What are the potential causes of steatorrhea (excess fat in feces) in a 24-year-old male with vitamin D deficiency, subclinical hypothyroidism, and secondary hypogonadism after consuming shrimp and spaghetti?

From the Guidelines

Steatorrhea in this 24-year-old male with vitamin D deficiency, subclinical hypothyroidism, and secondary hypogonadism after consuming shrimp and spaghetti is most likely due to pancreatic exocrine insufficiency (PEI), which can be effectively managed with pancreatic enzyme replacement therapy (PERT) as recommended by the ESPEN guideline on clinical nutrition in acute and chronic pancreatitis 1. The patient's symptoms, including steatorrhea, vitamin D deficiency, and subclinical hypothyroidism, suggest malabsorption, which can be caused by PEI. According to the ESPEN guideline, PEI is consistently associated with biochemical and clinical signs of malnutrition, and management involves replacing the inadequate pancreatic enzymes to maintain weight and improve symptoms of maldigestion 1. Key considerations in the management of this patient include:

• Initiating PERT to replace inadequate pancreatic enzymes and improve malabsorption symptoms
• Monitoring for signs of malnutrition, including weight loss, alteration of body compartments, and low nutritional markers
• Considering celiac disease testing with tissue transglutaminase antibodies and total IgA levels, followed by upper endoscopy with duodenal biopsies if antibodies are positive, as celiac disease can also cause malabsorption leading to vitamin D deficiency and autoimmune thyroiditis
• Evaluating hypogonadism with morning testosterone levels, LH, FSH, and prolactin to determine if treatment with testosterone replacement is needed
• Treating vitamin D deficiency with vitamin D3 supplementation (50,000 IU weekly for 8 weeks, then 2000 IU daily) as recommended by general clinical guidelines. The ESPEN guideline on clinical nutrition in acute and chronic pancreatitis 1 provides the most recent and highest quality evidence for the management of PEI, and its recommendations should be prioritized in the management of this patient.

From the Research

Potential Causes of Steatorrhea

The potential causes of steatorrhea (excess fat in feces) in a 24-year-old male with vitamin D deficiency, subclinical hypothyroidism, and secondary hypogonadism after consuming shrimp and spaghetti may include:

• Malabsorption of fat-soluble vitamins, as seen in patients with pancreatic insufficiency 2
• Subclinical hypothyroidism, which may be associated with impaired gastrointestinal function and malabsorption 3
• Vitamin D deficiency, which may contribute to impaired calcium absorption and subsequently affect fat absorption 4, 5, 6

Relationship Between Vitamin D Deficiency and Subclinical Hypothyroidism

There is evidence to suggest that vitamin D deficiency is common in patients with subclinical hypothyroidism 4, 5, 6. Additionally, vitamin D replacement has been shown to improve subclinical hypothyroidism by reducing serum TSH levels 4.

Potential Mechanisms

The potential mechanisms underlying steatorrhea in this patient may include:

• Impaired pancreatic function, leading to malabsorption of fat-soluble vitamins 2
• Altered gastrointestinal function and motility, associated with subclinical hypothyroidism 3
• Impaired calcium absorption, due to vitamin D deficiency, affecting fat absorption 4, 5, 6