This transcript has been edited for clarity.
I'm Dr David Whitcomb, a physician scientist who has dedicated his career to studying the pancreas. It is my privilege to talk to you today about exocrine pancreatic insufficiency [EPI]. This is a disorder caused by failure of the pancreas to deliver a minimum level of specific pancreatic digestive enzymes into the intestine, leading to the maldigestion of micro- and macronutrients, resulting in their deficiencies and large impacts on health.
Underdiagnosis is a problem because the patients may not only have unexpected weight loss, but have deficiencies in key fat-soluble D vitamins and vitamin B12.
Also, maldigestion gives unpleasant symptoms, such as abdominal pain, bloating, steatorrhea, and diarrhea. Obviously, these symptoms overlap with other digestive diseases, such as celiac disease, IBD, IBS, bile acid malabsorption, and others.
Another problem is overdiagnosis when the diagnosis is based on symptoms alone or a false-positive human fecal elastase test when it's taken on a liquid stool.
Greater awareness of these problems and insights is needed, but the good news is that treatment is available.
Diagnosis of EPI is most accurate when there is a high pretest probability; this is in suspected high-risk conditions such as chronic pancreatitis, recurrent acute pancreatitis, pancreatic ductal adenocarcinoma — especially in the head of the pancreas — cystic fibrosis, and previous pancreatic surgery.
It's also considered in moderate-risk [causes], including duodenal diseases such as celiac disease, Crohn's disease, Zollinger-Ellison syndrome, dumping syndromes or bypass surgery, or other types of pancreatic disease, such as severe long-standing diabetes mellitus.
The fecal elastase is the best test we have. It's not perfect, but it is the one that we recommend using first. It must be collected in a stool, and the stool must be solid or semi-solid. When the value comes back at less than 100 micrograms per gram of stool, that supports the diagnosis of EPI. If it's between 100 and 200, it's indeterminate and should be repeated. And if it's greater than 200, then EPI is unlikely.
Other diagnostic tests are available, such as fecal fat testing, diagnostic trial of PERT [pancreatic enzyme replacement therapy], breath test, direct testing with an endoscope, or abdominal imaging, but these are not accurate and they're not recommended.
Another challenge in assessing EPI is the huge interpatient variability. We recognize that the real goal is adequate nutrition, and this requires the assessment of nutritional needs, the diet, and the nutritional intake of the patient; the actual pancreatic function, recognizing that there's usually a physiologic reserve but it disappears with age; intestinal absorption capacity; and adaptation to the loss of pancreatic enzymes. In many cases, the intestine can adapt to reduced protein digestion, but it cannot adapt to loss of the lipases.
Treatment is the good news. With severe EPI, PERT is essential. The dose should be 400 to 500 USP units of lipase per meal, and half with a snack, unless it is a sugar snack; then PERT is not needed.
With moderate EPI, PERT may be helpful, but it should be included with a modified diet, such as an easy-to-digest diet and multiple small meals.
Multiple vitamins and antioxidants are very important, and they can minimize deficiencies. One needs to track the patient's weight and levels of fat-soluble vitamin in the blood.
Ruling out celiac disease is important because it often coexists with pancreatic disease and the symptoms are similar, but it will not respond to PERT. It responds to a gluten-free diet.
Also, in pancreatitis, if there is EPI and diabetes, which is common, PERT may improve early digestion and absorption of nutrients to correspond with the antidiabetic treatment so that they are synchronized. And, of course, PERT should be used in patients with cancer.
In conclusion, EPI is a potentially serious impediment to essential nutrition and the digestion and absorption of these important components. EPI symptoms are important, but they cannot be used alone to diagnose EPI or to guide treatment. PERT is highly effective in treating severe EPI and it may be useful in moderate EPI when managing other disorders such as diabetes.
I'm Dr David Whitcomb. Thank you for your attention and interest in learning about EPI symptoms, diagnosis, and treatment.
