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What Is Exocrine Pancreatic Insufficiency?

Medically Reviewed by Neha Pathak, MD on September 17, 2021

Exocrine pancreatic insufficiency (EPI) causes problems in how you digest food. Your pancreas doesn't make enough of the enzymes that your body needs to break down and absorb nutrients.

Enzymes speed up chemical reactions in your body. The enzymes made by your pancreas move into your small intestine, where they help break down the food you eat.

When you have EPI, you don't get the nutrition you need because your body can't absorb fats and some vitamins and minerals from foods. You might lose weight or have pain in your belly.

There are drugs that work for most people that give you a new supply of enzymes, so you can go back to digesting food the right way.

Besides taking medicine, you can manage your symptoms by making sure you follow the right diet. Your doctor will recommend foods that will help you get enough nutrients and protein that you might be missing.

What Causes EPI?

Damage to your pancreas causes EPI. There are many reasons this can happen but some of the most common are:

Your pancreas gets inflamed often. Doctors call this chronic pancreatitis. It happens when the enzymes made by the pancreas start working while they're still inside it, before they get to the small intestine. You're at risk for this if you're a heavy drinker, though there can be other causes as well. For instance, your pancreas could get inflamed if some passageways in it are blocked or if you have very high levels of triglycerides (a type of blood fat) or an immune system disorder.

You've had surgery on your pancreas, stomach, or intestines.

You have one of these inherited diseases:

If you have cystic fibrosis, your body makes unusually thick and sticky mucus. This mucus blocks passageways in your pancreas and stops enzymes from getting out.

If you have Shwachman-Diamond syndrome, you may be missing cells in your pancreas that make enzymes.

Crohn’s disease and celiac disease can also lead to EPI in some people.

What Are the Symptoms of EPI?

You may not have any symptoms at first. But once your pancreas gets so damaged that it starts to hurt your ability to absorb fat, you may get some symptoms, such as:

  • Pain or tenderness in your belly
  • Bad-smelling bowel movements
  • Diarrhea
  • Gas
  • Feeling full

You might also lose weight and get other problems, because your body doesn’t absorb enough vitamins. For instance, you could develop a bleeding disorder if you're not getting enough vitamin K. Or you could get bone pain if you don't get enough vitamin D.

How Is EPI Diagnosed?

Your doctor may diagnose your condition by checking your symptoms. They may ask you questions such as:

  • Do you have pain in your upper belly?
  • Have you had bad-smelling bowel movements that are oily and hard to flush down the toilet?
  • Do you have gas or diarrhea?
  • Have you lost weight?

Several tests can help diagnose EPI. First, you may need some blood tests that check to see if you're getting enough vitamins and that your pancreas is making enough enzymes. Other blood tests can check for things that can lead to EPI, like celiac disease.

You may also need to take the "3-day fecal test." It checks for the amount of fat in your bowel movements. You'll need to collect samples of your stool in special containers for 3 days.

Your doctor may also ask you to take a test called "fecal elastase-1." For this, you also need to collect a sample of your bowel movement in a container. It will be sent to a lab to look for an enzyme that's important in digestion. The test can tell you if your pancreas is making enough of it.

You may also need to get some tests that check to see if your pancreas is inflamed, including:

  • CT scan. This uses a powerful X-ray to make detailed pictures inside your body.
  • MRI. It uses strong magnets and radio waves to make pictures of organs and structures inside your body.
  • Endoscopic ultrasound. This test uses sound waves to take pictures inside your digestive system. The sound waves are sent out by a thin tube that your doctor places through your mouth into your digestive system.

Questions for Your Doctor

When you find out you've got EPI, you'll probably have a lot of questions. You may want to start by asking your doctor:

  • What treatments do you recommend?
  • Do I need to follow a special diet?
  • Are there vitamins I should take?
  • Can I drink alcohol?
  • What can I do if I'm losing weight?

How Is EPI Treated?

Apart from a healthy diet, the main treatment for EPI is pancreatic enzyme replacement therapy (PERT). You take prescription pills that replace the enzymes your pancreas isn't making.

These enzymes break down your food so you can more easily digest and absorb it. You have to take them during your meals. If you take them before you eat, the replacement enzymes may move through your stomach before your food gets there. If you take the pills after you eat, you have the opposite problem.

You may also need to take an antacid to keep your stomach from breaking down pancreatic enzymes before they can start to work.

