What is exocrine pancreatic insufficiency, and who should get tested?

Most bloating and loose stools after meals have ordinary explanations: a rich dinner, a trigger food, a sensitive gut. This article is about a less common cause that is easy to overlook. A 2023 expert review from the American Gastroenterological Association (AGA) described it as frequently underdiagnosed, with many patients not treated appropriately (Whitcomb et al., 2023).

It isn't something to self-diagnose, and over-the-counter enzymes aren't the fix. But knowing the signs can help you ask the right questions.

What it is

Your pancreas has two main jobs. One is making hormones such as insulin. The other, its exocrine function, is making digestive enzymes that break down fat, protein and carbohydrates in the small intestine.

Exocrine pancreatic insufficiency, or EPI, happens when the pancreas doesn't deliver enough of those enzymes to the intestine. Food, and fat in particular, isn't fully digested, and the body can come up short on nutrients (Whitcomb et al., 2023).

The symptoms

According to the AGA review, the clinical features of EPI include (Whitcomb et al., 2023):

• Fatty stools, called steatorrhea, with or without diarrhea. They often look pale, greasy or bulky and can be hard to flush.
• Weight loss
• Bloating and excessive gas
• Deficiencies of the fat-soluble vitamins A, D, E and K
• Protein and calorie malnutrition

Notice the overlap with everyday digestive complaints. That's part of why EPI can be missed. In a study of 314 people diagnosed with diarrhea-predominant irritable bowel syndrome, 6.1% had stool test results indicating EPI. After enzyme therapy, their stool frequency, stool consistency and abdominal pain improved (Leeds et al., 2010).

Who is at risk

The AGA review lists conditions in which EPI should be suspected:

• Chronic pancreatitis, or acute pancreatitis that keeps coming back
• Pancreatic cancer
• Cystic fibrosis
• Previous pancreatic surgery

It also lists moderate-risk conditions in which EPI should be considered, including celiac disease, Crohn's disease, previous intestinal surgery, long-standing diabetes, and rare conditions that cause the stomach to make too much acid (Whitcomb et al., 2023).

Age plays a role, too

Pancreatic function changes over a lifetime. A systematic review found that pancreas volume plateaus between about 20 and 60 and declines after that. Based on a stool test, an estimated 5% of people over 70 and 10% over 80 have EPI, and many have few symptoms (Löhr et al., 2018).

In a study of 106 older adults aged 60 to 92 without known digestive disease, digestive surgery or diabetes, 21.7% had stool elastase levels below the usual cutoff for EPI (Herzig et al., 2011). Those numbers describe people older than most of our readers. But they're a reminder that "normal aging" and "needs testing" can overlap.

How it's diagnosed

• Fecal elastase test. The AGA review calls this the most appropriate first test. It needs a formed or semi-solid stool sample. A level below 100 μg/g provides good evidence of EPI, while 100 to 200 μg/g is considered indeterminate.
• An enzyme trial isn't a diagnosis. Feeling better while taking enzymes is not a reliable way to confirm EPI.
• Imaging has a different job. CT, MRI and endoscopic ultrasound can't identify EPI itself, but they're important for checking the pancreas for other disease (Whitcomb et al., 2023).

How it's treated, and why supplements aren't a substitute

Once EPI is diagnosed, the AGA review says treatment with pancreatic enzyme replacement therapy, or PERT, is required. Untreated EPI leads to complications of fat malabsorption and malnutrition. PERT is taken during meals, starting at a minimum of 40,000 USP units of lipase per meal for adults, then adjusted for meal size and fat content. The review also recommends checking fat-soluble vitamin levels and bone density (Whitcomb et al., 2023).

That's a prescription treatment at a medical dose, managed by a doctor. Over-the-counter digestive enzyme blends are dietary supplements and are not a replacement for it. If you suspect EPI, ask for testing rather than trying to treat it yourself.

When to talk to your doctor

• Stools that are often greasy, oily, pale or hard to flush
• Weight loss without trying
• Diarrhea, bloating or gas after most meals that doesn't improve with simple changes
• Any of the above along with a history of pancreatitis, pancreatic or intestinal surgery, celiac disease, Crohn's disease or long-standing diabetes
• Blood in your stool, black stools, anemia or persistent vomiting

Sources

1. Whitcomb DC, Buchner AM, Forsmark CE. AGA clinical practice update on the epidemiology, evaluation, and management of exocrine pancreatic insufficiency: expert review. Gastroenterology. 2023;165(5):1292-1301. PMID 37737818
2. Leeds JS, Hopper AD, Sidhu R, et al. Some patients with irritable bowel syndrome may have exocrine pancreatic insufficiency. Clin Gastroenterol Hepatol. 2010;8(5):433-8. PMID 19835990
3. Löhr JM, Panic N, Vujasinovic M, Verbeke CS. The ageing pancreas: a systematic review of the evidence and analysis of the consequences. J Intern Med. 2018;283(5):446-460. PMID 29474746
4. Herzig KH, Purhonen AK, Räsänen KM, et al. Fecal pancreatic elastase-1 levels in older individuals without known gastrointestinal diseases or diabetes mellitus. BMC Geriatr. 2011;11:4. PMID 21266058

This article is for general information and isn't medical advice. Don't start, stop or change enzyme treatment without talking to your healthcare provider.