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Your Undiagnosed Digestive Disorder Could Be Exocrine Pancreatic Insufficiency (EPI)

Many people with exocrine pancreatic insufficiency (EPI) suffer from smelly diarrhea for many years, oftentimes after eating fatty foods. People with EPI can also lose weight unexpectedly. And dealing with this chronic condition can also lead to mental health problems. Sadly, EPI is often overlooked or misdiagnosed, but it’s easy to treat.

Aravind Sugumar, MD, a gastroenterologist with Banner Health, explained more about the condition, what causes it and how to treat it.

What is exocrine pancreatic insufficiency?

Your pancreas has two main functions:

  • The endocrine function regulates your blood sugar.
  • The exocrine function helps in digesting, primarily with fats. 

With EPI, the exocrine function doesn’t work properly, so you lose the ability to digest fats. The fat passes through your digestive system and causes diarrhea.

What causes EPI? 

Certain diseases and conditions can cause EPI:

  • Chronic pancreatitis
  • Celiac disease
  • Diabetes
  • Cystic fibrosis (CF)
  • Inflammatory bowel disease (IBD)
  • Weight-loss surgery (bariatric surgery)
  • Pancreatic or gastrointestinal surgery
  • Shwachman-Diamond syndrome

In a small number of people, the cause of EPI is unknown.

“The most common cause is the destruction of the pancreas through alcohol or tobacco use,” Dr. Sugumar said. “Smoking and drinking are prime contributors, and when you do both together, it multiplies your risk.”

What are the symptoms?

The top symptom is oily diarrhea. “Unfortunately, doctors don’t always delve into the subtype of diarrhea, and people suffer in silence until someone asks and they say, ‘This diarrhea is different.’” The diarrhea is often worse after you eat greasy or fatty foods. 

It’s also usually foul-smelling. “Many times, a spouse will complain of the smell without me asking any leading questions. That’s an important clue that it could be EPI,” Dr. Sugumar said.

People with EPI may also notice unexplained weight loss since so much of the fat they eat passes through their system undigested.

EPI can lead to deficiencies in the fat-soluble vitamins—vitamins A, D, E and K. Vitamin D deficiencies can lead to bone density loss. “Untreated, these deficiencies can lead to night blindness and affect your quality of life.,” Dr. Sugumar said. 

“Not all diarrhea is the same,” he said. Tell your doctor if you have signs of oily diarrhea, such as:

  • A sheen on the water in the toilet after you have diarrhea
  • Soft stools that float
  • Stools or diarrhea that remain in the toilet after you flush

How is it diagnosed?

There are two ways your doctor can test for EPI:

  • Fecal elastase test. You provide a stool sample that can be evaluated for signs of EPI. It doesn’t require any prep and it’s relatively accurate. 
  • 48-hour fecal fat collection test. You follow a 100-gram fat diet for five days. On the fourth and fifth days, you collect stool samples for evaluation to see how much fat wasn’t absorbed. Most people who don’t have EPI will absorb about 90 grams of fat, so there will be 10 grams or less of fat in their stool samples. “With EPI, we can see 30, 40, 50 or 60 grams of fat in the stool,” Dr. Sugumar said. “It’s a harder test, but it’s the gold standard.” Your doctor might recommend this test if the results from a fecal elastase test don’t show for sure whether you have EPI or not.

There’s also a test called the pancreatic function test, where your doctor stimulates your pancreas and collects some fluids to see if they are abnormal. But it’s rarely done anymore since the other tests get good results less invasively.

Can it be prevented or treated?

In many cases, you can prevent EPI. You can quit smoking and reduce or eliminate the amount of alcohol you drink to keep from developing the condition.

To treat EPI, you need to know what’s causing it. “Going after the cause is more important than treating the symptoms,” Dr. Sugumar said. Controlling another health condition can help manage EPI. For example, if you have celiac disease, following a gluten-free diet can help reverse EPI. People with diabetes, especially type 1 diabetes, are prone to EPI, and managing diabetes well can help control EPI symptoms.

If weight loss, pancreatic or gastrointestinal surgery caused the condition, you can take pancreatic enzyme supplements to replace the enzymes that aid in digestion. 

“With the right diagnosis, people see a huge response within a week. It’s easily and effectively treated,” Dr. Sugumar said. “Unfortunately, people go five to eight years on average before they get the proper treatment.”

The bottom line

Exocrine pancreatic insufficiency, which causes oily, smelly diarrhea and vitamin deficiencies, is often overlooked or misdiagnosed. On average, people with the condition go five to eight years before getting an accurate diagnosis. But once it’s diagnosed, it’s easy to treat, and people usually feel better within a week. 

Need help diagnosing and treating unexplained diarrhea or any other gastrointestinal condition?

Schedule an appointment with a gastroenterologist.

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