What is the best approach to evaluate a 41-year-old female with floating stools, but no other symptoms, who is concerned about pancreatic cancer despite recent normal laboratory results and no symptoms suggestive of Irritable Bowel Syndrome (IBS)?

Evaluation of Floating Stools in a 41-Year-Old Female Without Other Symptoms

Reassure this patient that isolated floating stools with well-formed, normal-colored stools and no other symptoms do not warrant investigation for pancreatic cancer or pancreatic exocrine insufficiency at this time. 1

Clinical Context and Risk Assessment

This patient presents with an isolated finding that does not meet criteria for concerning pathology:

• Age under 55 years: The British Society of Gastroenterology recommends urgent abdominal CT scanning only in patients aged ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer 1
• No alarm features present: She lacks weight loss, abdominal pain, nocturnal symptoms, family history of pancreatic cancer, or recent onset diabetes—all key features that would raise concern 1
• Normal laboratory results: Recent normal labs further reduce concern for underlying pancreatic pathology 1

Understanding Floating Stools

Floating stools are commonly benign and related to:

• Dietary factors: Increased fiber intake or gas content in stool (most common cause) 1
• Normal variation: Many healthy individuals have floating stools without pathology 1

True steatorrhea (fat malabsorption from pancreatic exocrine insufficiency) presents with visible oil in the toilet water, greasy stools that are difficult to flush, and is typically accompanied by other symptoms including diarrhea, abdominal distention, weight loss, and increased flatulence 1, 2. This patient explicitly denies obvious oil and reports well-formed, normal-colored stools.

When to Investigate Further

Testing for pancreatic pathology would be indicated if she develops:

• Weight loss (especially if unexplained and progressive) 1
• New-onset diabetes mellitus (particularly concerning in patients over age 50) 1
• Persistent abdominal pain with back radiation 1
• True steatorrhea with visible oil, loose watery stools, or undigested food 1
• An unexplained episode of acute pancreatitis 1

Diagnostic Approach If Symptoms Progress

Should concerning features develop, the evaluation pathway would be:

• Fecal elastase-1 testing on a semi-solid stool specimen (not watery) as the initial test for pancreatic exocrine insufficiency; levels <100 μg/g indicate EPI, while 100-200 μg/g are indeterminate 1
• Cross-sectional imaging (contrast-enhanced CT or MRI with MRCP) if clinical suspicion for pancreatic malignancy arises based on age, symptoms, and risk factors 1

Common Pitfall to Avoid

Do not order fecal elastase testing in patients with watery diarrhea, as this can produce falsely low results and lead to unnecessary concern 1. The test must be performed on semi-solid stool specimens for accuracy.

Recommended Management

• Reassurance and education about the benign nature of isolated floating stools 1
• Dietary review: Assess fiber intake, as both excessive and insufficient fiber can cause gas-related stool changes 1
• Watchful waiting: Instruct the patient to return if she develops weight loss, persistent abdominal pain, visible oil in stools, or other concerning symptoms 1
• No further testing indicated at this time given her age, lack of symptoms, and normal laboratory results 1