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Exocrine Pancreatic Insufficiency

Table of Contents

Exocrine Pancreatic Insufficiency

EPI

Exocrine pancreatic insufficiency (EPI) is a rare condition that occurs when the intestine can’t digest food completely because of problems with enzymes produced by the pancreas. It can lead to malnutrition. Learn more about EPI, including symptoms, causes, diagnosis, and treatment with pancreatic enzyme replacement therapy (PERT).

Normal pancreas

Image by ChocChocsugarsugar

About

Pancreas

Image by Blausen.com staff. \"Blausen gallery 2014\"

Pancreas

Illustration of anatomy of Human Pancreas

Image by Blausen.com staff. \"Blausen gallery 2014\"

What Is EPI?

Exocrine pancreatic insufficiency (EPI) is a condition in which your small intestine can’t digest food completely because of problems with digestive enzymes from your pancreas. EPI often develops slowly, over many years.

The pancreas is a large gland behind your stomach. The pancreas is both

an endocrine gland that makes hormones
an exocrine gland that makes digestive juice containing enzymes

The pancreas delivers the digestive juice to the small intestine through a single duct. In the small intestine, the enzymes from the pancreas help digest food, breaking down carbohydrates, fats, and proteins.

You may develop EPI if

the amount of enzymes your pancreas makes is severely reduced
not enough enzymes reach your small intestine
other problems prevent the enzymes from mixing with food or otherwise working well

The pancreas is a large gland that makes digestive juice containing enzymes.

Source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Is It Common?

Populations - How Common

Image by geralt/Pixabay

Populations - How Common

Image by geralt/Pixabay

How Common Is EPI?

EPI is rare. However, problems with enzymes from the pancreas occur more often in people with certain health conditions.

Although study results vary, experts think problems with enzymes from the pancreas may occur in

30% to 90% of people with chronic pancreatitis
80% to 90% of people with cystic fibrosis

Less commonly, problems with enzymes in the pancreas may occur in people who have

pancreatic cancer that has not been removed by surgery
type 1 diabetes or type 2 diabetes
inflammatory bowel disease
untreated celiac disease
surgery of the pancreas or upper gastrointestinal tract
Sjogren’s syndrome
a history of smoking or drinking alcohol

Source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

How Does It Affect Nutrition?

What Is Osteoporosis?

Image by TheVisualMD

What Is Osteoporosis?

Osteoporosis is a silent but debilitating disease, in which bone density decreases, leaving the bone weak and prone to fracture.

Image by TheVisualMD

How Does EPI Affect Nutrition?

If you have exocrine pancreatic insufficiency (EPI), your small intestine can’t digest food normally because of problems with enzymes produced by the pancreas. When the small intestine doesn’t digest food as it should, it may not absorb enough nutrients—a condition called malabsorption.

Malabsorption can lead to

malnutrition
low levels of fat-soluble vitamins A, D, E, and K
low bone mass, called osteopenia, and osteoporosis
problems with growth in children

EPI treatment can help correct malabsorption.

Source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Additional Materials (2)

osteoporosis

An illustration depicting osteoporosis.

Image by BruceBlaus

Osteoporosis Locations

Image by BruceBlaus/Wikimedia

osteoporosis

BruceBlaus

Osteoporosis Locations

BruceBlaus/Wikimedia

Risk Factors

Pancreatic Cancer

Image by Scientific Animations, Inc.

Pancreatic Cancer

Image by Scientific Animations, Inc.

Who Is More Likely to Have EPI?

People who have advanced pancreatic diseases are more likely to develop EPI. For example, EPI is more common in people who have

chronic and acute pancreatitis
cystic fibrosis
pancreatic cancer
surgery of the pancreas or upper gastrointestinal tract

Source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Causes

3D Medical Animation still shot of Acute Pancreatitis

Image by Scientific Animations, Inc.

3D Medical Animation still shot of Acute Pancreatitis

3D Medical Animation still shot of pancreas showing acute pancreatitis

Image by Scientific Animations, Inc.

What Causes EPI?

Common causes of EPI include

chronic and acute pancreatitis
cystic fibrosis
pancreatic cancer
surgery of the pancreas or upper gastrointestinal tract

Less common causes of EPI include

diabetes—type 1 and type 2
untreated celiac disease
inflammatory bowel disease, including Crohn’s disease and ulcerative colitis
HIV
rare genetic disorders, such as Shwachman-Diamond syndrome and Johanson-Blizzard syndrome
Zollinger-Ellison syndrome

Source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Symptoms

Abdominal Pain, Pain

Image by derneuemann/Pixabay

Abdominal Pain, Pain

Image by derneuemann/Pixabay

What Are the Symptoms of EPI?

