Steatorrhea is a condition where your stool contains excessive amounts of fat. This can result of fat malabsorption, primarily linked to pancreatic and liver disease, bile acid deficiency, and small intestine problems.¹

How is fat normally absorbed?

First, let’s understand how fat in your body is normally absorbed and how this can lead to steatorrhea disorder. Fat digestion involves digestive enzymes from the pancreas, bile salts produced by your liver, and the intestinal mucosa, facilitating the uptake of these hydrophobic complexes. Upon  ingesting dietary lipids found in a fat-rich meal, they are broken down with the help of stomach enzymes. This process continues in your small intestine using pancreatic enzymes and bile salt, breaking them into smaller components such as fatty acids and monoglycerides. These smaller components will be packed and absorbed by the intestine, before being transported to the circulation via the lymphatic system. 

More than 90% of the fat you consume daily is typically absorbed into the bloodstream for energy or storage. If there are issues with any of the steps in this absorption process, it can lead to decreased uptake and result in a condition called steatorrhea.³

Cause of Steatorrhea

There are many conditions associated with fat malabsorption due to problems within your digestive system. Some examples include: issues with pancreas, liver disease, bile duct disorders, and various conditions affecting the small intestine. All of these are known to contribute to the development of steatorrhea.

Exocrine Pancreatic Insufficiency (EPI)

This occurs when there is no sufficient pancreatic enzymes being produced. It can be caused by:

• Chronic pancreatitis
• Cystic fibrosis (CF)
• Pancreatic tumours
• Zollinger-Ellison syndrome

Bile Acid deficiency

This condition can be caused by cholestasis (when the bile flow through the biliary system is reduced or blocked) or the inability of the distal ileum, part of the small intestine, to absorb the bile acid. The disorders include: 

• Primary biliary cholangitis (PBC)
• Primary sclerosing cholangitis (PSC)
• Crohn's disease
• Small Intestinal Bacterial Overgrowth (SIBO)

Liver Diseases

• Liver failure
• Liver cirrhosis

Diseases that affect part of the small intestine

• Celiac disease
• Giardiasis
• HIV enteropathy
• Amyloidosis
• Lymphoma
• Short gut syndrome.

What are the symptoms? 

Fatty stools (steatorrhea) typically have an unusual foul and strong smell. They may seem bulky, greasy or oily, sometimes accompanied by oil drops in extreme cases. The colour is paler than usual or light-coloured. Due to its high fat content, the stool can float, making it difficult to flush.

Other intestinal issues that commonly appear include

• Diarrhoea
• Abdominal pain
• Cramping/bloating
• Weight loss
• Flatulence/gas.¹

Diagnosis 

Many underlying conditions can cause steatorrhea. To find out the specific cause, the healthcare providers would usually ask about your symptoms and medical history, order tests to check your stool and do additional examinations as necessary.

Faecal fat test

This test will examine the presence and the amount of fat in your stool. There are two types of faecal fat tests. 

• Qualitative faecal fat test: This will measure fat globus presence in your stool. A sample of your stool will be smeared on a slide and examined under a microscope. 
• Quantitative faecal fat test: This test will measure the amount of fat in your stool using a stool sample collected over three days. 

D-Xylose test

D-xylose is a type of glucose/simple sugar. This test measures the ability of the intestine to absorb glucose. You may be confused as to why you need this test for fat absorption problems. Well, this test will help differentiate the cause of steatorrhea itself. It helps us know whether the steatorrhea is caused by pancreatic insufficiency or by small intestine mucosal problem. 

Additional Test

To fully identify the problem behind steatorrhea, sometimes other tests are needed. These include enzyme analysis, organ imaging, a biopsy, endoscopy, blood tests, and more.¹

Treatment for steatorrhea

The treatment for your steatorrhea will depend on its underlying cause. If there is a problem with exocrine pancreatic insufficiency, then you might need Pancreatic Enzyme Replacement Therapy (PERT). In a case where your steatorrhea is caused by biliary insufficiency, addressing the issue may require bile acid replacement, surgical management of bile duct obstruction, or the use of medications to regulate the bile flow.

