6 Exocrine Pancreatic Insufficiency Symptoms That Can Cause GI Trouble

When you develop funky digestive symptoms like diarrhea or stomach pain, it’s easy to give the side-eye to more commonly discussed gastrointestinal (GI) conditions like irritable bowel syndrome or celiac disease. And for good reason: For most people dealing with these types of symptoms, there’s usually a well-known explanation behind them.

But exocrine pancreatic insufficiency (EPI) can be a sneaky force that wreaks havoc on your GI tract—it’s just usually underdiagnosed. Never heard of EPI before? You’re not alone. Exocrine pancreatic insufficiency doesn’t get as much airplay as other GI issues, but it can still cause plenty of misery when you’re on the quest for answers. 

It’s important to note that EPI is relatively uncommon and is still being studied, but it is worth being aware of it if you’re going through a lot of stomach distress and other, more common GI conditions have been ruled out by your doctor. Here’s what you need to know about the condition, plus common signs your stomach-related woes might be pointing to EPI.

Exocrine pancreatic insufficiency develops when your pancreas doesn’t make enough digestive enzymes or those enzymes don’t do their job efficiently, according to the Cleveland Clinic. Your pancreas, in case you’re not familiar with it, is an organ in your abdomen that contains glands that release substances to aid digestion and to control your blood sugar.

Those digestive enzymes are responsible for breaking down the food you eat, so your body can shuttle vital nutrients to where they’re needed. But when the different systems in your body aren’t getting the vitamins and minerals they need to do their jobs, you can understandably start to feel pretty crummy.

There are different types of pancreatic enzymes that EPI can impact, the Cleveland Clinic says, and each one has its own unique duties. The key players include:

• Amylase, to help you digest carbs
• Lipase, to help you digest fats
• Protease and elastase, to help you digest proteins

Here’s the thing that makes EPI slightly different from other, more well-known GI disorders: It’s almost always sparked by another health issue. Exocrine pancreatic insufficiency is most often caused by chronic pancreatitis, which is ongoing inflammation of the pancreas. But there’s a long list of other health conditions that can eventually lead to the co-diagnosis of EPI, including cystic fibrosis, pancreatic tumors, diabetes, celiac disease, inflammatory bowel disease, bariatric surgery, and HIV/AIDs.¹

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EPI isn’t just a lesser-known condition than some of its other GI counterparts—it’s also underdiagnosed, meaning it can take a while for someone with the condition to get a proper diagnosis, and therefore, a proper treatment plan². In fact, there isn’t even concrete data available on how often EPI is diagnosed.

One 2019 review of research published in the journal Clinical and Experimental Gastroenterology³ does have a breakdown of how often EPI is estimated to occur in the context of other health conditions:

• Chronic pancreatitis: up to 90% of cases
• Pancreatic cancer: up to 60% of cases
• Cystic fibrosis: up to 90% of cases
• Type 1 diabetes: up to 50% of cases
• Type 2 diabetes: up to 30% of cases
• Celiac disease: up to 80% of cases
• HIV: up to 50% of cases

Lea Ann Chen, MD, assistant professor of medicine and director of the Inflammatory Bowel Disease Translational Research at the Rutgers Robert Wood Johnson Medical School, tells SELF there are “many reasons” why EPI is underdiagnosed. “EPI symptoms are nonspecific and overlap with other more common GI diagnoses,” she explains. “Also, the tests to evaluate for EPI are very specific, so it is unlikely to be diagnosed incidentally.”

That means your doctor would specifically need to suspect that you have EPI and order the appropriate tests to verify it versus accidentally stumbling upon a diagnosis while testing you for other conditions—and they likely would not do that specific testing unless you had one of the above conditions associated with a higher risk of EPI or red flag symptoms, like unexplained weight loss or nutrient deficiencies (which we’ll explain more in-depth below). “For patients whose EPI is mild or is not caused by chronic pancreatitis, the condition can be missed,” Dr. Chen says.

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Because the signs and symptoms of EPI can overlap with those of other GI conditions, you can imagine they’re not exactly fun to deal with. “If EPI is untreated, the symptoms can be extremely uncomfortable,” Mohamed Othman, MD, professor of medicine - gastroenterology at Baylor College of Medicine, tells SELF. However, there are a few tip-offs that you may be dealing with EPI symptoms compared to those of another health condition².

Diarrhea is a common issue that is usually caused by something you ate, a stomach bug, or a more serious condition like inflammatory bowel disease, according to the National Institute of Diabetes and Digestive and Kidney Diseases. 

