How to diagnose exocrine pancreatic insufficiency

Many people with exocrine pancreatic insufficiency don’t know they have it. Find out how this digestive disease can be diagnosed and treated.

Exocrine pancreatic insufficiency is a rare and relatively unknown digestive disorder caused by a decreased amount of pancreatic digestive juices — important enzymes needed to break down foods so the body can get the nutrients it needs. In exocrine pancreatic insufficiency, not enough of these essential juices get from the pancreas to the small intestine, and malnutrition and other health problems may develop.

“Actual information about people with exocrine pancreatic insufficiency isn’t well known,” says John Affronti, MD, a gastroenterologist at Loyola University Health System and a professor of medicine at the Stritch School of Medicine in Chicago. “According to Medicare statistics, the condition leads to 122,000 emergency department visits and 56,000 hospital visits per year, but it’s believed that these estimates are low, and the number of people with this condition is probably much higher.”

Symptoms of Exocrine Pancreatic Insufficiency

One of the main consequences of exocrine pancreatic insufficiency is the body’s inability to break down the fat in foods. This results in fatty stools, a symptom called steatorrhea. Fatty stools are oily, pale, bulky, smelly, and may be hard to flush because they float or stick to the toilet. Other symptoms include:

• Abdominal discomfort with gas or bloating
• Muscle cramps
• Bone pain
• Easy skin bruising or bleeding
• Night blindness
• Weight loss

How Exocrine Pancreatic Insufficiency Is Diagnosed

Symptoms of exocrine pancreatic insufficiency can range from very mild to severe. However, there currently aren’t reliable, non-invasive pancreatic tests that can determine mild to moderate pancreatic insufficiency. “Findings in lab tests can come back negative even if exocrine pancreatic insufficiency is present,” Dr. Affronti says. An X-ray or computerized tomography (CT) scan may help, and a fecal fat test can be effective, although it requires large stool samples.

These tests are commonly used to help diagnose exocrine pancreatic insufficiency:

• A fecal fat test involves looking at a stool sample under a microscope. A stool sample can also be checked to see if the pancreatic enzymes trypsin and elastase are in the intestine as they should be.
• Blood tests can measure trypsinogen, the pancreatic enzyme that converts to trypsin.
• An endoscopic retrograde cholangio-pancreatography (ERCP) is a test that uses a flexible telescope inserted through the mouth and passed down through the stomach to take pictures of the pancreas and look for damage to it. A biopsy of the pancreas may be taken during ERCP to be used for additional testing.

Treatment for Exocrine Pancreatic Insufficiency

According to a review of the treatment options for exocrine pancreatic insufficiency published in the American Journal of Gastroenterology, treatment needs to be individually tailored because the condition can be caused by so many different diseases and circumstances that can damage the pancreas and keep it from functioning properly.

“Pancreatic surgery, diabetes, cystic fibrosis, autoimmune disorders, pancreatitis, inflammatory bowel diseases such as Crohn’s disease, and other digestive diseases can all cause pancreatic insufficiency,” Affronti says.

Treatment options your doctor may suggest include:

• Taking pancreatic digestive enzyme medications, which is usually the most effective form of treatment.
• Following a very low-fat diet.
• Taking antioxidants, such as vitamins A, E, and C, as well as dietary supplements like methionine, selenium, and grape seed extract, which may help prevent further damage to the pancreas.

In particular, people with pancreatitis as the cause of exocrine pancreatic insufficiency need to take pancreatic enzyme replacements and supplements for vitamins A, D, E, and K, Affronti says.

If you’re diagnosed with exocrine pancreatic insufficiency, work closely with your doctor to find the best treatment for you.

What Is EPI?

Like other rare conditions, exocrine pancreatic insufficiency (EPI) is often difficult to diagnosis, especially if you’re only experiencing mild to moderate symptoms.

Keep reading to learn more about the diagnosis process and what tests you can expect.

How Is EPI Diagnosed?

Diagnosing EPI will likely begin with your doctor performing a physical examination and asking about your medical history. Your medical history will provide important clues for diagnosing EPI. For example, EPI is more common in those who’ve had digestive tract surgery or have a history of pancreatic disease. Your doctor will also ask questions about your family’s medical history.

