While it's not the most glamorous topic, paying attention to your stool can provide clues about what's happening inside your body. One condition that often reveals itself through changes in stool is steatorrhea, which describes fatty, greasy stools.
Steatorrhea is a symptom of fat malabsorption, one of the most common malabsorption syndromes. It arises from underlying defects in fat digestion and absorption for a variety of reasons, some of which are serious and require medical attention. Recognizing steatorrhea is the first step in treating fat malabsorption and preventing its possible consequences.
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What Is Steatorrhea?
Steatorrhea is a medical condition characterized by excess fat in the stool. It's a sign that the digestive system is not properly absorbing fats.
Why Steatorrhea Occurs
When you eat foods that contain fat, the digestive tract works to break it down into small units that can be absorbed into circulation:
- The food bolus travels to the stomach, which secretes an enzyme called gastric lipase that begins to break fat down into smaller building blocks.
- When fats enter the small intestine from the stomach, bile, produced by the liver and stored in the gallbladder, is released into the small intestine to act like a detergent, breaking down large fat molecules into smaller droplets.
- The pancreas secretes digestive enzymes (lipases) into the small intestine to further break down fat droplets into fatty acids and glycerol.
- The small intestine absorbs these broken-down nutrients through its walls into circulation.
When any part of this digestive process is disrupted, fat cannot be adequately broken down or absorbed, leading to steatorrhea. This condition can arise from defects in different stages of fat digestion. Broadly speaking, the reasons for steatorrhea can be grouped into three main categories:
- Conditions that cause exocrine pancreatic insufficiency (EPI), which reduces the enzymes needed for digestion
- Bile acid deficiency, which impairs the breakdown of fat
- Diseases that affect the small intestine, where fat absorption takes place
Symptoms of Steatorrhea
In its early stages, steatorrhea may go unnoticed. As it goes untreated, symptoms of fat malabsorption may become evident.
If you have steatorrhea, you will likely notice the following changes in your stool:
- Diarrhea
- Larger, bulkier bowel movements
- Pale (clay-colored)
- Oily or shiny in appearance
- Foul-smelling
- Float in the toilet bowl
- Challenging to flush
Besides changes in stool appearance, steatorrhea can also be accompanied by the following symptoms:
- Gas and bloating
- Abdominal pain
- Unexplained weight loss
- Fatigue
- Anemia
- Oral ulcers
- Rash
- Itching
- Jaundice (yellowing of the skin and the whites of the eyes)
- Itching
Causes and Risk Factors
Identifying the cause of steatorrhea is important for effective treatment. Let's discuss some of the causes of fatty stool changes.
Exocrine Pancreatic Insufficiency (EPI)
EPI is a condition where the pancreas does not produce enough digestive enzymes to properly break down macronutrients (carbohydrates, fats, and proteins) in food.
Common causes of EPI include:
- Chronic pancreatitis
- Cystic fibrosis
- Celiac disease
- Diabetes
- Inflammatory bowel disease (IBD)
- Pancreatic cancer
- Gastrointestinal surgery
Celiac Disease
Celiac disease is an autoimmune disorder in which exposure to gluten (a protein found in grains like wheat, barley, and rye) triggers an immune response that damages the lining of the small intestine.
Celiac disease is triggered by the interplay of environmental factors in genetically predisposed individuals. The vast majority of individuals with the condition carry specific genes called HLA-DQ2 or HLA-DQ8. Risk factors for celiac disease include gastrointestinal infections, antibiotic use, stress, alcohol, and smoking.
Cystic Fibrosis (CF)
CF is a genetic disorder that causes thick, sticky mucus to build up in various organs, particularly the lungs and pancreas. In the pancreas, the thick mucus obstructs the ducts that carry digestive enzymes, impairing nutrient absorption.
CF is caused by mutations in the CFTR gene, which codes the protein that regulates the movement of salt and water in and out of cells. These genetic mutations disrupt the production of normal mucus, making it thick and sticky. CF is inherited in an autosomal recessive pattern, meaning a person must inherit two copies of the defective gene (one from each parent) to develop the condition.
Cholestatic Diseases
Cholestatic liver diseases are a group of conditions in which the flow of bile from the liver is reduced or blocked, leading to a buildup in the liver.
Primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) are the two most common cholestatic diseases. Both of these are believed to be caused by an autoimmune response that attacks the bile duct system, leading to chronic inflammation, scarring, and liver damage over time.
Small Intestinal Bacterial Overgrowth (SIBO)
As the name suggests, SIBO is the overgrowth of bacteria in the small intestine, where normally only a small number of bacteria should reside. This overgrowth can cause inflammation and interfere with normal digestion.
Anything that disrupts normal intestinal motility or digestive enzyme production increases the risk of developing SIBO.
Diagnosis and Medical Evaluation
If you suspect you have steatorrhea, a medical evaluation is necessary to determine the cause and appropriate treatment.
How Steatorrhea Is Diagnosed
Fecal tests quantify the amount of fat in stool. Steatorrhea is defined as more than 7 grams of fat excreted in stool in a 24-hour period when consuming 100 grams of fat daily.