COMMENTARY
Diagnosis and Management of Exocrine Pancreatic Insufficiency
David C. Whitcomb, MD, PhD
DISCLOSURES
| November 19, 2024This transcript has been edited for clarity.
I'm Dr David Whitcomb, a physician scientist who has dedicated his career to studying the pancreas. It is my privilege to talk to you today about exocrine pancreatic insufficiency [EPI]. This is a disorder caused by failure of the pancreas to deliver a minimum level of specific pancreatic digestive enzymes into the intestine, leading to the maldigestion of micro- and macronutrients, resulting in their deficiencies and large impacts on health.
Underdiagnosis is a problem because the patients may not only have unexpected weight loss, but have deficiencies in key fat-soluble D vitamins and vitamin B12.
Also, maldigestion gives unpleasant symptoms, such as abdominal pain, bloating, steatorrhea, and diarrhea. Obviously, these symptoms overlap with other digestive diseases, such as celiac disease, IBD, IBS, bile acid malabsorption, and others.
Another problem is overdiagnosis when the diagnosis is based on symptoms alone or a false-positive human fecal elastase test when it's taken on a liquid stool.
Greater awareness of these problems and insights is needed, but the good news is that treatment is available.
Diagnosis of EPI is most accurate when there is a high pretest probability; this is in suspected high-risk conditions such as chronic pancreatitis, recurrent acute pancreatitis, pancreatic ductal adenocarcinoma — especially in the head of the pancreas — cystic fibrosis, and previous pancreatic surgery.
It's also considered in moderate-risk [causes], including duodenal diseases such as celiac disease, Crohn's disease, Zollinger-Ellison syndrome, dumping syndromes or bypass surgery, or other types of pancreatic disease, such as severe long-standing diabetes mellitus.
The fecal elastase is the best test we have. It's not perfect, but it is the one that we recommend using first. It must be collected in a stool, and the stool must be solid or semi-solid. When the value comes back at less than 100 micrograms per gram of stool, that supports the diagnosis of EPI. If it's between 100 and 200, it's indeterminate and should be repeated. And if it's greater than 200, then EPI is unlikely.
Other diagnostic tests are available, such as fecal fat testing, diagnostic trial of PERT [pancreatic enzyme replacement therapy], breath test, direct testing with an endoscope, or abdominal imaging, but these are not accurate and they're not recommended.
Another challenge in assessing EPI is the huge interpatient variability. We recognize that the real goal is adequate nutrition, and this requires the assessment of nutritional needs, the diet, and the nutritional intake of the patient; the actual pancreatic function, recognizing that there's usually a physiologic reserve but it disappears with age; intestinal absorption capacity; and adaptation to the loss of pancreatic enzymes. In many cases, the intestine can adapt to reduced protein digestion, but it cannot adapt to loss of the lipases.
Treatment is the good news. With severe EPI, PERT is essential. The dose should be 400 to 500 USP units of lipase per meal, and half with a snack, unless it is a sugar snack; then PERT is not needed.
With moderate EPI, PERT may be helpful, but it should be included with a modified diet, such as an easy-to-digest diet and multiple small meals.
Multiple vitamins and antioxidants are very important, and they can minimize deficiencies. One needs to track the patient's weight and levels of fat-soluble vitamin in the blood.
Ruling out celiac disease is important because it often coexists with pancreatic disease and the symptoms are similar, but it will not respond to PERT. It responds to a gluten-free diet.
Also, in pancreatitis, if there is EPI and diabetes, which is common, PERT may improve early digestion and absorption of nutrients to correspond with the antidiabetic treatment so that they are synchronized. And, of course, PERT should be used in patients with cancer.
In conclusion, EPI is a potentially serious impediment to essential nutrition and the digestion and absorption of these important components. EPI symptoms are important, but they cannot be used alone to diagnose EPI or to guide treatment. PERT is highly effective in treating severe EPI and it may be useful in moderate EPI when managing other disorders such as diabetes.
I'm Dr David Whitcomb. Thank you for your attention and interest in learning about EPI symptoms, diagnosis, and treatment.
Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
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