Your doctor will also try to rule out other conditions that can cause similar symptoms such as:

If you have symptoms of severe EPI, such as fatty, oily stools, unexplained diarrhea and weight loss, some doctors may diagnose you based on your physical exam and medical history alone. More likely, you’ll also undergo specific diagnostic tests to help your doctor identify any underlying condition that’s causing your EPI, such as pancreatitis or pancreatic cancer.

Imaging Tests

CT Scans

CT scans are a special type of X-ray used to examine soft tissue for damage or abnormalities, such as masses and tumors.

Endoscopic Ultrasound

In this test a probe is inserted into your mouth, down your esophagus, and into your stomach, until the probe reaches the first part of your small intestine. It provides a detailed image of the pancreas and lets your doctor look for pancreatitis, pancreatic tumors, and cysts.

If more information is needed about the appearance of your pancreas, your doctor may use an MRI instead of a CT scan to look for pancreatic cancer.

Abdominal X-ray

An X-ray may be used to look for damage in the pancreas.

Pancreatic Function Tests

In addition to imaging tests, you can also expect to undergo laboratory tests that measure the functionality of your pancreas.

Stool Tests

Fat in the stool is one of the first signs of EPI. This can be measured or looked for under a microscope.

The Van de Kamer test measures the amount of fat in the stool and is considered one of the most sensitive ways to diagnose EPI. However, the test is difficult to complete because it requires collecting stool samples for three days and keeping strict measurements of your fat intake. The test is challenging to do and the large volume of stool samples makes it unpleasant for the patient and laboratory staff. Because of this, doctors rarely use it.

A test called fecal elastase is widely used for EPI. It measures levels of the enzyme elastase in a person’s stool, which people with EPI have in smaller amounts. While it’s easy to use, it’s only reliable for detecting moderate to severe EPI.

Breath Test

A breath test is the most reliable and practical way to diagnose moderate EPI. This test involves eating a meal with a special chemical signature in it. After you digest the meal and breathe out an air sample, the chemicals in the air are measured to see how much of the signature remains. The amount of the signature that you exhale is related to how well your pancreas is working.

The breath test is also the only test that can measure the success of therapy to replace your pancreatic enzymes. However, this test is not yet widely available due to its expense.

Secretin Test

While the secretin test is a direct measurement of how well your pancreas is working, it requires inserting a tube into the small intestine. Since it’s so invasive, it’s rarely used compared to other tests.

Blood Tests

Your doctor can order a blood test to determine nutrient shortages or signs of malnutrition caused by EPI.

The Takeaway

If you have symptoms of EPI it’s important that you talk with your doctor. Diagnosing EPI and any underlying conditions as early as possible will help improve your quality of life and prevent further complications.

Last medically reviewed on February 3, 2016

Pancreatic insufficiency is a condition in which the pancreas is not able to produce and/or transport enough digestive enzymes to break down food in the intestine. This condition is also known as exocrine pancreatic insufficiency or EPI.

The pancreas is a narrow, flat gland about six inches long located deep in your abdominal cavity, behind the stomach and below the liver. It has head, middle, and tail sections. Its head section connects to the first part of the small intestine (duodenum).

• Inside the pancreas, small ducts (tubes) feed digestive enzymes and bicarbonate produced by the pancreas into the pancreatic duct. This large duct carries the digestive enzymes and bicarbonate down the length of the pancreas, from the tail to the head section, and into the duodenum.
• The common bile duct also runs through the head section of the pancreas, carrying bile from the liver and gallbladder into the small intestine.
• The bile duct and pancreatic duct usually join just before entering the duodenum and share a common opening into the small intestine.

The pancreas consists of two kinds of tissues that perform different functions:

• The exocrine pancreas makes, stores and releases powerful enzymes to digest fats, proteins, and carbohydrates in the small intestine. The enzymes normally are produced and carried in an inactive form to the small intestine, where the enzymes are activated as needed. Exocrine tissues also make and release bicarbonate that neutralizes stomach acids and allows for the activation of pancreatic enzymes.
• The endocrine pancreas produces hormones, including insulin and glucagon, and releases them into the blood. These hormones regulate sugar (glucose) transport into the body’s cells, where it is used for energy and to help maintain normal blood sugar levels.

