Exocrine pancreatic insufficiency (EPI)
Exocrine pancreatic insufficiency occurs when the pancreas does not release enough digestive enzymes. As a result, food is not digested properly, and the body doesn’t receive the nutrition it needs.
Symptoms of EPI include abdominal discomfort, bloating, unintentional weight loss, diarrhea and oily stool. Without treatment, malnutrition and deficiencies of trace elements and vitamins occur. Over time, this can result in weakened or fragile bones (osteopenia or osteoporosis), which can take a serious toll on someone’s life.
EPI is common in individuals with pancreatic disease, yet insufficiently diagnosed and treated
EPI can occur in people with acute and chronic pancreatitis, pancreatic cancer, cystic fibrosis, diabetes, and those undergoing pancreatic surgery to remove benign or malignant tumors.
Up to 62% of patients hospitalized for acute pancreatitis have EPI, and 33% at follow-up appointments after their hospitalization. In people with chronic pancreatitis, EPI tends to develop 5 to 10 years after the onset of chronic pancreatitis and is present in 30-90% of patients.
A few tests for EPI exist but are often cumbersome and unpleasant. The most commonly used test for EPI is a stool test called fecal elastase-1. Unfortunately, nonspecific early symptoms of EPI can make it’s identification difficult and delay diagnosis. Studies show that not all patients at high risk for EPI are currently tested, and those who do get tested and diagnosed with EPI, are not treated with high enough dosages of EPI medication.
Treatment for EPI is safe and improves general health
The treatment for EPI consists of improving diet, decreasing alcohol and smoking, and a medication called PERT, which stands for pancreatic enzyme replacement therapy. PERT is taken by mouth to provide additional digestive enzymes during a meal. Taking PERT helps with digestion and absorption of fats and vitamins that require fats in order to be absorbed into the body (vitamins A, D, E, and K).
Treatment of EPI by PERT doesn’t only improve symptoms of EPI, but also makes it less likely that a person develops osteopenia and osteoporosis. PERT may also improves the survival of patients with pancreatic cancer, those undergoing pancreatic surgery for CP, and cystic fibrosis. One 51-week study of PERT showed that people who had chronic pancreatitis and EPI, in addition to improvements in general health, PERT improved bodily pain, vitality, and mental health.
What role do genetics play in EPI?
EPI can be caused by a combination of genetic and environmental factors, such as alcohol and tobacco use. Genetic variants can also cause or increase the risk for conditions which in turn, can cause EPI. For example, genetic variants influence the risk of chronic pancreatitis, cystic fibrosis, pancreatic cancer, and diabetes. The severity of EPI can depend on the specific genetic variant found. In addition, variants in the gene SBDS can cause Shwachman-Diamond syndrome, one of the symptoms of which is EPI.
If you suspect that you may have EPI, speak with your doctor — getting a diagnosis, and starting treatment early may improve your quality of life and prevent more serious consequences.
Brennan GT, Saif MW. Pancreatic Enzyme Replacement Therapy: A Concise Review. JOP. 2019; 20(5):121-125.
Capurso G, Traini M, Piciucchi M, Signoretti M, Arcidiacono PG. Exocrine pancreatic insufficiency: prevalence, diagnosis, and management. Clin Exp Gastroenterol. 2019; 12; 129-139.
De la iglesia garcia D, Huang W, Szatmary P, et al. Efficacy of pancreatic enzyme replacement therapy in chronic pancreatitis: systematic review and meta-analysis. Gut. 2017; 66(8):1354-1355.
Huang W, De la iglesia-garcia D, Baston-rey I, et al. Exocrine Pancreatic Insufficiency Following Acute Pancreatitis: Systematic Review and Meta-Analysis. Dig Dis Sci. 2019; 64(7):1985-2005.
Layer P, Kashirskaya N, Gubergrits N. Contribution of pancreatic enzyme replacement therapy to survival and quality of life in patients with pancreatic exocrine insufficiency. World J Gastroenterol. 2019; 25(20):2430-2441.
Perbtani Y, Forsmark CE. Update on the diagnosis and management of exocrine pancreatic insufficiency. F1000Res. 2019; 8.
Schechter MS, Michel S, Liu S, et al. Relationship of Initial Pancreatic Enzyme Replacement Therapy Dose With Weight Gain in Infants With Cystic Fibrosis. J Pediatr Gastroenterol Nutr. 2018; 67(4):520-526.