The prevalence of EPI is not known in the general population, according to an article published in March 2019 in the journal Clinical and Experimental Gastroenterology, but it tends to be most common among those with chronic pancreatitis or cystic fibrosis, among other diseases.
Symptoms of EPI
One of the main consequences of EPI is the inability to break down the fat in foods. This results in fatty stools, called steatorrhea, which are oily, pale, bulky, and smelly. They may also be hard to flush, because they float or stick to the toilet. Other symptoms include:
Abdominal discomfort with gas or bloatingMuscle crampsBone painEasy skin bruising or bleedingNight blindnessWeight loss
How EPI Is Diagnosed
“Many patients with EPI are not appropriately tested and miss out on a therapy that could help them nutritionally,” says Steven D. Freedman, MD, PhD, a professor of medicine at Harvard Medical School and the director of the Pancreas Center at Beth Israel Deaconess Medical Center in Boston. A patient can come in with diarrhea, he explains, but EPI is not necessarily at the top of the list of reasons for it. Moreover, EPI can be masked by other simultaneously occurring health conditions that may be related. “Diabetes is rampant in the United States, for example, but many doctors do not realize diabetes predisposes [patients] to EPI,” he says. Symptoms of EPI can range from very mild to severe, but there are currently no reliable, noninvasive pancreatic tests that can determine the severity of a person’s condition. “Findings in lab tests can come back negative even if exocrine pancreatic insufficiency is present,” says John Affronti, MD, a gastroenterologist and professor of clinical medicine at Tulane University, in New Orleans. An X-ray or computed tomography (CT) scan may help, and a fecal fat test can be effective, although it requires large stool samples. These tests are commonly used to help diagnose EPI:
A fecal fat test involves looking at a stool sample under a microscope. The most common test, according to Dr. Affronti, is the fecal elastase test, in which a stool sample is checked to see if the pancreatic enzymes trypsin and elastase are present in the intestines as they should be. Unfortunately, the test is not as sensitive as doctors would like it to be, says Affronti.Blood tests can measure trypsinogen, the pancreatic enzyme that converts to trypsin.An endoscopic ultrasound (EU) uses a flexible telescope inserted in the mouth and passed down through the stomach to take pictures of the pancreas and look for damage. A biopsy of the pancreas may be taken during the EUS to be used for additional testing.
“Pancreatic surgery, diabetes, cystic fibrosis, autoimmune disorders, pancreatitis, inflammatory bowel diseases, such as Crohn’s disease, and other digestive diseases can be associated with pancreatic insufficiency,” Affronti says. Treatment and management options your doctor may suggest include:
Taking pancreatic digestive enzyme medications, which is usually the most effective treatmentFollowing an EPI-friendly meal planTaking antioxidants, such as vitamins A, E, and C, as well as the dietary supplements methionine, selenium, and grape seed extract, which may help prevent further damage to the pancreas
People who have developed EPI as a result of pancreatitis, in particular, need to take pancreatic enzyme replacements and supplements for vitamins A, D, E, and K, Affronti says. Dr. Freedman says new research on recombinant pancreatic enzymes could significantly improve enzyme therapy. Currently, enzyme capsules are comprised of purified pig pancreas, which are not as effective as our own native enzymes. “With recombinant versions of enzymes, we can design enzymes for all conditions in the gastrointestinal tract,” he says. For example, in patients with cystic fibrosis and EPI, the pancreatic secretions are thick and acidic. Recombinant enzymes could be tailored to be effective under those conditions. The recombinant enzymes would also significantly reduce the pill burden for EPI patients. People with EPI take up to seven pills with a meal. These new enzymes would require only one pill. He expects clinical trials to begin for these new treatments in the next one to two years. If you’re diagnosed with EPI, work closely with your doctor to find the best treatment for you. Additional reporting by Nina Wasserman