In adults, pancreatic insufficiency typically occurs as a result of ongoing (progressive) pancreatic damage that may be caused by repeated bouts of acute pancreatitis or by chronic pancreatitis due to a variety of conditions.

In children, it is most frequently associated with cystic fibrosis (CF) or Shwachman-Diamond Syndrome (SDS). SDS is the second most common cause of inherited pancreatic insufficiency, after CF. All those with SDS have some degree of pancreatic insufficiency that begins when they are infants.

People with the following conditions may also develop EPI:

Zollinger-Ellison syndrome is a rare condition caused by a tumor of the pancreas that stimulates the cells of the stomach to release excess acid. This excess acid may cause temporary pancreatic insufficiency. Once the excess acid is treated, the pancreatic insufficiency usually goes away.

Some surgical procedures that affect the function of the digestive tract or the pancreas can lead to EPI.

The most common signs and symptoms of exocrine pancreatic insufficiency include:

• Frequent gas and/or abdominal bloating
• Abdominal pain, cramps (the pain is sometimes referred to as “epigastric” because it occurs in the upper middle part of the abdomen)
• Unexplained weight loss (inability to gain weight in children)
• Fatigue (tiredness)
• Frequent diarrhea
• Greasy, foul-smelling stools that sometimes float

People with EPI may experience malabsorption, malnutrition and vitamin deficiencies. Laboratory evaluation is often necessary to diagnose pancreatic insufficiency because symptoms may not be evident or may be similar to those of other digestive tract disorders.

Laboratory tests that may be used to detect pancreatic insufficiency include:

• Stool elastase—this test measures the level of elastase (an enzyme made by the pancreas) in a sample of your stool. The amount of this enzyme is reduced in pancreatic insufficiency. This test is more effective at detecting moderate to severe EPI than milder cases.
• Chymotrypsin—this test measures chymotrypsin (a pancreatic enzyme that breaks down proteins) in your stool. With EPI, chymotrypsin is absent in the stool.
• Immunoreactive trypsinogen (IRT)—this is a blood test that measures trypsinogen, an inactive precursor produced by the pancreas that is converted to the enzyme trypsin. Trypsin is the pancreatic enzyme that digests proteins. IRT may be elevated with pancreatitis, which may cause EPI.
• Fecal fat (fat in the stool)—this test detects excess fat in your stool, often the first sign of EPI. Because the stool elastase test (see above) is easier to perform, it has largely replaced this test.
• 13 C-mixed triglyceride breath test—this is a newer method of diagnosing moderate pancreatic insufficiency, but it is not widely used and not commonly available. The test may also be used to evaluate the effectiveness of enzyme therapy on fat digestion in people with EPI.

Non-laboratory tests used in diagnosing pancreatic insufficiency may include:

• Computed tomography (CT) scan: can be used to detect inflammation or scarring of the pancreas
• Endoscopic retrograde cholangiopancreatography (ERCP): an endoscope (a hollow tube) is guided through your mouth, down your throat and stomach to your small intestine. A smaller tube (catheter) is inserted through the endoscope to inject contrast dye into the pancreatic and bile ducts. Abdominal x-rays are taken to examine the pancreas, gallbladder, and the ducts that carry digestive enzymes from those organs to the small intestine. ERCP can be used look for blockages or damage to the ducts.
• Magnetic resonance cholangiopancreatography (MRCP): a specific type of magnetic resonance imaging (MRI) that uses powerful magnets and radio waves to create images of the pancreas, pancreatic duct, and bile ducts. It is often used before or instead of ERCP to look for abnormalities in the pancreas because it is faster and non-invasive. It is also useful in distinguishing pancreatitis from pancreatic cancer.
• Ultrasound: may be used to create and send images of your pancreas to a video monitor. An endoscopic ultra sound is an exam that involves a thin, flexible tube that is used to view inside the digestive tract and is more accurate than an abdominal ultrasound.

For more on imaging studies, see RadiologyInfo.org.