When you have celiac disease as the root problem of steatorrhea, you’ll be recommended a long-life gluten-free diet and receive management of nutritional deficiencies. Again, the treatment will be based on your specific underlying problem.^1,3

Dietary adjustments

Making dietary changes can  greatly improve your body's ability to absorb fat. Here are some dietary adjustments you can make: 

• Reduce your total fat intake. Focus on healthy fats, such as those found in nuts, avocados, and olive oil, and oily fish like tuna, salmon, or mackerel. 
• Avoid certain foods that contain too much fat or will cause difficulty in digesting fats such as coconut and palm oil, red meat, butter, coffee creamers, and alcohol. Try to limit saturated and trans fats that are found in fried foods, fatty meals, or processed food.
• Eat in smaller portions and more frequent meals which will help with digestion and improve the utilisation of enzymes.
• Restricting the amount of fibre consumed. Foods high in fibre may bind to fat and prevent it from being absorbed.
• Make sure you have sufficient consumption of fat-soluble vitamins. Because fat malabsorption affects the absorption of vitamins A, D, E, and K, you may need to take these supplements.

Complications

With the variety of steatorrhea root causes, various complications can arise as a consequence. Here are some of the possible complications that can occur if you have steatorrhea:

• Vitamin deficiency (fat-soluble vitamins including A,D,E, and K) and all related conditions caused by long-term lack of these vitamins.
• Malnutrition, weight loss, and increased risk of infections
• Iron and zinc deficiency especially in celiac disease
• Megaloblastic anaemia due to deficiency of vitamin B12
• Bone diseases 
• Non-Hodgkin lymphoma and adenocarcinoma of the upper gastrointestinal tract (celiac disease)
• Cirrhosis, malignancies, and end-stage liver disease.
• Other gastrointestinal problems.¹

FAQs

What is the main cause of steatorrhea?

Steatorrhea happens as a result of fat malabsorption. The digestive system fails to absorb and assimilate the fat properly. The underlying causes can vary including pancreatic insufficiency, celiac disease, liver diseases, or other gastrointestinal disorders that affect fat absorption.

How to deal with steatorrhea?

There are two main things you can  do. First, managing the symptoms that can be helped with medications and dietary modifications. Second, you need to address the underlying cause. This will vary based on your condition and diagnosis.¹

Is steatorrhea a symptom of IBS?

No, it’s not. IBS stool contains mucous rather than a high amount of fat. Steatorrhea is caused by fat malabsorption, while IBS involves many factors such as gut mobility, stress, and diet.

How do I know if I have steatorrhea?

Your stool will be bulky, pale, foul-smelling and oily. It also tends to float in the toilet and is often challenging to flush. To further confirm, the healthcare provider might order a faecal fat test.¹

What happens if steatorrhea is left untreated?

It will result in vitamin deficiencies that can lead to chronic conditions such as bone problems and anaemia. It can also lead to other digestive problems such as diarrhoea, abdominal pain, and bloating due to irritation of the digestive tract. Various complications may emerge depending on the underlying cause of your steatorrhea.

What foods to avoid if you have steatorrhea?

Avoid butter, whole nuts, coconut oil, palm oils, lard, red meat, alcohol

Summary

Steatorrhea is a condition where there is too much fat in your stools due to fat malabsorption. It can happen as a consequence of pancreatic insufficiency, bile acid problems, or other small intestine issues. Your stools will look bulky, greasy, and oily. It has a foul smell and will tend to be floating in the toilet.

To further confirm the diagnosis and identify the underlying cause, your doctor will assess your symptoms and medical history and may order some tests such as a faecal fat test, D-xylose test, and other necessary tests. The treatment will be tailored based on the root problem that causes steatorrhea. It is important to make diet modifications while receiving medical treatment from healthcare providers to effectively address the steatorrhea you have and prevent the risk of potential complications.