TableĀ 30

Investigation and management of steatorrhoea

InvestigationsPotential resultsClinical management plan
First line
Stool sample for faecal elastasePancreatic insufficiencyManagement of EPI (p. 26).
Routine and additional blood testsAddison's disease
Coeliac disease
Thyroid dysfunction
Follow treatment for abnormal blood results (p. 2).
Blood tests for malabsorptive symptomsMalabsorptive pathologyFollow treatment for abnormal blood results (p. 2).
SeHCAT scanBAMManagement of BAM (p. 25).
OGD and SI aspirate and biopsies (p. 25)SIBOManagement of SIBO (p. 27).
Intestinal parasitesTreat with antibiotics within level of confidence or discuss with microbiologists and supervising clinician.
Glucose hydrogen methane breath testSIBOManagement of SIBO (p. 27).
Second line
Gut hormones (Chromogranin A and B, gastrin, substance P, VIP, calcitonin, somatostatin, pancreatic polypeptide) and urinary 5-HIAA and CT/MRI liver and abdomenNeuroendocrine tumourDiscuss and refer urgently to the appropriate neuroendocrine MDT requesting an appointment within 2 weeks.
CT abdomen pelvis/capsule endoscopy/MRI enteroclysisSmall intestinal diseaseDiscuss immediately and refer to the appropriate MDT requesting an appointment within 2 weeks, or if no malignancy to a gastroenterologist.
Third line
If normal investigations/no response to intervention
  1. Trial of empirical antibiotics to exclude test negative SIBO.

  2. Trial of low fat diet.

  • 5HIAA, 5-hydroxyindole acetic acid; BAM, bile acid malabsorption; CT, computerised tomography; EPI, exocrine pancreatic insufficiency; MDT, multidisciplinary team; MRI, magnetic resonance imaging; OGD, upper GI endoscopy (oesophago-gastroduodenoscopy); SeHCAT, 23-seleno-25-homotaurocholic acid; SIBO, small intestinal bacterial overgrowth; VIP, vasoactive intestinal protein.