The Value Of Stool Testing

• Why Stool Test First?|
• 2 Stool Test Markers|
• Validation|
• Treatment Options|
• Recommended Stool Test|

Stool testing identifies easily treatable GI disorders with Dr. Ilana Gurevich.

Dr. Ilana Gurevich came on the podcast in 2019 to critique gut function tests with me. I recently invited her back to clarify the value of steatocrit and elastase-1, two markers included on the GI MAP that she finds invaluable for diagnosing two treatable digestive tract conditions that can be otherwise missed.

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Why Stool Test First

I often have my patients focus on diet and the other foundational practices I discuss in my book Healthy Gut, Healthy You before moving on to more expensive testing, such as stool testing, that sometimes provides little clinical value.

Dr. Gurevich suggests that stool analysis should be one of the first things to do, especially for patients with chronic diarrhea. Stool tests like the GI MAP include fecal steatocrit and fecal elastase-1 markers, which can help uncover two easily treatable conditions: bile acid malabsorption (BAM) and exocrine pancreatic insufficiency (EPI), both of which can cause severe, chronic diarrhea.

Dr. Gurevich has found that patients sometimes waste months or longer chasing solutions that are not matched with their actual condition if these tests are skipped. She noted, “When people come to me and start with empiric testing, I’ve seen them waste months—years—sometimes not being able to figure it out. And when we run some testing that’s fairly easy and expensive, but not prohibitory, we find these really obvious answers.”

Stool Test Markers for Bile Acid Malabsorption & Exocrine Pancreatic Insufficiency Diagnosis

Fecal steatocrit and elastase-1 can easily help diagnose Bile Acid Malabsorption (BAM)—which is also called bile acid diarrhea—and Exocrine Pancreatic Insufficiency (EPI).

The previous gold standard test for bile acid malabsorption was a fecal fat test, which asked patients to do a provocation diet, and then collect all of their bowel movements for three days. This was a rather uncomfortable proposition for someone already suffering with BAM or EPI symptoms.

The steatocrit test is a single stool collection, so is much more user friendly, and is just as clinically relevant as the fecal fat test.

The elastase-1 test is also well validated, and if elevated, diagnoses exocrine pancreatic insufficiency. The previous gold standard test was very invasive.

Differential Diagnosis

Dr. Gurevich noted several other reasons for chronic diarrhea. She said, “The other things that would match these symptoms would be SIBO, a parasite infection, microscopic colitis, IBS diarrhea, and fungal overgrowth.” But as she sees it, the challenge is, “The symptom picture that both of these conditions illustrate is the same symptom picture that virtually all chronic diarrhea patients come in with… When I… run the functional GI test and I see these right away, it just really gives me the ability to point my treatment where I think it needs to go to get patients results a lot faster.”  

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Validation of Elastase & Steatocrit Test Results

According to Dr. Gurevich, the fecal elastase-1 test is “very well validated, it’s not even a negotiable matter… If steatocrit is under 200 ug/g, it’s considered positive for moderate to severe pancreatic insufficiency… There are some studies that say that you’re looking for a steatocrit over 500 to call it a completely healthy [pancreas].”

“Steatocrit is a newer lab and it is not being used in the standard medical system. But the studies…that I found showed really high specificity and sensitivity.” “Steatocrit has a 92% specificity, and is equal to the gold standard fecal fat test.’

“There is also a blood test that’s put out by Prometheus to look for fecal fat, it’s called a 7C4 test, but it only looks at one type of bile acid diarrhea and not all four types. So it’s actually not a very useful test.”

EPI & BAM Natural Treatment Options

Exocrine Pancreatic Insufficiency

Dr. Gurevich recommends using the fecal elastase-1 to confirm diagnosis. Then she uses digestive enzymes, either prescription or over the counter, to assist with fat digestion. She uses:

• Vital Nutrients Pancreatic Enzyme: 500 mg, 4-8 capsules per meal
• Creon (prescription enzyme): “The Creon is the 24,000 [units of] amylase, and it’s usually between two-to-four capsules, depending on their weight.”

Dr. Gurevich uses the patient’s weight and an enzyme calculator for dosing. She notes, “It takes three days for the large intestine to process most things… And so usually within a week, you’ll know if they’re, you’re getting clinical efficacy.”

Bile Acid Malabsorption

Dr. Gurevich suggests using the fecal elastase-1 test to first exclude maldigestion due to pancreatic insufficiency, and then using the steatocrit test to confirm. The primary natural treatment she likes to offer as a bile acid sequestrant is sunflower lecithin, which binds excess bile and heals the gut lining.

Which Stool Test is Best?

About which test Dr. Gurevich recommends, she said, “You know, at this point I use [the] GI MAP… I do feel like I’ve read enough literature to say that DNA-PCR is the testing method of choice… And so that’s who I’m using, but I’ll also use Quest or Labcorp or any standard lab tests.”