Exocrine Pancreatic Insufficiency (EPI)

What Is Exocrine Pancreatic Insufficiency?

Your pancreas has two important jobs:

• Exocrine function: Makes digestive enzymes that help break down food.
• Endocrine function: Makes hormones such as insulin that help control blood sugar.

When pancreatic disease or surgery affects the pancreas, it can sometimes affect one or both of these functions.

When there are not enough pancreatic enzymes, food may not be fully digested. This can lead to digestive symptoms, including excess intestinal gas, bloating, abdominal cramping and oil in the stools, or difficulty maintaining weight, and deficiencies of important vitamins and other nutrients.

EPI is often associated with conditions that affect the pancreas, including chronic pancreatitis, cystic fibrosis, pancreatic cancer, and pancreatic surgery. However, you can have EPI without ever having pancreatitis.

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What Causes EPI?

EPI can develop when the pancreas is damaged or when digestive enzymes fail to mix with the meal properly. Common causes include:

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Chronic pancreatitis: Long-term inflammation can permanently damage the pancreas and reduce its ability to produce digestive enzymes. Chronic pancreatitis can also affect the insulin-producing cells of the pancreas.

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Cystic fibrosis (CF): CF can cause thick, sticky mucus to block the pancreatic ducts. This can prevent digestive enzymes from reaching the small intestine.

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Pancreatic surgery: Surgery that removes part or all of the pancreas can reduce the amount of pancreatic tissue available to make digestive enzymes. Changes to the digestive system after surgery can also affect how enzymes mix with food.

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Pancreatic cancer: Pancreatic tumors or changes caused by treatment can interfere with the production or delivery of digestive enzymes.

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Other conditions:

EPI may also occur with conditions affecting the pancreas or digestive system, including:

• Diabetes
• Celiac disease
• Inflammatory bowel disease
• Abdominal surgeries such as gastrectomy or gastric bypass
• Certain genetic conditions
• Previous pancreatic injury or acute pancreatitis

Symptoms of EPI can vary from person to person. Some people have mild symptoms, while others may have significant digestive problems.

Common symptoms include:

• Bloating / gas
• Abdominal pain
• Diarrhea
• Greasy or foul-smelling stools
• Unexplained weight loss or difficulty maintaining weight
• Feeling full quickly
• Changes in appetite
• Fatigue

Not everyone with EPI has obvious greasy stools or diarrhea. Symptoms can overlap with many other digestive conditions, so it is important to talk with your healthcare provider if you have ongoing digestive symptoms.

EPI symptoms can look similar to other digestive conditions, so your healthcare provider may use several pieces of information to determine whether EPI is contributing to your symptoms.

Your evaluation may include:

• Your medical and surgical history
• A discussion of your symptoms and bowel movements
• Your weight and nutritional status
• Blood tests to check for nutritional deficiencies or other problems
• Stool testing  
• Imaging or other tests to evaluate the pancreas

There is no single test that is appropriate for every person. Your healthcare provider can determine which tests are most useful based on your symptoms and medical history.

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What Should You Tell Your Healthcare Team?

Before your appointment, it can be helpful to keep track of:

• Digestive symptoms and how often they occur
• Changes in your bowel movements
• Observation of stools with oil or that float
• Unintentional weight changes
• Foods that seem to worsen symptoms
• All prescription and over-the-counter medications
• Vitamins and supplements
• Your history of pancreatitis, pancreatic surgery, diabetes, cystic fibrosis, or other digestive conditions

The main treatment for EPI is pancreatic enzyme replacement therapy (PERT).

Treatment may also include nutrition support, vitamin supplementation, and treatment of the underlying condition causing EPI.

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What is Pancreatic Enzyme Replacement Therapy (PERT)?  

PERT is a prescription treatment that replaces the digestive enzymes your pancreas is not producing or delivering in sufficient amounts. PERT acts on the meal, not the pancreas, so coordinating PERT with meals is very important.

PERT contains enzymes that help digest:

• Fat
• Protein
• Carbohydrates

PERT works best when it is taken with meals and snacks so the enzymes are present when food enters the small intestine.

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Tips for Taking PERT

• Take PERT with every meal and snack that contains fat, protein, or carbohydrates, as directed by your healthcare provider.
• Follow your prescribed dose and instructions.
• If a meal or snack lasts for a long time, ask your healthcare team how to space your dose during the meal.
• Keep track of your symptoms and bowel movements so you can tell your healthcare provider whether your treatment is working.

Do not change your PERT dose on your own. If you continue to have symptoms despite taking PERT correctly, talk with your healthcare provider. Your dose or timing may need to be adjusted, or another condition may need to be considered.

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How Do You Know If PERT Is Working?

When EPI is adequately treated, you may notice improvements such as:Less bloating/ gas

• Fewer loose or greasy stools
• Less abdominal discomfort
• Improved ability to maintain or gain weight
• Better energy
• Improved nutrient absorption

Treatment response can take time, and symptoms may have more than one cause. Regular follow-up with your healthcare team is important.

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Nutrition and EPI

Eating a balanced, nutrient-rich diet is an important part of managing EPI. Because EPI can affect digestion and nutrient absorption, overly restricting your diet may make it harder to get the calories and nutrients your body needs.

In general:

• Eat regular meals and snacks as tolerated.
• Include a variety of nutrient-rich foods.
• Get adequate calories and protein.
• Do not automatically avoid healthy sources of fat unless your healthcare provider recommends it for another reason.
• Take PERT as prescribed with meals and snacks.
• Work with a registered dietitian or other qualified nutrition professional when additional support is needed.

There is no single diet that works for everyone with EPI. Your nutritional needs may vary based on your underlying pancreatic condition, weight, symptoms, and treatment.

EPI is often a long-term condition, but it can be managed. Managing EPI may involve:

1. Taking PERT correctly and consistently
2. Eating enough calories, protein, fat, and other nutrients
3. Monitoring your weight and nutritional status
4. Checking for vitamin and nutrient deficiencies
5. Treating the underlying pancreatic condition
6. Following up with your healthcare team

It may take some time to find the right combination of enzyme dose, timing, diet, and other treatments. If symptoms continue, let your healthcare team know rather than simply eliminating more foods from your diet.

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EPI is more than a digestive problem. When your body cannot properly digest and absorb food, it can affect your weight, energy, nutrition, and overall health.

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The good news is that EPI can often be managed. Taking PERT correctly, meeting your nutritional needs, monitoring for deficiencies, and staying connected with your healthcare team can help you get the most nutrition from the food you eat.