woman with exocrine pancreatic insufficiency symptoms

This Sh*t Matters! What Your Poop Is Telling You about Your Health

Article Highlights
  • Exocrine Pancreatic Insufficiency (EPI) is a condition that occurs when you don’t have enough digestive enzymes in your pancreas to break down nutrients and digest food properly.
  • People with diabetes are at a higher risk for EPI, although the exact reasons aren’t known.
  • Exocrine pancreatic insufficiency symptoms include GI issues like diarrhea, fatty stools (stools that look oily and float), flatulence, bloating, and abdominal pain.
  • Taking digestive enzymes in pill form at each meal and making nutritional changes to your diet can provide significant relief.

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Did you know the pancreas does more than produce insulin? Most of us are familiar with the endocrine dysfunctions of the pancreas which can cause abnormal insulin production, but a lesser known (though equally important) function of the pancreas is its exocrine function. 

The exocrine cells of the pancreas make digestive enzymes that help break down nutrients (mainly fats) that we eat. When there aren’t enough enzymes to do the job, it can lead to a condition called exocrine pancreatic insufficiency.

This article explains the details of this disease and discusses exocrine pancreatic insufficiency treatment options.

What Is Exocrine Pancreatic Insufficiency?

Exocrine Pancreatic Insufficiency (EPI) occurs when your pancreas doesn’t produce enough enzymes on its own to digest food. 

Digestive enzymes and alkaline (bicarbonate) rich fluids are released by the exocrine pancreas into the small intestine to help us absorb nutrients and vitamins. 

In people with EPI, the pancreas does not produce enough of these enzymes, leading to difficulty digesting food.

Exocrine Pancreatic Insufficiency Causes

Any condition that leads to the deficiency of the exocrine pancreatic function and the reduction of key enzymes can cause EPI.

Chronic pancreatitis is the most common cause of EPI in adults. Studies suggest between 30% and 90% of people with chronic pancreatitis develop EPI.

The Main Causes of EPI Include:

  • Chronic or recurrent pancreatitis in adults, typically from long-term overindulgence in alcohol, or from very high triglycerides
  • Type 3c diabetes (pancreatogenic diabetes), a condition that occurs when the pancreas is damaged
  • Cystic Fibrosis in children

Other Causes of EPI Include:

Why Are People with Diabetes at a Higher Risk for EPI?

An exact reason why people with diabetes are at a higher risk for EPI is unclear. There are hypotheses about scarring from endocrine pancreas burnout and an increase in inflammation leading to EPI. Moreover, the small blood vessel diseases that people with diabetes develop (like retinopathy, nephropathy, and neuropathy), could also happen in the exocrine pancreas, resulting in EPI. Additionally, autoantibodies against certain exocrine enzymes have been observed in up to 39% of people with type 1 diabetes and 0.9% of people with type 2 diabetes.

How Common is Exocrine Pancreatic Insufficiency?

The exact prevalence is unknown, but in people who are diagnosed with chronic pancreatitis, 60-90% can get EPI within 10-12 years of the diagnosis. Around 66-92% of people with advanced pancreatic cancer can get EPI. 

In contrast, EPI prevalence in people with type 1 and type 2 diabetes is much lower. Some studies have shown that in type 1 diabetes, 10% to 30% had severe EPI and 22% to 56% had moderate EPI. The EPI prevalence in type 2 diabetes is more variable and wider, between 5% to 46%.

Exocrine Pancreatic Insufficiency Symptoms

A question healthcare providers often get is “What are the first signs of exocrine pancreatic insufficiency?” We explore the answer below. 

Since it’s hard to break down fats and proteins into smaller, digestible particles without the key exocrine enzymes, people with the condition can experience the following exocrine pancreatic insufficiency symptoms:

  • Loose stools
  • Fatty stools/steatorrhea (stools look oily and float)
  • Flatulence
  • Bloating
  • Abdominal pain
  • Malnutrition
  • Nausea/vomiting
  • Weight loss
  • Vitamin A, D, E, K deficiency (these vitamins are “fat-soluble” and need fats to be absorbed)

Some people have clear GI symptoms, but others may have milder exocrine pancreatic insufficiency symptoms.

According to Dr. Edelman, “EPI is frequently underdiagnosed because the symptoms are so common with other gastrointestinal conditions, which unfortunately leads people to be undertreated.”

How Is Exocrine Pancreatic Insufficiency Diagnosed?

If you have all (or most) of the symptoms listed above without any other identifiable cause, and you have risk factors like diabetes that could predispose you to EPI, you should speak to your healthcare provider. 

A stool test called fecal elastase-1 (FE-1) and a 72-hour fecal fat excretion test have had mixed results in large studies, but, if there is a very high suspicion for EPI with severe symptoms, a fecal elastase-1 may be a valuable and a cost-effective test, with levels less than 200 micrograms/gram indicating possible EPI, and levels well under 100 mcg/g strongly indicative of EPI.

Since some people with type 1 diabetes could have celiac disease, and people with type 2 diabetes are often taking metformin and GLP-1-agonist medications that can cause gastrointestinal symptoms, these confounders should be excluded before giving a diagnosis of EPI. 

Metformin and GLP-1s can cause diarrhea, so they could be stopped for a few weeks to see if symptoms improve or dissipate, but do not stop any medications without speaking with your doctor first.

Exocrine Pancreatic Insufficiency Treatment

Treatment of EPI involves the following:

  • Replacing pancreatic exocrine enzymes (taking a pill made of pancreas enzymes at each meal)
  • Nutritional counseling on low-fat, high-fiber foods
  • Smoking and alcohol cessation
  • Replacing fat-soluble vitamins A, D, E, and K

For people with diabetes and EPI, pancreatic enzyme replacement has been shown to improve glycemic control and insulin sensitivity.

What Foods to Avoid with EPI

While individual dietary needs can vary, here are some foods that are generally best avoided or limited with EPI:

  • High-fat foods like fatty meats, fried foods, and high-fat dairy
  • Processed and sugary foods like candy, pastries, and sugary sodas
  • High-fiber foods like raw broccoli, cauliflower, and kale
  • Whole grains like quinoa and brown rice
  • Legumes like lentils and black beans
  • Alcohol

Processed and deep-fried foods often contain hydrogenated oils that can be harder to digest. Consuming too much fiber and alcohol can disrupt the functioning of the digestive enzymes, which can worsen EPI symptoms. Eating larger meals can make it harder for the pancreas to secrete enough enzymes to adequately break down food, so eating smaller meals throughout the day is often recommended.

foods to avoid with EPI

Preventative Measures and Lifestyle Recommendations

To reduce the risk of developing EPI and manage its impact on diabetes, consider the following recommendations:

  • Quit smoking

  • Limit alcohol consumption

  • Maintain a healthy weight

  • See your doctor for regular medical check ups

lifestyle tips to manage EPI

Key Takeaways

EPI is characterized by inadequate production of digestive enzymes by the pancreas, leading to difficulties digesting food and absorbing nutrients. 

People with diabetes, particularly type 1, are at an increased risk of developing EPI. 

Some healthcare providers may not know about the connection between diabetes and EPI, so talk to your doctor about being screened if you’re experiencing exocrine pancreatic insufficiency symptoms, such as GI issues.

Managing diabetes and EPI requires a coordinated approach involving enzyme replacement therapy, nutritional support, blood sugar management, and regular checkups. By taking proactive steps to manage both conditions, you can optimize your health and quality of life.

Check out the TCOYD® Video Vault for more diabetes management resources.

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