B ust os, Pre ci ous Ca ba nt a c, Rhe a Ca bung ca l , Kri st i ne Ca da , Kri st e l Joy Ca da , Kri st i a n 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 Objectives 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 Definition of terms Digestive disorders- affect the production and release of the enzymes lipase from the pancreas or bile from the liver, which are substances that aid digestion of fats. Absorptive disorders- disturb the absorptive and enzyme functions of the intestine. Definition of terms Deficiency of bile- this may be due to a complete obstruction in the common bile duct due to a stone, stricture or an intraluminal tumor. The stool is clay colored due to the absence of bile pigment (stercobilin). Feces contain large amount of digested but unabsorbed lipids. Definition of terms Deficiency of Pancreatic Juice- this may be due to the cancer of the pancreas, tuberculosis or severe inflammation. Feces contain large amount of undigested lipids due to the absence of stepsin. Color of stool is normal. Definition of terms Defect in Intestinal Mucosa this may be due to celiac disease. Feces contain large amont of digested but unabsorbed lipids. Color of stool is normal, villi atrophic or absent; hyperplastic and elongated crypts; chronic inflammatory infiltrate in lamina propria; epithelial surface infiltrated with lymphocytes. Steatorrhea Presence of more than 5g of lipid in feces per 24 hours The source of fecal lipid is largely dietary, gastrointestinal excretions, cellular desquamation and bacterial metabolism Lipids are normally present as soap and triglycerides Steatorrhea fat excretion in feces in excess of 0.3 (g/kg)/day is considered indicative of steatorrhea Steatorrhea is the third most common cause: chronic diarrhea (greasy, foul-smelling stools) that leave an oily residue in the toilet bowl increased flatulence weight loss. The Normal Digestion and Absorption of Lipids Ingestion An adult ingests about 60-150 g of lipids/day 90% is Triacylglycerol. Mastication Stomach Bolus is mixed with acidic digestive juices Emulsification The Normal Digestion and Absorption of Lipids The Normal Digestion and Absorption of Lipids The Normal Digestion and Absorption of Lipids The Normal Digestion and Absorption of Lipids The Normal Digestion and Absorption of Lipids The Normal Digestion and Absorption of Lipids Normal composition of stool Normal feces are: 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. Possible Biological Cause of Steatorrhea. Steatorrhea is due to abnormal digestion and/or intestinal absorption of fat. This primarily caused by three factors namely: enzyme defect, bile deficiency, and intestinal epithelium integrity. 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 is a bitter, alkaline, brownish-yellow or greenish- yellow fluid that is secreted by the liver, stored in the gallbladder, and discharged into the duodenum and aids in the emulsification, digestion, and absorption of fats. The two main bile acids: cholic acid and chenodeoxycholic acid 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 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. Integrity of the Intestinal Epithelium Changes in the integrity of the intestinal epithelium/ intestinal mucosal cells cause the lipid digestion mechanisms to be ceased/ altered. Integrity of the Intestinal Epithelium 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 Crohns disease. Underlying Conditions that Causes Steatorrhea 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 Underlying Conditions that Causes Steatorrhea 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 Possible Complications of Malabsorption and Maldigestion of Fats Celiac Disease - digestive disease that damages the small intestine and interferes with absorption of nutrients from food. - cannot tolerate a protein called gluten. - When people with celiac disease eat foods containing gluten, their immune system responds by damaging the small intestine. Possible Complications of Malabsorption and Maldigestion of Fats Pancreatitis - inflammation of the pancreas, an organ that is important in digestion - Pancreatitis can be: - acute (beginning suddenly, usually with the patient recovering fully) or, - chronic (progressing slowly with continued, permanent injury to the pancreas). Possible Complications of Malabsorption and Maldigestion of Fats Exocrine pancreatic insufficiency (EPI) - inability to properly digest food due to a lack of digestive enzymes made by the pancreas. - caused by a progressive loss of the pancreatic cells that make digestive enzymes. - treated with Pancreatic Enzyme Products (PEPs), such as pancrelipase Possible Complications of Malabsorption and Maldigestion of Fats Choledocholithiasis - Presence of gallstones in the common bile duct. - This condition causes jaundice and liver cell damage - Required endoscopic retrograde cholangiopancreatography (ERCP) procedure or surgical treatment. Possible Complications of Malabsorption and Maldigestion of Fats Primary sclerosing cholangitis (PSC) - a form of cholangitis due to an autoimmune reaction. - Bile ducts, both intra- and extrahepatically, are inflamed and develop scarring called cholangitis, obstructing the flow of bile. - Can lead to cholestasis Possible Complications of Malabsorption and Maldigestion of Fats Short bowel syndrome (SBS) - malabsorption disorder caused by the surgical removal of the small intestine, or rarely due to the complete dysfunction of a large segment of bowel. - The symptoms of SBS can include: 1) Abdominal pain, 2) diarrhea and steatorrhea 3) fluid retention, 4) weight loss and malnutrition, and 5) Fatigue 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, which can Help Diagnose and Determine the Causes of Steatorrhea. tests for fat malabsorption: Sudan Staining, van de Kamer method, and Acid Steatocrit are undertaken to measure and assess the amount of fecal fat. Different Laboratory Procedures, which can Help Diagnose and Determine the Causes of Steatorrhea. 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). Different Laboratory Procedures, which can Help Diagnose and Determine the Causes of Steatorrhea. 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. Several tests are used to determine 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 Several tests are used to determine the type of steatorrhea. more specific diagnostic tests: upper endoscopy, colonoscopy, barium x-rays are also utilized in diagnosing the cause of malabsorption. According to Merck Manual of Geriatrics (2000), TREATMENT OF STEATORRHEA Causes Treatment iron deficiency ferrous sulfate tablets folate deficiency Oral folic acid cobalamin deficiency. intramuscular vitamin B12 injections can be given monthly Main Goal: Identify and treat the underlying causes of the disease and this involves correcting deficiencies of nutrients, vitamins, and trace minerals. TREATMENT OF STEATORRHEA 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 THANK YOU FOR LISTENING!