Symptoms of exocrine pancreatic insufficiency (EPI) may include

bloating
cramps, discomfort, or pain in the abdomen
diarrhea
loose, greasy, bad-smelling stools
passing excess gas, or flatulence
weight loss

In rare cases, EPI may lead to problems seeing at night or problems with your bones, such as low bone mass or osteoporosis.

Symptoms of EPI may include cramps, discomfort, or pain in the abdomen.

Source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Diagnosis

Comprehensive Clinical Assessment physical exam

Image by Craig Breil - University of Michigan Medical School Information Services

Comprehensive Clinical Assessment physical exam

Comprehensive Clinical Assessment physical exam

Image by Craig Breil - University of Michigan Medical School Information Services

How Do Doctors Diagnose EPI?

To diagnose exocrine pancreatic insufficiency (EPI), your doctor will ask about your medical and family history, perform a physical exam, and order tests.

Medical and family history

To help diagnose EPI, your doctor will ask about your

symptoms
history of diseases and conditions that may cause EPI
family history of pancreatitis
history of excessive alcohol consumption, which may increase your chance of developing chronic pancreatitis
history of smoking, which may increase your chance of developing pancreatitis and pancreatic cancer

To help diagnose EPI, your doctor will ask about your symptoms and medical and family history.

Physical exam

During a physical exam, your doctor may

examine your body for signs of weight loss or malnutrition
check your abdomen for swelling
listen to sounds within your abdomen using a stethoscope
tap on your abdomen checking for tenderness or pain

Source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

What Tests Are Done?

Stool sample test for fecal occult blood

Image by NIDDK Image Library

Stool sample test for fecal occult blood

Fecal occult blood test.

Image by NIDDK Image Library

What Tests Do Doctors Use to Diagnose EPI?

Doctors most often order stool tests, blood tests, and sometimes pancreatic function tests to diagnose EPI. Doctors may order additional tests to check for diseases that can cause EPI, if the cause is unknown.

Stool tests

Stool elastase test, also called fecal elastase-1 or FE-1 test, is the most commonly used stool test. Low levels of FE-1 in the stool may be a sign of EPI. Your doctor will give you a container for catching and holding a stool sample. You should provide a solid or semisolid stool sample for this test. You will receive instructions on where to send or take the kit for testing.

Blood tests

A health care professional will take a blood sample from you and send the sample to a lab. Doctors may use blood tests to check for low levels of fat-soluble vitamins and minerals or other signs of malnutrition.

Pancreatic function test

Your doctor may order a pancreatic function test to measure how your pancreas responds to secretin, a hormone made by the small intestine. The test measures pancreatic fluid instead of pancreatic enzymes and may not accurately diagnose EPI. This test is done only at some centers in the United States.

During a pancreatic function test, health care professionals give you intravenous (IV) secretin and insert a tube through your nose and into your small intestine. Health care professionals will collect fluid samples with the tube and send the samples to a lab for analysis.

In some cases, doctors use upper gastrointestinal (GI) endoscopy to perform part or all of this test.

Source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Stool Elastase Test

Stool Elastase Test

Also called: Pancreatic Elastase, Fecal Pancreatic Elastase, Fecal Elastase, FE-1

This test measures the amount of elastase in your stool. Elastase is an enzyme made in the pancreas. It helps you digest food. Low amounts of elastase can be a sign of pancreatitis or other pancreatic disorders.

Stool Elastase Test

Also called: Pancreatic Elastase, Fecal Pancreatic Elastase, Fecal Elastase, FE-1

This test measures the amount of elastase in your stool. Elastase is an enzyme made in the pancreas. It helps you digest food. Low amounts of elastase can be a sign of pancreatitis or other pancreatic disorders.

