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Steatorrhea

SE CT ION A2/ G ROUP IV


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
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