Snap Shot A 46-year-old female alcoholic with a long history of chronic pancreatitis presents with weight loss, and a three-month history of frequent greasy stool PE shows pitting edema in the lower extremities, mild hepatomegaly, and scattered echymosis in the areas of trauma. An ultrasound of the pancreas shows calcifications. Endoscopic biopsy of multiple locations of the small bowel are normal. Introduction Malabsorption refers to: increased fecal excretion of fat concurrent deficiencies of vitamins, minerals, proteins, and carbohydrates Can be the result of small bowel disease leading to decreased reabsorption of fat pancreatic insufficiency that leads to improper breakdown due to the lack of lipases bile salt deficiency which interfers with micellixation of fat and absorption by the villi in the small intestine. Presentation Hypovitaminosis symptoms malabsorption leads to loss of fat soluble vitamins A, D, E, K. Hypoalbuminemia results in decreased plasma oncotic pressure loss of the transudate in the interstitial tissue clinical evidence of pitting edema Hypoproteinemia leads to reduced synthesis of apolipoproteins (necessary to surround the lipid VLDL before it is excreted into the blood) therefore hepatomegaly may form due to fatty change Electrolyte disturbances Evaluation Quantitative stool fat test is > 6 g/day D-xylose absorption test differentiates small bowel disease from pancreatic disease and bile salt deficiency an oral form is given which does not need pancreatic enzymes to be broken down if levels continue to be low then it is not being absorbed due to small bowel disease Radioactive bile breath test to rule out bile salt deficiency from bacterial overgrowth