There are six FDA-approved pancreatic enzyme products that are only available by prescription:

  • Creon
  • Pancreaze
  • Pertzye
  • Ultresa
  • Viokace
  • Zenpep

If your doctor prescribes this medication, take it at the start of meals or before you eat snacks, along with a liquid like water. Don't dissolve the pill in a liquid like milk or take it with any over-the-counter stomach acid medicine that has calcium or magnesium. These products can break down the coating and enzymes in your pills.

The amount you take depends on your body weight. You'll start with the lowest possible dosage and take more if you need it.

You may also take drugs to lower stomach acid along with your PERT. Your doctor can prescribe these, and they're also available over the counter:

  • Proton pump inhibitors like esomeprazole or omeprazole
  • H2 blockers like cimetidine, famotidine, or ranitidine

You may also need medicine to treat pain. If your doctor says it's okay, you may take over-the-counter pain medicines such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) on occasion. If those don't bring you relief, your doctor may prescribe stronger pain drugs, such as hydrocodone and oxycodone. Keep in mind that ibuprofen may lead to internal bleeding in the digestive tract and that drugs such as hydrocodone and oxycodone should be used with caution because of addiction potential.

Emotional stress can also trigger pancreas inflammation. Tricyclic antidepressants like amitriptyline or nortriptyline may help ease pain. Gabapentin (Gralise, Neurontin), a drug that helps control seizures, can also help fight EPI pain. Pregabalin (Lyrica), which is used to treat seizures and nerve pain, also shows promise.

How to Treat Conditions That Cause EPI

You also can treat the health problem that causes your EPI, like cystic fibrosis, Shwachman-Diamond syndrome, or chronic pancreatitis.

Cystic fibrosis. Treatments include enzyme replacement therapy, antibiotics, laxatives, and enemas. You can also eat a high-calorie, high-fat diet or take supplements to get the nutrition you need.

If you have cystic fibrosis and EPI, you may also get diabetes. Keep your blood sugar levels under control, and take insulin or other medications if your doctor prescribes them.

Shwachman-Diamond syndrome. Your doctor may prescribe PERTs, a high-fat and high-calorie diet, and vitamins and supplements. Scientists are also working to see if stem cell transplants will treat this genetic disease.

Chronic pancreatitis. If you have alcoholic pancreatitis, it's important to stop drinking. You may need to enter a treatment program or work with a counselor to stop. If you smoke, stop. If there are stones blocking your ducts, the doctor can remove them. If you have a systemic illness like lupus or cystic fibrosis, treatment for the underlying condition may help the chronic pancreatitis.

Is Surgery an Option?

Surgery can open ducts that are clogged or blocked by gallstones, and decompression can widen a main pancreatic duct that's too narrow.

Another option is to remove your pancreas and give you an autologous islet cell transplant. These are cells from your own body that make insulin. The doctor will get them into your body through a vein in your liver.

This surgery can ease severe chronic pancreatitis pain or prevent or ease diabetes caused by chronic pancreatitis. But it's only used if other treatments haven't worked.

If other treatments fail, the doctor might remove a portion of your pancreas, but this is usually a last resort.

Taking Care of Yourself

The right diet is very important for managing EPI. A dietitian can help you choose the foods that keep your energy level up and give you the nutrition you need. Here are a few tips:

  • Eat six small meals per day. Try that instead of the traditional three. A big meal might not be appealing if you have digestion troubles from EPI.
  • Don't drink or smoke. Alcohol can make it even harder for your body to absorb fat, and can damage your pancreas over time. Alcoholism is one possible cause of EPI. Smoking can lead to calcium buildup in your pancreas.
  • Take vitamins. You may need to take vitamins A, D, E, and K to replace ones that aren't getting absorbed from your diet. EPI makes it hard for you to get the right nutrients because your body can't break down your foods. You also probably don't take in enough fats. Your doctor can prescribe vitamin supplements to help you get the right levels of these nutrients. They can also tell you which over-the-counter supplements and what dosage to take.

What to Expect

You can manage the symptoms of EPI by taking enzyme replacements and following an eating plan that gives you the right nutrition. Make sure you get the advice of a dietitian or nutritionist. One of your big challenges is to make sure you don't lose weight. A nutritionist can help you choose foods that have enough protein and nutrients.

Also, talk with your family and friends to get the support you need while you're getting treatment. Ask your doctor about support groups, which let you talk to others who are going through the same things you are.

Getting Support

You can find more information about pancreas problems by visiting the web site of the National Pancreas Foundation.

You can also learn more by visiting the web sites of the Cystic Fibrosis Foundation and the Shwachman-Diamond Syndrome Foundation.

Show Sources

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