Practical Clinical Immunology/ Fecal Fat Test/ GIT Dz./ Prof. Dr. Batool A.

Al-Haidary

Fecal Fat Test

In the duodenum, dietary fat (primarily triglycerides) is digested by enzymes such
as pancreatic lipase into smaller molecules of 1,2-Diacylglycerols and free fatty acids,
which can be absorbed through the wall of the jejenum of the small intestine [1] and
enter circulation for metabolism and storage. Since fat is a valuable nutrient,
human feces normally contains very little undigested fat. However, a number of diseases
of the pancreas and gastrointestinal tract are characterized by fat mal absorption.
Examples of such diseases are:
 disorders of exocrine pancreatic function, such as chronic pancreatitis, cystic
fibrosis and Shwachman–Diamond syndrome (these are characterized by deficiency
of pancreatic digestive enzymes)
 celiac disease (in which the fat mal absorption in severe cases is due to inflammatory
damage to the integrity of the intestinal lining)
 short bowel syndrome (in which much of the small intestine has had to be surgically
removed and the remaining portion cannot completely absorb all of the fat).
 small bowel bacterial overgrowth syndrome

Microscopy
In the simplest form of the fecal fat test, a random fecal specimen is submitted to
the hospital laboratory and examined under a microscope after staining with a Sudan
III or Sudan IV dye ("Sudan staining"). Visible amounts of fat indicate some degree of fat
mal absorption.

Quantitative
Quantitative fecal fat tests measure and report an amount of fat. This is usually done over
a period of three days, the patient collecting all of their feces into a container.
The container is thoroughly mixed to homogenize the feces, without using specific mixer
equipment. A small sample from the feces is collected. The fat content is extracted
with solvents and measured by saponification (turning the fat into soap).
Normally, up to 7 grams of fat can be mal absorbed in people consuming 100 grams of fat
per day. In patients with diarrhea, up to 12 grams of fat may be malabsorbed since the
presence of diarrhea interferes with fat absorption, even when the diarrhea is not due to
fat mal absorption.
Fecal fat testing is typically ordered along with or as a follow up to other stool tests and
blood tests to investigate the cause of chronic diarrhea and loose, fatty, foul-smelling
stools (steatorrhea).
Stool tests may include:
blood test (FOBT) – to detect blood in the stool
– to detect parasites
– to detect white blood cells in the stool
Fecal elastase – a protein-cleaving enzyme produced and secreted by the pancreas; it
is resistant to degradation by other enzymes and so is excreted and can be measured in the
stool. The amount of this enzyme is reduced in pancreatic insufficiency.

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Practical Clinical Immunology/ Fecal Fat Test/ GIT Dz./ Prof. Dr. Batool A. Al-Haidary

Fecal fat, qualitative – usually a suspension of stool placed on a glass slide that is
treated with a special stain and examined under the microscope to detect the presence of
fat droplets
Blood tests may be ordered to further investigate mal absorption symptoms and may
include:
(CBC) – to evaluate red and white blood cells
(CMP) – to evaluate liver function, proteins, and
electrolytes
Celiac disease antibody tests – to detect this condition

Tests for cystic fibrosis may be performed as part of the investigation:

Trypsin and chymotrypsin
Trypsinogen
Sweat test
CF mutation panel
If the qualitative fecal fat is negative, then a 72-hour quantitative fecal fat test may be
ordered. This is a better evaluation of fat digestion and absorption. There are two reasons
for this:

amount of fat per day prior to and during sample collection so their absorption ability is
being "challenged."
rate so the combination and mixing of the
stool from a 72-hour collection gives a more accurate picture of average absorption and
elimination than a single sample.

A fecal fat test is primarily ordered when a person has signs and symptoms of mal
absorption such as:
-smelling (steatorrhea)
Persistent diarrhea
Abdominal pain, cramps, bloating, and gas
Weight loss
Failure to thrive (in children)

These symptoms may or may not be accompanied by other indicators such as fatigue,
anemia and/or specific nutritional deficiencies in, for example, iron or vitamin B12.

What does the test result mean?

A positive qualitative fecal fat test or an increased amount of fat in a 72-hour quantitative
fecal fat test indicates that fat is likely not being absorbed normally and that the person
may have impaired digestion or mal absorption.
Mal absorption is seen with a wide variety of diseases and conditions. Some causes of mal
absorption include:
1. Diseases affecting the intestines such as:

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 Practical Clinical Immunology/ Fecal Fat Test/ GIT Dz./ Prof. Dr. Batool A. Al-Haidary

2. Pancreatic insufficiency caused by:

-Diamond Syndrome
3. Diseases and conditions of the bile ducts and/or gallbladder

the liver and gallbladder to the intestines

Other laboratory tests used in conjunction with the fecal fat test are usually required to
determine the underlying cause of fat mal absorption.
A negative qualitative fecal fat test does not necessarily rule out mal absorption so it may
be followed up with a quantitative test.
In a 72-hour fecal fat test, a low level of fecal fat generally indicates that the person tested
is digesting and absorbing fats normally and suggests that the symptoms being
experienced are likely due to another cause.
Sample Required?
A random stool collection; sometimes a 72-hour stool collection

Procedure
The faecal fat test is a rather unpleasant procedure, which involves collecting 3 full days’
worth of faeces in a bucket with a lid, while consuming at least 100 grams of fat per day.
The stool collection is then analyzed in a laboratory. It is not really a necessary test when
there is obvious fat mal absorption, but may be helpful in less obvious cases.
This test rather unpopular and is rapidly being replaced by other tests of pancreatic
function.

Test/Range/Collection
Fecal fat, stool
Random: < 60 droplets of fat/high power field
72-hour: < 7 g/day
Qualitative: Random stool sample is adequate.
Quantitative: Dietary fat should be about 100 g/day for 5 days before and during stool
collection. Then all stools should be collected for 72 hrs and refrigerated.
A random, qualitative fecal fat (so-called Sudan stain) is useful only if positive.
Furthermore, it does not correlate well with quantitative measurements. Sudan stain
appears to detect triglycerides and lipolytic by-products, whereas 72-hour fecal fat
measures fatty acids from a variety of sources, including phospholipids, cholesteryl esters,
and triglycerides.
The quantitative method can be used to measure the degree of fat mal absorption initially
and then after a therapeutic intervention.

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Practical Clinical Immunology/ Fecal Fat Test/ GIT Dz./ Prof. Dr. Batool A. Al-Haidary

A normal quantitative stool fat reliably rules out pancreatic insufficiency and most forms
of generalized small intestine disease.
Besides fecal fat quantification, fecal pancreatic elastase 1 can be used to evaluate
pancreatic insufficiency with excellent sensitivity. The13C-mixed triglycerides breath test
has also been introduced and adopted by many laboratories.