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Steatorrhea is the passage of fat > 6 g/24 hr stools. Confirmed by repeating the test for 3 consecutive days.

The 1st step after proving steatorrhea is to differentiate between absorptive abnormality and digestive abnormality. This is done by the D-xylose test. D-xylose is a sugar that does not need to be digested (but needs to be absorbed to appear in urine). Hence if urinary excretion is low this infers an absorptive cause for steatorrhea.

1. Malabsorption

Low D-xylose in urine

Jejunal disease

  • Bacterial overgrowth (breath test)
  • Celiac disease
  • Dermatitis herpetiformis
  • Tropical sprue
  • Intestinal resection
  • Whipple's disease
  • Radiation enteritis
  • Parasitic infestation (Giardia lamblia)
  • Primary lactase deficiency
  • Intestinal lymphoma
  • Intestinal lymphangiectasia
  • Crohn's disease
  • Intestinal ischaemia

Bacterial overgrowth is diagnosed by a breath test. Some diseases may require a jejunal biopsy.

2. Maldigestion

Normal D-xylose in urine

1. Pancreatic insufficiency

+ve Benteromide test

  • Chronic pancreatitis
  • Pancreatic cancer

2. Bile salt deficiency

+ve Bile acid breath test

  • Cholestasis (biliary cirrhosis)
  • Bacterial overgrowth (deconjugation of bile salts)
  • Ilial disease or surgery (decreased reabsorption)
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3. Mixed defects

  • Postgastrectomy syndrome
  • Zollinger Ellison syndrome

4. Selective defects

e.g. B12 deficiency due to lack of intrinsic factor, drugs impairing certain nutrients.

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