What is the most common cause of steatorrhea (excess fat in feces)?

From the Guidelines

The most common cause of steatorrhea is pancreatic insufficiency, particularly chronic pancreatitis, as evidenced by recent studies 1. This condition occurs when the pancreas fails to produce and secrete enough digestive enzymes, especially lipase, which is essential for fat digestion. Without adequate lipase, dietary fats cannot be properly broken down and absorbed in the small intestine, resulting in their excretion in the stool. Some key points to consider in the management of steatorrhea due to pancreatic insufficiency include:

• The use of pancreatic enzyme replacement therapy (PERT) such as pancrelipase (Creon, Zenpep) taken with meals to aid in fat digestion, with a typical starting dose of 500 lipase units per kg per meal, adjustable based on symptom response and nutritional status 1.
• Dietary modifications, including a low-fat diet in some cases, may also help manage symptoms while the underlying condition is being treated.
• The presence of steatorrhea, coupled with poor dietary intake, renders patients with chronic pancreatitis at considerable risk for undernutrition, muscle depletion, and fat-soluble vitamin deficiency 1. Other causes of steatorrhea include cystic fibrosis, pancreatic cancer, celiac disease, Crohn's disease, and certain medications that interfere with fat absorption. However, chronic pancreatitis is highlighted as a primary concern due to its direct impact on pancreatic enzyme production and the consequent malabsorption of fats 1. In clinical practice, the diagnosis of pancreatic exocrine insufficiency (PEI) can be challenging, but the presence of steatorrhea and other symptoms of malabsorption should prompt consideration of this condition and the initiation of appropriate treatment, including PERT, to improve nutritional status and quality of life 1.

From the Research

Causes of Steatorrhea

The most common causes of steatorrhea (excess fat in feces) include:

• Pancreatic diseases such as chronic pancreatitis, cystic fibrosis, severe acute necrotizing pancreatitis, and pancreatic cancer 2, 3
• Extrapancreatic diseases like celiac disease and Crohn's disease 2, 3
• Gastrointestinal and pancreatic surgical resections 2, 3

Pancreatic Exocrine Insufficiency

Pancreatic exocrine insufficiency is a major consequence of these diseases, leading to steatorrhea 4, 2, 3, 5

• This condition is characterized by the impaired synthesis and secretion of lipase, resulting in malabsorption of fats 4
• The lack of pancreatic lipase activity is not compensated for by nonpancreatic mechanisms, leading to severe steatorrhea 4

Dietary Therapy and Enzyme Replacement

Dietary therapy and enzyme replacement are essential for managing steatorrhea 6

• The dietary treatment of steatorrhea requires knowledge of the underlying cause of the disease 6
• Pancreatic enzyme replacement therapy is based on the oral administration of pancreatic enzymes to provide sufficient active lipase at the time of gastric emptying of nutrients 2, 3, 5