{"label":"Stool Elastase Reference Range","scale":"lin","step":1,"hideunits":false,"units":[{"printSymbol":"ug\/g{feces}","code":"ug\/g{feces}","name":"microgram per gram of feces"}],"items":[{"flag":"abnormal","label":{"short":"Severe pancreatic insufficiency","long":"Severe pancreatic insufficiency","orientation":"horizontal"},"values":{"min":0,"max":100},"text":"A decreased amount of stool elastase indicates severe pancreatic insufficiency. Your provider will probably order more tests to diagnose the cause of the insufficiency.","conditions":["Exocrine pancreatic insufficiency","Chronic pancreatitis","Cystic fibrosis","Shwachman-Diamond syndrome","Post pancreatic surgery","Celiac disease","Diabetes mellitus"]},{"flag":"borderline","label":{"short":"Moderate pancreatic insufficiency","long":"Moderate pancreatic insufficiency","orientation":"horizontal"},"values":{"min":100,"max":200},"text":"A decreased amount of stool elastase indicates moderate pancreatic insufficiency. Your provider will probably order more tests to diagnose the cause of the insufficiency.","conditions":["Exocrine pancreatic insufficiency"]},{"flag":"normal","label":{"short":"Normal","long":"Normal","orientation":"horizontal"},"values":{"min":200,"max":500},"text":"A normal amount of elastase is present in the stool of healthy individuals.","conditions":[]}],"value":350}[{"abnormal":0},{"borderline":0},{"normal":0}]
Use the slider below to see how your results affect your health.
ug/g{feces}
100
200
Your result is Normal.
A normal amount of elastase is present in the stool of healthy individuals.
Related conditions
This test measures the amount of elastase in your stool. Elastase is an enzyme made by special tissue in the pancreas, an organ in your upper abdomen. Elastase helps break down fats, proteins, and carbohydrates after you eat. It's a key part of your digestive process.
In a healthy pancreas, elastase will be passed in the stool. If little or no elastase is found in your stool, it can mean this enzyme isn't working as it should. This is called pancreatic insufficiency. Pancreatic insufficiency can cause a number of health problems, including malabsorption and malnutrition, disorders that affect your ability to digest and take in nutrients from food.
In adults, pancreatic insufficiency is often a sign of chronic pancreatitis. Pancreatitis is an inflammation of the pancreas. Chronic pancreatitis is a long-lasting condition that tends to get worse over time. It can lead to permanent damage of the pancreas. Acute pancreatitis, another form of the disease, is a short-term condition. It is usually diagnosed with blood and/or imaging tests, rather than a stool elastase test.
In children, pancreatic insufficiency can be a sign of:
- Cystic fibrosis, an inherited disease that causes mucus to build up in the lungs, pancreas, and other organs
- Shwachman-Diamond syndrome, a rare, inherited disease that causes problems with the skeletal system, bone marrow, and pancreas
You may need a stool elastase test if you or your child has symptoms of pancreatic insufficiency. These include:
- Abdominal pain
- Smelly, greasy stools
- Malabsorption, a disorder that affects your ability to digest and absorb nutrients from food. It can cause malnutrition, a condition in which your body does not get the calories, vitamins, and/or minerals needed for good health.
- Losing weight without trying. In children, this can delay growth and development.
You will need to provide a stool sample. Your provider or your child's provider will give you specific instructions on how to collect and send in your sample. Your instructions may include the following:
- Put on a pair of rubber or latex gloves.
- Collect and store the stool in a special container given to you by your health care provider or a lab. You may get a device or applicator to help you collect the sample.
- Make sure no urine, toilet water, or toilet paper mixes in with the sample.
- Seal and label the container.
- Remove the gloves, and wash your hands.
- Return the container to your health care provider or the lab by mail or in person.
If your results show a low amount of elastase, it probably means you have pancreatic insufficiency. Your provider will probably order more tests to diagnose the cause of the insufficiency. These tests may include:
- Blood tests to measure levels of pancreatic enzymes
- Imaging tests to look at the pancreas and surrounding organs
Your child's health care provider may order different types of tests to help diagnose cystic fibrosis or Shwachman-Diamond syndrome.
If you have questions about your results, talk to your health care provider.
1. https://medlineplus.gov/lab-tests/stool-elastase/ [accessed on Apr 05, 2019]
2. https://labtestsonline.org/tests/stool-elastase [accessed on Apr 05, 2019]
3. https://www.labcorp.com/test-menu/32666/pancreatic-elastase-fecal [accessed on Apr 05, 2019]
4. https://ltd.aruplab.com/Tests/Pub/0080526 [accessed on Apr 05, 2019]
5. https://www.childrensmn.org/references/lab/urinestool/pancreatic-elastase-stool.pdf [accessed on Apr 05, 2019]
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5301368/ [accessed on Apr 05, 2019]

Normal reference ranges can vary depending on the laboratory and the method used for testing. You must use the range supplied by the laboratory that performed your test to evaluate whether your results are "within normal limits."

Pancreatic Function Test

Pancreatic Function Test

Also called: PFT, Secretin Stimulation, Secretin Endoscopic Pancreatic Function Test (ePFT)

This test measures how your pancreas responds to secretin, a hormone made by the small intestine when partially digested food is present. When secretin is given to you during this test, certain chemicals may be increased in your blood. This is measured during the test. This test is done to check the digestive function of the pancreas.

