EPI has also been linked to a slew of other illnesses, including celiac disease, diabetes, and inflammatory bowel disease, but the exact relationship isn’t clearly understood, according to a study published in December 2021 in the Journal of Clinical Medicine. Diminished pancreatic function also seems to have a strong correlation to small intestinal bacterial overgrowth (SIBO). SIBO is a condition in which the small intestine is colonized by excessive microorganisms that are normally present in the colon. An imbalance in the microorganisms in your gut can disrupt your digestive system and cause SIBO, leading to uncomfortable symptoms such as gas and diarrhea. Over time, it can also lead to malnutrition and serious illness, according to StatPearls.
Understanding Your Gut and SIBO
A healthy small intestine typically comprises no more than 1,000 bacteria/milliliter, plus smaller amounts of other organisms, such as fungi and viruses, according to StatPearls. SIBO occurs when that number increases dramatically, says John Lieb, MD, an associate professor of medicine in the division of gastroenterology, hepatology, and nutrition at the University of Florida. This buildup of bacteria can cause a biofilm, which reduces the small intestine’s ability to absorb nutrients. Common symptoms include cramping, oil in the stool, more frequent stools, and vitamin and nutrient deficiencies (especially the fat-soluble vitamins A, D, E, and K, as well as B12, magnesium, calcium, and zinc). It’s not just the quantity of bacteria, but also the type. SIBO occurs when there’s an overgrowth of “bad” bacteria: bacteria that are not normally found in the digestive tract or are usually found elsewhere in the digestive tract such as in the colon. SIBO commonly occurs when surgery (such as gastric bypass) or structural abnormalities (such as a small bowel obstruction) slow down the movement of food and waste in the digestive tract, which can cause bacteria to flourish. “That’s the classic situation of bacteria overgrowth,” says Tamas Gonda, MD, chief of endoscopy and director of the pancreatic disease program at NYU Langone Health’s Tisch Hospital in New York. But, he adds, anything that can alter the gut microbiome can also lead to SIBO, whether it’s inflammation in the gut from inflammatory bowel disease or certain medications, such as stomach-acid reducers or antibiotics.
Where EPI and SIBO Meet
Many studies have found a correlation between EPI and SIBO. “There are suggestions that when there is pancreatic deficiency, that can result in bacterial overgrowth,” Dr. Gonda explains. One review, published in the September 2019 issue of Clinical and Translational Gastroenterology, found that SIBO is a common complication of chronic pancreatitis, particularly in people with EPI. It also says that treating SIBO in patients with pancreatitis helped improve pancreatitis symptoms and could be an alternative treatment when symptoms do not improve with pancreatic enzyme replacement therapy (PERT) in patients with chronic pancreatitis and EPI. According to the Journal of Clinical Medicine study, the relationship between EPI and SIBO seems to go both ways: Not only does having EPI raise the risk of SIBO, but SIBO may also cause inflammatory changes in the pancreas and make EPI worse. Given this, the study researchers suggest that screening and treatment of SIBO would be beneficial for people who have EPI.
How Diagnosing and Treating SIBO Can Help EPI
Having SIBO on your radar if you have EPI can be especially important, because they can share symptoms, including diarrhea, abdominal pain, and weight loss. The key distinction between EPI and SIBO, according to Dr. Lieb, is maldigestion versus malabsorption. “The problem in EPI is more related to difficulty breaking down the nutrients [maldigestion] rather than absorbing them [malabsorption], as you see in SIBO,” he explains, adding that people who have SIBO tend to have a higher volume of loose stools, while people with EPI have denser, fattier stools. And because other gut conditions, such as irritable bowel syndrome, celiac disease, and even excessive sugar-substitute intake, can mimic SIBO symptoms, it’s important to get tested and work with a clinician who is experienced in treating SIBO. The main treatment for SIBO is antibiotics — often multiple courses of different types to avoid developing a resistance, says Lieb. According to Gonda, antibiotics “reorient or recolonize the gut with new microbial flora.” Other, less common treatments include prokinetics, which stimulate movement of the gastrointestinal tract, and surgical interventions to correct any physical issues that may be causing SIBO. You can also help manage your SIBO by eating prebiotic and probiotic foods. While studies have shown that probiotics do not effectively treat SIBO, Lieb says he has seen some benefits, especially restoring the microbiome after a course of antibiotics, in his patients. Good sources of prebiotics include beans, legumes, oats, berries, garlic, and onions. Probiotics can be found in fermented foods, such as sauerkraut, kimchi, and kombucha. Bottom line: Gonda and Lieb agree that it’s important to consider testing for and treating SIBO if you have EPI and aren’t able to successfully control your symptoms with PERT. “Ultimately, both conditions have relatively harmless treatments that are highly effective,” Gonda says. If you have EPI or SIBO, “It’s important to think of treating the other condition when you don’t have a sufficient clinical response to existing treatment,” he adds.
