From the Guidelines
Yes, pancreatitis can cause steatorrhea, as evidenced by the most recent and highest quality study available 1. Steatorrhea, characterized by fatty, oily, foul-smelling stools, occurs when the pancreas is unable to produce sufficient digestive enzymes to break down dietary fat. In pancreatitis, inflammation damages the pancreatic tissue responsible for producing these enzymes, particularly lipase which is essential for fat digestion. This enzyme deficiency leads to malabsorption of fats in the intestine, resulting in steatorrhea.
Key Points
- The condition is more common in chronic pancreatitis where long-term inflammation causes progressive pancreatic damage and fibrosis.
- Patients with steatorrhea due to pancreatitis typically require pancreatic enzyme replacement therapy (PERT) such as pancrelipase (Creon, Zenpep) taken with meals, usually at doses of at least 40,000 USP units of lipase during each meal in adults and one-half of that with snacks, as recommended by the AGA clinical practice update 1.
- The capsules should be swallowed whole with meals to effectively mix with food.
- Patients should also be monitored for fat-soluble vitamin deficiencies (A, D, E, K) and may need supplementation.
- A low-moderate fat diet with frequent smaller meals and avoiding very-low-fat diets is recommended, as stated in the AGA clinical practice update 1.
Management and Treatment
- PERT should be taken during the meal to maximize mixing and digestion of nutrients.
- The primary goal of PERT is to ensure adequate digestion of lipids to meet macro-nutritional needs, with a secondary goal to reduce steatorrhea and intestinal symptoms that may be diet-related.
- Routine supplementation and monitoring of fat-soluble vitamin levels are appropriate.
- Measures of successful treatment with PERT include reduction in steatorrhea and associated gastrointestinal symptoms; a gain of weight, muscle mass, and muscle function; and improvement in fat-soluble vitamin levels, as outlined in the AGA clinical practice update 1.
From the Research
Pancreatitis and Steatorrhea
- Pancreatitis, particularly chronic pancreatitis, can lead to exocrine pancreatic insufficiency, which is a major cause of steatorrhea 2, 3, 4, 5, 6.
- Steatorrhea is characterized by the fecal excretion of more than 6 g of fat per day, resulting in weight loss, abdominal discomfort, and abdominal swelling sensation 6.
- The lack or absence of pancreatic enzymes in pancreatitis leads to inadequate absorption of fat, proteins, and carbohydrates, causing steatorrhea and other nutritional deficiencies 4.
Mechanisms and Treatment
- The treatment of exocrine pancreatic insufficiency in pancreatitis involves oral administration of pancreatic enzymes to provide the duodenal lumen with sufficient active lipase at the time of gastric emptying of nutrients 2, 3, 4, 5.
- Factors such as acidic intestinal pH, bacterial overgrowth, and improper timing of enzymes can prevent normalization of fat digestion even in compliant patients 2, 3, 5.
- Modern pancreatin preparations are engineered as acid-resistant, pH-sensitive microspheres, which can reduce steatorrhea to <15 g fat per day during supplementation of 25,000-40,000 IU of lipase per meal 5.
Diagnosis and Management
- Measurement of fecal concentration of elastase may be sufficient to diagnose exocrine pancreatic insufficiency, while fecal fat analysis is useful to establish malabsorption and monitor pancreatic enzyme replacement therapy 5.
- Components essential to the optimal management of chronic pancreatitis include control of pain, improvement of maldigestion, management of diabetes, and alcohol and nicotine abstinence 5.
- Treatment success is defined clinically by improved body weight and consistency of feces 5.