Pancreatic Function Test

Also called: PFT, Secretin Stimulation, Secretin Endoscopic Pancreatic Function Test (ePFT)

This test measures how your pancreas responds to secretin, a hormone made by the small intestine when partially digested food is present. When secretin is given to you during this test, certain chemicals may be increased in your blood. This is measured during the test. This test is done to check the digestive function of the pancreas.

{"label":"Pancreatic Function Test Reference Range","scale":"lin","step":1,"hideunits":false,"units":[{"printSymbol":"pg\/mL","code":"pg\/mL","name":"picogram per milliliter"}],"items":[{"flag":"abnormal","label":{"short":"Low","long":"Low","orientation":"horizontal"},"values":{"min":0,"max":12},"text":"Abnormal values may mean that the pancreas is not working properly.","conditions":["Achlorhydria","Pernicious anemia"]},{"flag":"normal","label":{"short":"Normal","long":"Normal","orientation":"horizontal"},"values":{"min":12,"max":75},"text":"Normal value ranges may vary slightly depending on the lab doing the test. Talk to your provider about the meaning of your specific test results.","conditions":[]},{"flag":"abnormal","label":{"short":"High","long":"High","orientation":"horizontal"},"values":{"min":75,"max":200},"text":"Abnormal values may mean that the pancreas is not working properly.","conditions":["Chronic pancreatitis","Duodenal ulcer","Exocrine pancreatic insufficiency","Zollinger-Ellison syndrome"]}],"value":44}[{"abnormal":0},{"normal":0},{"abnormal":0}]
Use the slider below to see how your results affect your health.
pg/mL
12
75
Your result is Normal.
Normal value ranges may vary slightly depending on the lab doing the test. Talk to your provider about the meaning of your specific test results.
Related conditions
1. Diagnosis of Pancreatitis - NIDDK. National Institute of Diabetes and Digestive and Kidney Diseases. Aug 4, 2023 [accessed on Aug 04, 2023]
2. Secretin stimulation test: MedlinePlus Medical Encyclopedia Image [accessed on Aug 04, 2023]
3. Mansour A Parsi. Update on endoscopic pancreatic function testing. World Journal of Gastroenterology : WJG. Aug 4, 2023. doi:10.3748/wjg.v17.i35.3957 [accessed on Aug 04, 2023]
4. Secretin Stimulation | Labcorp [accessed on Aug 04, 2023]
5. Quest Diagnostics: Test Directory [accessed on Aug 04, 2023]

Normal reference ranges can vary depending on the laboratory and the method used for testing. You must use the range supplied by the laboratory that performed your test to evaluate whether your results are "within normal limits."

Treatment

Pancreatic enzymes (medication)

Image by BarbariSka88/Wikimedia

Pancreatic enzymes (medication)

Pancreatin

Image by BarbariSka88/Wikimedia

How Do Doctors Treat EPI?

Doctors treat exocrine pancreatic insufficiency (EPI) with pancreatic enzyme replacement therapy (PERT) and lifestyle changes.

Doctors may recommend additional treatments for the diseases or conditions that cause EPI.

PERT

To treat EPI, doctors typically prescribe PERT. PERT involves taking pills that contain pancreatic enzymes. PERT can improve your symptoms and help you get enough nutrients from what you eat and drink.

PERT is taken during meals or snacks to help your small intestine with digestion. Follow your doctor’s instructions about how and when to take PERT.

Taking PERT during meals or snacks can help your body with digestion.

Lifestyle changes

Lifestyle changes can also help treat EPI. Your doctor may recommend you

avoid alcohol
make changes to eating, diet, and nutrition
quit smoking

Source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

What Are Complications?

Myocardial infarction

Image by TheVisualMD

Myocardial infarction

Heart attack (myocardial infarction) is a condition when blood flow to the heart is reduced or blocked. Heart cells die when the blood supply is cut off; the longer the blood supply is cut off, the greater the area of heart damage.

Image by TheVisualMD

What Are the Complications of EPI?

In EPI, the small intestine doesn’t digest food as it should and may not absorb enough nutrients—a condition called malabsorption. EPI and malabsorption can lead to complications such as

malnutrition
low levels of fat-soluble vitamins A, D, E, and K in the body
low bone mass, called osteopenia, and osteoporosis
problems with growth in children
weakness of the immune system
increased risk of cardiovascular events, such as heart attack and stroke

Source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

How Are Complications Prevented?

