Exocrine Pancreatic Insufficiency (EPI) Diagnosis

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Exocrine pancreatic insufficiency (EPI) is a rare but serious malabsorptive condition that occurs when the pancreas fails to produce important digestive enzymes. Digestive enzymes include amylase (to break down carbohydrates), protease (to break down proteins), and lipase (to break down fats). Without these enzymes, the body cannot properly digest food and absorb nutrients, particularly fat.

EPI most often occurs in people who have conditions affecting the pancreas such as chronic pancreatitis, celiac disease, diabetes, and cystic fibrosis. Most people don't experience symptoms until the condition has become advanced, as mild forms of EPI may not warrant an immediate visit to a doctor. Additionally, symptoms become more apparent when the pancreas loses its ability to produce essential digestive enzymes.

A thorough medical evaluation by a gastroenterologist (doctor who diagnoses and treats problems in the gastrointestinal tract, or GI) can help rule out GI problems and determine if your symptoms are EPI-related. This may involve certain tests, such as stool, blood, breath analyses, and imaging.

This article will review how a gastroenterologist evaluates someone for EPI.

Female microbiologist using a microscope. Female biochemist working in high-tech lab.

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Self-Checks and At-Home Testing

There are no in-home tests or self-exams able to diagnose EPI. However, knowing the signs and symptoms of EPI—and how to communicate them to your healthcare provider—can increase your chance of a correct diagnosis.

Diagnostic Questions

A diagnosis of EPI is made after other, more common causes of gastrointestinal symptoms have been ruled out, such as Crohn's disease or chronic gastritis. If your healthcare provider suspects you could have EPI, you may be asked questions and undergo tests to confirm a proper diagnosis. Topics may include:

  • Your symptoms: This includes how long you've had them, and if there is anything that makes them better or worse (such as eating a meal or having a bowel movement).
  • Changes in your bowel habits: This includes how often you have a bowel movement, the color, shape, and odor of your stool.
  • Lifestyle habits: This includes how often you drink alcohol and whether you smoke or use other tobacco products.
  • Medications you take: This includes those prescribed by a healthcare provider, purchased over the counter, as well as supplements or herbal remedies.
  • Your diet: This includes the types of food you eat and what you drink, when you usually eat meals, and any food intolerances, sensitivities, or allergies.
  • Weight: This includes any unexplained weight loss you've experienced without intentionally trying.
  • Other medical conditions: This may include any surgeries you've had and your family's medical history.
  • Other topics: These may be exercise, social and work history, and mental health.

Labs and Tests

Common tests that your healthcare provider may perform to determine EPI include:

  • Fecal elastase test (FE-1): This test is done to look for an enzyme called elastase that is released from the pancreas during digestion. Normally, this enzyme will be found in stool. If little or none is found, it can be a sign of EPI. For this test, you will be asked to collect a sample of formed stool (solid) to be sent to a lab. If liquid stool is submitted, the test may not be accurate, as elastase may be more difficult to detect.
  • Fecal fat test: If your stool has too much fat, it is a sign that food is not being broken down and absorbed properly.

The Two Types of Fecal Fat Tests

There are two kinds of fecal fat tests:

  • Qualitative test: This test is typically used as a screening test to look for excess fecal fat. Similar to FE-1, this test involves sending a sample of stool to a lab. The sample is studied under a microscope and the amount of fat is assessed.
  • Quantitative test: If your qualitative test is negative, your healthcare provider may order a quantitative test to better evaluate fat absorption and digestion. In this test, you will be asked to eat a specific amount of fat over three days. After stool samples are collected, the amount of fat that remains will be measured. In this type of test, fat is not released into the stool at a constant rate. So, the results from collecting stool over three days (72 hours) gives a more accurate picture of average absorption and elimination than a single sample.
  • Secretin stimulation test (pancreatic function test): When food enters the duodenum from the stomach, a hormone called secretin is released. A secretin stimulation test checks whether the pancreas has a normal response to secretin. In this test, secretin is given through an intravenous (IV) line, in which the fluid from the duodenum is collected and tested.
  • Breath tests: Some people with EPI will have a condition called small intestinal bacterial overgrowth (SIBO). Your healthcare provider may use a hydrogen breath test to detect SIBO. While the condition has a number of causes, it can also be an indicator of malabsorption (difficulty digesting or absorbing nutrients from food). Other breath tests can also be used, such as those to assess bile salt and carbohydrate metabolism.

Imaging

If you have EPI, your doctor may order computerized tomography scans (CT scans), ultrasounds, and magnetic resonance imaging (MRI) to see inside your abdomen and assess whether your pancreas is visibly damaged, obstructed, or inflamed. While there are a few highly specialized diagnostic imaging tests that can assess pancreatic function, these tests are mostly used to rule out other conditions that could explain a person's symptoms rather than specifically diagnose EPI.

Summary

Knowing the signs and symptoms of EPI—and how to communicate them to your healthcare provider—can increase your chance of getting a correct diagnosis.

A diagnosis of EPI is usually made by a gastroenterologist after more common causes of gastrointestinal symptoms have been ruled out, such as Crohn's disease or chronic gastritis. Several diagnostic tests, including fecal elastase and fecal fat, can be used to determine if an individual has EPI. This can be done by looking for the accumulation of elastase and undigested fats, respectively, which are common effects of EPI.

Alternatively, a gastroenterologist may order diagnostic imaging, such as CT scans, ultrasounds, and MRIs, to rule out other gastrointestinal conditions that resemble EPI.

A Word From Verywell

While EPI is considered rare in the general population, it may also be underdiagnosed, as mild forms of EPI may not warrant an immediate visit to see a doctor. Among those who do seek treatment, they may not be correctly diagnosed with EPI until the condition has become more advanced.

It is important that you see your healthcare provider if you have any symptoms related to EPI so your provider can properly monitor pancreatic function over time. This way, the loss of function of pancreatic enzymes can be detected early and treated accordingly.

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4 Sources
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