Your doctor may order one of the following tests to diagnose steatorrhea:
- Fecal Fat: The 72-hour fecal fat test measures the amount of fat in a person's stool over three days and remains the gold-standard test for diagnosing steatorrhea. The test involves eating 100 grams of fat daily for 3-5 days and then collecting all stools for three consecutive days.
- Steatocrit: This test is a simpler alternative to the 72-hour fecal fat test that measures fecal fat as a percentage of total stool volume. It does not require the patient to make any dietary modifications before stool collection and only requires a single stool sample.
Additional Tests
Additional tests may be necessary to identify the exact cause of steatorrhea once stool testing has confirmed its presence. These may include:
- Liver Enzymes: Measure liver enzymes to check for liver dysfunction that could affect bile production and fat absorption.
- Pancreatic Enzymes: Elevations in amylase and lipase indicate pancreatic inflammation.
- Fecal Elastase: Levels below 200 mcg/g are indicative of EPI.
- Fecal Calprotectin: Elevations above 50 µg/g are considered elevated and may suggest the presence of inflammatory bowel diseases.
- Genetic Tests: Genetic testing plays a role in diagnosing CF and celiac disease.
- Celiac Disease Antibodies: Elevations in specific antibodies made in response to gluten exposure suggest a diagnosis of celiac disease, and a small intestinal biopsy is required to confirm.
- SIBO Breath Test: A glucose or lactulose SIBO breath test can diagnose SIBO based on the hydrogen, methane, and hydrogen sulfide gas levels measured in collected breath samples.
- Abdominal Imaging: X-ray, ultrasound, CT, and MRI are imaging modalities that help visualize the digestive tract and its accessory organs.
- Endoscopy and Colonoscopy: Sometimes, your doctor may order an endoscopy or colonoscopy. These are medical procedures in which a small flexible camera is inserted inside the upper (endoscopy) or lower (colonoscopy) portion of the digestive tract to visualize and biopsy the intestinal tissues.
Treatment Options
Treatment options should always be tailored to the underlying cause of steatorrhea, and a healthcare provider can help determine the most appropriate course of action. Examples are described below:
Medical Interventions
- Pancreatic enzyme replacement therapy (PERT) is the cornerstone of EPI treatment. This involves supplementing pancreatic enzymes with meals to support healthy digestion of carbohydrates, proteins, and fats.
- Antibiotic, broncho-dilating, mucus-thinning, and anti-inflammatory medications are used as needed to alleviate symptoms and manage complications of CF.
- Antibiotic therapy with prescription antibiotics or antimicrobial herbs is most commonly used to eradicate SIBO. In severe cases, your doctor may prescribe a two-week course of an elemental diet.
- Ursodeoxycholic acid is the first-line treatment for PBC. This is a type of bile salt that can help clear bile from the liver to reduce and slow down liver damage.
Lifestyle Changes
- Gluten-Free Diet: Strict adherence to a lifelong gluten-free diet is the only known treatment for celiac disease.
- Low-Fat Diet: A low-fat diet may be recommended for a short period to alleviate the symptoms of fat malabsorption and normalize bowel movements as you work to treat the underlying cause of steatorrhea. This is defined as having less than 30% of total daily calories from fat. Foods low in fat include fruits, vegetables, seafood, poultry, legumes, and whole grains.
- Nutrient Supplementation: Fat-soluble vitamin (A, D, E, and K) deficiencies are a possible complication of chronic steatorrhea. In addition to focusing on eating foods naturally rich in these nutrients, talk to your doctor about replacing these vitamins with dietary supplements to maintain optimal nutrient levels.
- Stress Management: Stress is known to negatively impact gastrointestinal health and function by altering intestinal motility, inhibiting digestive secretions, directing blood flow away from the intestines, and changing the intestinal microbiome. If avoiding stressful triggers is not an option, you can work on reducing stress levels with mind-body therapies, exercising regularly, prioritizing sleep, and using adaptogenic supplements.
Steatorrhea Prognosis
Steatorrhea tends to have a good prognosis as long as the underlying cause is addressed and treated. Some conditions, like CF and cholestatic diseases, have poorer prognoses due to their chronic and progressive nature.
When steatorrhea goes undiagnosed, fat malabsorption does have negative consequences, primarily related to malnutrition. Malabsorption of fats and fat-soluble vitamins can lead to deficiencies over time that impair vital bodily functions and cause their own complications, like chronic fatigue, osteoporosis, blood clotting disorders, and night blindness.
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Key Takeaways
- Steatorrhea is defined as excessive fat in the stool. It is a symptom of fat malabsorption, which can be caused by various factors related to pancreatic function, bile acid deficiencies, and small intestinal disorders.
- To diagnose steatorrhea, your doctor will measure the amount of fat in your stool with a stool test. Additional diagnostic tests and imaging can be performed to identify the underlying cause of fat malabsorption.
- Effective treatment of steatorrhea depends on the root cause. Work with your doctor to decide on medical interventions and lifestyle modifications most appropriate for your specific condition.
- It's time to start paying attention to your bowel movements. Pale, foul-smelling, and floating stools signal that it's time to consult a doctor, as early intervention is the key to treating fat malabsorption and preventing potential complications.
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