However, diarrhea is also an issue in people with untreated or under-treated EPI, Dr. Othman says, and there are a few reasons for this. One is that the food you’re eating doesn’t get properly absorbed in your gastrointestinal tract. This allows the bacteria that naturally hang out in your gut to ferment that undigested food, he says. At the same time, water collects around it which can make your stool more liquidy.

There’s also this to consider: That undigested food can include fat, Amy Tyberg, MD, a professor of gastroenterology at Rutgers Robert Wood Johnson Medical School, tells SELF. “The fat subsequently stays in the GI tract and acts as a laxative as it travels through the intestines,” she says. Cue the constant diarrhea.

EPI can also lead to fatty poops, which are literally bowel movements that have a higher fat content than usual. Medically known as steatorrhea⁴, these poops are often paler than usual, oily, and smellier than you might be used to, per the Cleveland Clinic. “It’s a result of the lack of absorption of fat in the intestines,” Philip Hart, MD, a gastroenterologist at the Ohio State University Wexner Medical Center, tells SELF.

So if your body has difficulty absorbing fat in your diet due to EPI, it simply comes out in your stool. Heads up: You might also see fat or oil droplets in your poop or an oily residue floating on top of the toilet water after you go, Dr. Othman says.

When your body can’t break down nutrients in the food you eat, you can’t properly absorb them—and that can cause you to lose weight without trying, Dr. Othman says. Diarrhea caused by EPI can also lead to weight loss if it’s constant.

This tends to be a more indirect symptom. EPI can cause excessive gas and bloating due to digestion issues, so your stomach may not feel great as a result. Your body’s difficulty absorbing fat can be a major reason for this symptom, Dr. Hart says.

Also, remember that EPI is usually something that develops due to chronic pancreatitis. Upper abdominal pain is common with this condition, along with stomach tenderness, per the Mayo Clinic.

This might be a little harder for you to detect than, say, diarrhea or fatty poop, but your doctor may pick up a nutrient deficiency if they order blood work due to other symptoms you’re experiencing.

“Because pancreatic enzymes help one digest food and nutrients, EPI can result in malabsorption of vitamins, specifically fat-soluble vitamins,” Nuzhat Ahmad, MD, interim chief of gastroenterology at the Perelman School of Medicine at the University of Pennsylvania, tells SELF. Some of the biggies to be aware of include vitamins A, D, E, and K, although you can also develop deficiencies of calcium, folic acid, thiamine, magnesium, and zinc, Dr. Ahmad says. Symptoms of these deficiencies can vary by the vitamin or mineral, but Dr. Othman says you just might not feel like your body is working as well as it normally should (like something is “off”) if you’re lacking an essential nutrient.

In the early stages, you may not notice this symptom at all. But if your body has difficulty absorbing vitamins, bone density issues may become a problem if you’re low in vitamin D specifically, Dr. Tyberg says. That can lead to complications like osteoporosis², a condition that causes bones to become weak and brittle, which may eventually cause symptoms like bones that seem to fracture or break easily, back pain, or a stooped posture, per the Mayo Clinic.

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The most common treatment for exocrine pancreatic insufficiency is pancreatic enzyme replacement therapy (PERT). This is a prescription oral medication that helps replace your body’s lack of digestive enzymes, according to the Cleveland Clinic.

Here’s how it works: Your doctor will recommend a certain amount of PERT based on the results of your lab work. Once you have your prescription, you take PERT with meals to help your body break down the nutrients in the food you eat. “I generally recommend that my patients have a full dose of pancreatic enzymes at the beginning of a meal,” Dr. Hart says. “It’s simple that way.”

While taking PERT should help you regain any weight you may have lost, your doctor may also recommend that you eat more calories and fat to bridge any other gaps in the meantime, the Cleveland Clinic says. You may also need to take certain supplements to help compensate for possible nutritional deficiencies, which your doctor can help you identify.

Whether you’ve been diagnosed with EPI or you suspect you might have EPI, Dr. Hart recommends having honest and constant communication with your doctor about your symptoms. “Many patients do not feel comfortable discussing GI-related symptoms with their health care providers, but it’s important,” he says. “EPI is highly treatable and manageable. We’re a team and we’ll work together.”

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Sources:

1. StatPearls, Pancreatic Insufficiency
2. F1OOO Research, Update on the Diagnosis and Management of Exocrine Pancreatic Insufficiency
3. Clinical and Experimental Gastroenterology, Exocrine Pancreatic Insufficiency: Prevalence, Diagnosis, and Management
4. StatPearls, Steatorrhea

Related:

• 10 Protein Deficiency Symptoms to Be Aware Of
• I’m Pooping Blood—Do I Need to See a Doctor?
• What It Could Mean If You Have Stomach Cramps After Eating