Steatorrhea, an excess of fat in stools, indicates a problem with either fat digestion or fat absorption. There are few descriptive studies on steatorrhea outside of patients with pancreatic disease and thus much of our understanding of fat malabsorption comes from this population.
Normal fat absorption
Normal fat absorption involves a complex mixture of digestive enzymes, bile salts, and an intact intestinal mucosa to enable uptake of these hydrophobic complexes. After ingestion, dietary lipids are initially emulsified in the stomach and then hydrolyzed by the action of gastric and pancreatic lipase and colipase. The hydrolyzed lipids are then aggregated into micelles or liposomes with the addition of bile salts in the duodenum and jejunum. These micelles are absorbed across the intact intestinal villi by both active and passive processes. Finally, they are packaged into chylomicrons within intestinal epithelial cells and transported to the circulation via the lymphatic system.
More than 90% of daily dietary fat is absorbed into the general circulation, but any defects in the processes can reduce this uptake and lead to steatorrhea.
Categories of steatorrhea
Patients with steatorrhea can be considered in 3 broad etiologic categories.
Pancreatic exocrine insufficiency. These patients have insufficient lipase and colipase to allow normal lipid hydrolysis. This most commonly occurs due to chronic pancreatic inflammation and loss of acinar cells.
Bile salt deficiency due to impaired production or secretion, or reduced circulating bile acids.
Malabsorption due to small intestinal disease, surgery, or medications.
- Chronic pancreatitis
- Celiac disease
- Whipple disease
- Gastrointestinal amyloidosis
- Medication-induced malabsorption
- Bacterial overgrowth
- Crohn disease
- Resection of stomach, pancreas, or small bowel
- Primary biliary cholangitis
- Primary sclerosing cholangitis
Alan C. Moss, MD
Associate Professor of Medicine
Harvard Medical School
ACM declares that he has no competing interests.
Christina M. Surawicz, MD
Professor of Medicine
Section Chief Gastroenterology
Harborview Medical Center
Assistant Dean for Faculty Development
University of Washington School of Medicine
CMS declares that she has no competing interests.
Raffaele Pezzilli, MD
Chief of the Pancreas Unit
Department of Internal Medicine and Gastroenterology
Sant’ Orsola-Malpighi Hospital
RP declares that he has no competing interests.
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