubMed]|
|Lanspa SJ,Chan AT,Bell JS 3rd,Go VL,Dickson ER,DiMagno EP, Pathogenesis of steatorrhea in primary biliary cirrhosis. Hepatology (Baltimore, Md.). 1985 Sep-Oct [PubMed]|
|Holtmeier J,Leuschner U, Medical treatment of primary biliary cirrhosis and primary sclerosing cholangitis. Digestion. 2001 [PubMed]|
|Gasbarrini A,Lauritano EC,Gabrielli M,Scarpellini E,Lupascu A,Ojetti V,Gasbarrini G, Small intestinal bacterial overgrowth: diagnosis and treatment. Digestive diseases (Basel, Switzerland). 2007 [PubMed]|
|Sharma P,Baloda V,Gahlot GP,Singh A,Mehta R,Vishnubathla S,Kapoor K,Ahuja V,Gupta SD,Makharia GK,Das P, Clinical, endoscopic, and histological differentiation between celiac disease and tropical sprue: A systematic review. Journal of gastroenterology and hepatology. 2019 Jan [PubMed]|
|Poles MA,Fuerst M,McGowan I,Elliott J,Rezaei A,Mark D,Taing P,Anton PA, HIV-related diarrhea is multifactorial and fat malabsorption is commonly present, independent of HAART. The American journal of gastroenterology. 2001 Jun [PubMed]|
|Grace E,Shaw C,Whelan K,Andreyev HJ, Review article: small intestinal bacterial overgrowth--prevalence, clinical features, current and developing diagnostic tests, and treatment. Alimentary pharmacology & therapeutics. 2013 Oct [PubMed]|
|Yadav D,Timmons L,Benson JT,Dierkhising RA,Chari ST, Incidence, prevalence, and survival of chronic pancreatitis: a population-based study. The American journal of gastroenterology. 2011 Dec [PubMed]|
|Paranjape SM,Mogayzel PJ Jr, Cystic fibrosis. Pediatrics in review. 2014 May [PubMed]|
|Singh P,Arora A,Strand TA,Leffler DA,Catassi C,Green PH,Kelly CP,Ahuja V,Makharia GK, Global Prevalence of Celiac Disease: Systematic Review and Meta-analysis. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2018 Jun [PubMed]|
|Kim WR,Lindor KD,Locke GR 3rd,Therneau TM,Homburger HA,Batts KP,Yawn BP,Petz JL,Melton LJ 3rd,Dickson ER, Epidemiology and natural history of primary biliary cirrhosis in a US community. Gastroenterology. 2000 Dec [PubMed]|
|Boonstra K,Beuers U,Ponsioen CY, Epidemiology of primary sclerosing cholangitis and primary biliary cirrhosis: a systematic review. Journal of hepatology. 2012 May [PubMed]|
|Lindkvist B,Phillips ME,Domínguez-Muñoz JE, Clinical, anthropometric and laboratory nutritional markers of pancreatic exocrine insufficiency: Prevalence and diagnostic use. Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.]. 2015 Nov-Dec [PubMed]|
|Fricker ZP,Lichtenstein DR, Primary Sclerosing Cholangitis: A Concise Review of Diagnosis and Management. Digestive diseases and sciences. 2019 Mar [PubMed]|
|Santiago P,Scheinberg AR,Levy C, Cholestatic liver diseases: new targets, new therapies. Therapeutic advances in gastroenterology. 2018 [PubMed]|
The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of CNS-Diabetes Management. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.
StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for CNS-Diabetes Management, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in CNS-Diabetes Management, you will already be prepared.
Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of CNS-Diabetes Management. When it is time for the CNS-Diabetes Management board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study CNS-Diabetes Management.