Patients with steatorrhoea often pass bulky, sticky and greasy stool that floats and is often difficult to flush away. Diarrhoea is the usual accompanying symptom (p. 100) for most of the causes. Jaundice with pale stools and dark urine implies obstruction to the flow of bile, which is essential for the absorption of fat and fat-soluble vitamins. The causes and diagnostic approach to jaundice are found on p. 256.

Abdominal pain

Vague epigastric abdominal pain experienced by patients with chronic pancreatitis may radiate to the back and is usually worse with food. Epigastric pain exacerbated by food may be a symptom of Zollinger–Ellison syndrome, which results in excessive gastric acid production (lowering the pH of gastric chyme), inactivating lipase. It usually presents with symptoms of peptic ulceration refractory to medical treatment. Abdominal pains associated with Crohn’s disease are often felt in the right iliac fossa due to regional ileitis.

Associated symptoms

Patients with coeliac disease may also suffer with growth retardation and nutritional deficiencies causing anaemia and muscle wasting. Other symptoms may include bone fracture due to demineralisation, cerebellar ataxia and peripheral neuropathy. Joint pains, pyrexia, skin pigmentation and peripheral lymphadenopathy are among the varied symptoms of Whipple’s disease, resulting from infection with the bacterium Tropheryma whipplei. Steatorrhoea is the primary manifestation of intestinal lymphoma. It may be accompanied by abdominal pains and pyrexia and occasionally present with intestinal obstruction. Mouth ulcers, perianal abscesses, right iliac fossa pains and blood PR are some of the symptoms experienced by patients with Crohn’s disease. Ataxia and night blindness from retinitis pigmentosa may result from abetalipoproteinaemia, which is caused by the absence of apolipoprotein B and therefore results in defective chylomicron formation.

Past medical history

Previous surgical resection involving the terminal ileum will predispose an individual to malabsorption of fat due to decreased enterohepatic circulation of bile salts. Moreover, with decreased length of absorptive intestine, intestinal transit time decreases and there is a decrease in concomitant fat absorption. Conditions associated with intestinal stasis, hypomotility and decreased gastric acid secretion predispose to intestinal bacterial overgrowth and increased degradation of bile salts.

Drug history

Ask about Orlistat medication used in the treatment of obesity (prevents absorption of fats from the diet).

Examination

Steatorrhoea is often associated with malabsorption and therefore patients may appear emaciated. Mouth ulcers may be due to Crohn’s or coeliac disease. Clubbing is associated with Crohn’s, liver cirrhosis, coeliac disease and cystic fibrosis, which is associated with pancreatic exocrine insufficiency. Jaundice may be present with bile duct obstruction and liver disease. Bruising may result from impaired clotting due to vitamin K deficiency. The classical rash of dermatitis herpetiformis may be seen with coeliac disease. Erythema nodosum is a feature of Crohn’s disease and may be accompanied by right iliac fossa tenderness, perianal abscesses and fistulae. Hepatomegaly may be found in liver disease, and splenomegaly with intestinal lymphoma.