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. Other recognized causes of steatorrhea include diseases associated with bile acid deficiency states and small intestinal malabsorption.
Summary
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.[1] 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.[2]
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.
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A patient's arms and hands show the presence of erythema nodosum
Lid retraction and mild proptosis
A scanning electron micrograph of an in vitro Giardia lamblia culture. The image shows trophozoites and a cluster of maturing cysts (bottom right)
Histologic image demonstrating small intestinal villous atrophy and crypt hyperplasia in celiac disease
Characteristic autoantibody patterns in primary biliary cholangitis. White arrow: antimitochondrial staining; red arrow: multiple nuclear dot ANA staining
Characteristic histologic appearances of primary biliary cholangitis: (a) early stage disease; (b) advanced-stage disease; (c) disease with a significant inflammatory component
CT scan demonstrating thickening of the terminal ileum in a patient with Crohn disease exacerbation
CT scan demonstrating thickening of the terminal ileum in a patient with Crohn disease exacerbation
Typical endoscopic retrograde cholangiopancreatography (ERCP) findings in a patient with primary sclerosing cholangitis (PSC): multifocal strictures of the intra- and extrahepatic bile ducts
Significant inflammation in the colonic wall, widening of submucosa, and dense lymphoid aggregates in the submucosa
Cryptitis and crypt abscess with morphologic distortion of the crypts accompanied by inflammation and abundant lymphatic and plasma cells
Congo red stain blood vessel in a bone marrow biopsy demonstrating green birefringence pathognomonic of amyloidosis
Citations
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