Cross Sections of Normal Bone and Osteoporosis bone

Image by TheVisualMD

Cross Sections of Normal Bone and Osteoporosis bone

N-Telopeptide Test for Bone Loss : N-telopeptide is a specific fragment of the bone protein called type 1 collagen (C-telopeptide is a related fragment). Levels of this protein in the bloodstream (or urine) reflect the rate of bone resorption, or bone loss. Bone is living tissue that is constantly being broken down and replaced. Bone consists of a protein network that is mineralized, mainly by calcium phosphate, and this provides bone with a framework of tremendous tensile strength. When bones lose minerals and mass, the result is osteopenia; further loss of bone density leads to osteoporosis, in which bones become weak, brittle and prone to fracture. Fifty percent of women and 25% of men will break a bone after age 50 due to osteoporosis.

Image by TheVisualMD

How Do Doctors Prevent and Treat Complications of EPI?

If you have EPI, your doctor may order tests to check for complications, such as

malnutrition
low levels of fat-soluble vitamins A, D, E, and K
low bone mass

Doctors may recommend you take dietary supplements of fat-soluble vitamins or other nutrients to help prevent or treat these complications.

For safety reasons, talk with your doctor before using dietary supplements, such as vitamins, or any complementary or alternative medicines or medical practices.

Source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Living With

CA19.9

Image by TheVisualMD

CA19.9

Cancer antigen 19.9 (CA 19.0) is a protein that is shed by pancreatic cancer cells. Existing research indicates that a high percentage of patients with pancreatic cancer - about 70% - will have elevated levels of the protein detectable in their bloodstream. While studies suggest CA19.9 may be a useful marker for pancreatic tumors, the test is not considered diagnostically reliable.

Image by TheVisualMD

What Should I Eat If I Have EPI?

Your doctor may refer you to a registered dietitian to help you create a healthy meal plan. Check on the cost of a dietitian’s services and whether your health insurance may pay for some or all of these services.

Your doctor or dietitian may recommend changes to eating and nutrition, such as

eating small, frequent meals
taking pancreatic enzyme replacement therapy (PERT) when you eat
taking dietary supplements for low levels of fat-soluble vitamins or other nutrients
avoiding alcohol and quitting smoking

Your doctor or dietitian may recommend additional changes to eating, diet, and nutrition to treat the cause of EPI.

Your doctor or dietitian may recommend you eat small, frequent meals.

Source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

Related HealthJournals

Pancreatic Diseases

Pancreatic diseases include pancreatitis, pancreatic cancer, and cystic fibrosis. The pancreas also plays a role in type 1 and type 2 diabetes.

Johanson-Blizzard Syndrome

Johanson-Blizzard syndrome (JBS) is an extremely rare genetic disorder that affects multiple organ systems of the body.

Pancreatic Cancer

Pancreatic cancer is a disease in which cancer cells form in the tissues of the pancreas. It is hard to catch early, as it doesn't cause symptoms right away. Learn more about the diagnosis, treatment, and prognosis for pancreatic cancer.

Pancreatic Neuroendocrine Tumors

A pancreatic neuroendocrine tumor, also called an islet cell tumor, is a type of neuroendocrine tumor (NET) that typically arises in the pancreas. However in some cases, a pancreatic NET occurs outside of the pancreas. Learn about risk factors, tests, treatment, and more.

Pancreatic Islets

An islet cell is a pancreatic cell that produces hormones (e.g., insulin and glucagon) that are secreted into the bloodstream. These hormones help control the level of glucose (sugar) in the blood. Also called endocrine pancreas cell and islet of Langerhans cell.

Pancreas

The pancreas is a long slender organ that lies behind your stomach. The pancreas produces a variety of enzymes to help break down the carbohydrates, proteins, and fats in your diet. It also produces hormones, such as insulin, that help regulate a variety of body functions, including blood sugar. Learn more about the role of the pancreas.

Digestion and Absorption

As you have learned, the process of mechanical digestion is relatively simple. It involves the physical breakdown of food but does not alter its chemical makeup. Chemical digestion, on the other...

Cystic Fibrosis

Cystic fibrosis (CF) is an inherited disorder that causes mucus to build up and damage organs in the body, particularly the lungs and pancreas. Cystic fibrosis is a common genetic disease within the white population in the United States, occurring in 1 in 2,500 to 3,500 white newborns. Learn more about the causes, symptoms, and treatment options.

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Exocrine Pancreatic Insufficiency

Exocrine pancreatic insufficiency (EPI) is a rare condition that occurs when the intestine can’t digest food completely because of problems with enzymes produced by the pancreas. It can lead to malnutrition. Learn more about EPI, including symptoms, causes, diagnosis, and treatment with pancreatic enzyme replacement therapy (PERT).

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