Gastrointestinal: “Floating oil droplets in the colonic fluid”: colonoscopic findings in a patient with pancreatic exocrine insufficiency and steatorrhea

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A 43-year-old man presenting with body weight loss (15% weight loss over a 6-month period) complained of diarrhea, bloating, flatulence, and abdominal discomfort aggravated by fatty meals taken over a 6-month period. He had a 12-year history of heavy alcohol consumption and was diagnosed with chronic pancreatitis 7 years ago using endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography at another hospital. The dietary fat intake of the patient was reduced because of gastrointestinal manifestations. No remarkable findings were observed by physical examination. Blood tests revealed decreased serum amylase (19 IU/L; normal range, 28–100 IU/L) and lipase levels (9 U/L, normal range, 13–60 U/L). The results of the liver and renal function tests and the complete blood count were normal; further, the serum vitamin A and E levels were within the normal range. Abdominal computed tomography (CT) scan revealed diffuse atrophic pancreatic parenchyma and mild dilatation of the duct in the tail of the pancreas (Fig. 1). Sudan staining performed on a random fecal specimen was negative. The 72-h fecal fat stool test failed because of the poor cooperation of the patient. Gastroscopy and colonoscopy were performed. Small-bowel mucosal biopsy did not reveal any signs of small-intestinal disease that could lead to fat malabsorption. On colonoscopy, we observed floating orange-colored oil droplets in the colonic fluid (Fig. 2). The symptoms of the patient improved after he was administered pancreatic enzyme supplements. Chronic pancreatitis is characterized by pancreatic acinar atrophy and fibrosis. The most common etiology of the condition is alcohol abuse. CT scans may reveal calcification, dilatation of the pancreatic duct, and parenchymal atrophy. Exocrine pancreatic insufficiency with fat maldigestion and steatorrhea is a major complication. Fat maldigestion occurs when the loss of pancreatic lipase capacity is higher than 90%. The traditional method for the evaluation of pancreatic lipase activity is the quantitative fecal fat analysis, in which stool samples are collected over a 72-h period. Qualitative tests, including Sudan staining of a random fecal specimen, can be performed; however, this test is best described in children. These tests are difficult to perform or yield results that have a low reliability; further, the successful performance of this test requires that the fat content in the diet of the patient be adequate to allow measurement of steatorrhea. Recent diagnostic methods, including fecal chymotrypsin and pancreatic elastase-1 measurements, are noninvasive and are useful in confirming a diagnosis of chronic pancreatitis with exocrine insufficiency. In this case, oil droplets were observed to float in the colonic fluid upon colonoscopy. Careful colonoscopic monitoring for the presence of oil droplets floating in the colonic fluid following administration of the bowel-preparation solution may be useful in the diagnosis of fat malabsorption. Contributed by