What Should I Know About Pancreatic Insufficiency?

Exocrine pancreatic insufficiency, or EPI, is a digestive condition in which your pancreas does not produce enough enzymes to properly break down food. Without adequate enzymes, the body struggles to absorb fat, protein, and key vitamins, leading to digestive symptoms and malnutrition over time. Although EPI is often underdiagnosed, early recognition and treatment can dramatically improve symptoms and your quality of life.

What Is Pancreatic Insufficiency?

Your pancreas plays a critical role in digestion by releasing digestive enzymes (lipase, amylase, and protease) into the small intestine. These enzymes help you to digest fats, carbohydrates, and proteins for absorption.

In EPI, enzyme production or delivery is impaired, so food is only partially digested. Undigested nutrients can lead to malabsorption and diarrhea, bloating, and nutrient deficiencies. EPI is not a problem with your appetite or the food you eat; it’s a problem with absorption.

Common Symptoms of EPI

Symptoms of pancreatic insufficiency often develop gradually and can be mistaken for those of other digestive conditions.

Common signs include:

Chronic diarrhea
Pale, bulky, greasy, or foul-smelling stools (steatorrhea)
Floating stools or oil in the toilet bowl
Bloating and excessive gas
Abdominal discomfort after meals
Unintentional weight loss
Fatigue and weakness
Deficiencies in fat-soluble vitamins (A, D, E, and K)

Because symptoms overlap with those of IBS, celiac disease, and SIBO, EPI may go unrecognised without proper testing.

What Causes Pancreatic Insufficiency?

EPI most commonly develops when pancreatic tissue is damaged or enzyme secretion is disrupted.

Common causes include:

Chronic pancreatitis (most common cause in adults – 8 in 10 adults)
Cystic fibrosis (leading cause in children)
Pancreatic cancer or pancreatic surgery
Surgery on the digestive tract, including weight loss surgery
Severe acute pancreatitis
Long-standing diabetes
Inflammatory bowel disease, especially Crohn’s disease, involves the small intestine
Celiac disease, in severe or untreated cases

Risk increases when pancreatic inflammation or scarring interferes with enzyme production.

How Is EPI Diagnosed?

Diagnosis is based on symptoms, risk factors, and specialised testing.

Faecal Elastase Test

This is the most commonly used test for EPI. A stool sample is analysed to measure elastase, an enzyme produced by the pancreas. Low or no levels can suggest pancreatic insufficiency.

A 72-hour fecal fat test can be used, which measures how much fat is lost in stool

Secretin pancreatic function test

This test is less common. It can be used to test how the pancreas responds to secretin, a hormone that triggers the release of digestive enzymes. For the test, you receive secretin through an intravenous (IV) line. Your doctor uses an endoscopic ultrasound to collect fluid and test it for enzymes.

Imaging tests

Imaging tests like CT, MRI, or endoscopic ultrasound can be used to evaluate pancreatic structure. Note that no single test is perfect, so results are interpreted alongside symptoms and medical history.

Treatment for Pancreatic Insufficiency

Many EPI patients experience malnutrition due to malabsorption. Strategies supporting digestion can assist with optimizing absorption, nutrition, and weight restoration.

1. Pancreatic enzyme replacement therapy (PERT)

The cornerstone of EPI treatment is pancreatic enzyme replacement therapy (PERT). These prescription enzymes contain lipase, amylase, and protease to help digest food. Different brands contain different levels of each enzyme. It is important to work with your doctor and/or dietitian to optimize your PERT regimen.

Enzymes are typically taken with meals and snacks to help your digestion, with doses adjusted based on meal size and fat content. Proper timing is critical for effectiveness.

When taken correctly, PERT can significantly reduce diarrhea, bloating, and weight loss.

2. Nutrition and diet support

Unlike people who have other digestive conditions, people with EPI should not avoid fat entirely. Fat is essential for calories, vitamins, minerals, and nutrient absorption. It is recommended to work with a dietitian to personalize nutrition strategies to ensure adequate energy, protein, and micronutrient intake.

Nutrition strategies often include:

Eating regular meals and snacks
Pairing enzymes with every eating occasion
Ensuring adequate protein and calorie intake
Supplementing fat-soluble vitamins if needed
Working with a dietitian to adjust enzyme dosing

Restricting fat unnecessarily can worsen malnutrition and weight loss.

3. Treating the underlying condition

Managing the condition that caused EPI, such as chronic pancreatitis, celiac disease, or diabetes, is essential to prevent progression and complications. Avoiding smoking and alcohol use can help limit stress on the pancreas.

When to See a Doctor

You should seek a medical evaluation if you have:

Persistent light/tan-colored diarrhea or greasy stools
Unexplained weight loss
Ongoing bloating after meals
A history of pancreatitis, pancreatic or bariatric surgery, or cystic fibrosis

An early diagnosis helps prevent long-term nutritional deficiencies and bone loss.

The Bottom Line

Pancreatic insufficiency is a serious but highly manageable condition. With a proper diagnosis, enzyme therapy, and nutrition support, most people can regain weight, reduce digestive symptoms, and improve overall health. If digestive symptoms persist despite diet changes, testing for EPI may be an important next step.

Credit: WebMD

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