Management of pancreatic insufficiency may include:

• Taking enzyme supplements (pancreatic enzyme replacement therapy, PERT) to replace the enzymes your pancreas isn’t making any more
• Eating a healthy, balanced diet; you might need guidance from a nutritionist to create a diet that meets your needs.
• Taking vitamin supplements (especially vitamins A, D, E, and K) if needed
• Making lifestyle changes, such not drinking alcohol and not smoking

Treatment of EPI also involves managing or resolving the underlying cause when possible.

In Shwachman-Diamond Syndrome (SDS), unlike in cystic fibrosis, production of pancreatic lipase (an enzyme that digests fats) often increases with age. The reasons for this are not yet known, but about 50% of children with SDS will experience improvements in pancreatic function and fat absorption as they get older and will no longer require enzyme replacement therapy.

For more information on other, less common conditions involving the pancreas, see Genetic and Rare Diseases Information Center.

Exocrine pancreatic insufficiency, also known as EPI, is a serious condition. Fortunately, it’s easy for your vet to detect EPI and once detected, it’s relatively easy to treat so your dog can return to normal health.

How EPI Affects Your Dog

Your dog’s pancreas is responsible for producing insulin that helps regulate sugar levels. In addition to being responsible for the production of insulin, the pancreas also plays a critical role in producing enzymes to aid in digestion. When the pancreas does not produce the correct amount of digestive enzymes, this leads to EPI, which affects your dog’s gastrointestinal system.

Cause of EPI

There are three main causes of Exocrine Pancreatic Insufficiency including:

• Pancreatic Acinar Atrophy: Pancreatic Acinar Atrphic, PAA, is the most common cause of EPI.
• Chronic Pancreatitis: If your dog has chronic pancreatitis, this can become EPI. When this happens it is especially dangerous because many pet owners continue to treat the pancreatitis without realizing the disease has advanced into the more severe EPI.
• Congenital hypoplasia: Congenital hypoplasia is when your dog was born without a fully functional pancreas.

Exocrine Pancreatic Insufficiency Symptoms

There are several symptoms you may notice in a dog with EPI including:

• Chronic diarrhea: The stool will be a light yellow or clay collar and have poor consistency
• Increased appetite: Your dog will appear to be hungry all the time. Your dog is not digesting properly, and his body will not detect a ‘full’ feeling. You may notice him even eating unusual things including plants and dirt.
• Weight loss: When your dog has EPI, regardless of how much he eats, his body is essentially starving. The food your dog does consume passes through the body without absorbing the proper nutrients necessary for survival.
• Frequent emission of gas
• Coprophagia (eating their feces)

These signs and symptoms may be apparent immediately or appear gradually.

Diagnosing EPI

To diagnose EPI, the veterinarian may run the following tests:

• Serum sample: Measures levels of Trypsinogen (TPI) in the serum of your dog’s body; a dog will have reduced amount of TPI if EPI is present.
• Blood sample: The complete blood count (CBC) will be analyzed.
• Urinalysis: Urine analysis, as well as blood samples, are often taken to rule out any additional conditions your dog may have.
• Feces analysis: The feces provide the veterinarian with a significant amount of information regarding diagnosis of EPI. The feces will show large amounts of undigested fats due to the enzymes necessary for digestion being limited or nonexistent.

EPI Treatment

There is no cure for Exocrine Pancreatic Insufficiency at this time; however, there is a treatment available which will allow your dog to return to a normal life. The treatment of EPI often includes the recommendation of an enzyme replacement. The enzyme replacement often comes as a powder to be mixed with your dog’s food at each meal. The enzymes provided to your dog will allow his body to begin to digest the food he is consuming. You will notice your dog begins to ‘get full’ once again and his skin and coat health will improve. There may be additional treatments necessary if there are any other medical conditions found. Other treatments include:

• A low fat, low fiber diet is also often recommended. This diet is easier for your dog to digest while recovering from this condition once on the supplements. You may think the low fat, low fiber diet would result in him still feeling hungry but you will notice your dog becoming satisfied once again with what he is eating.
• Antacids: The antacids will reduce the pH level in the stomach.
• Antimicrobials: Your vet may consider this option if your dog does not respond well to enzyme supplementation. The antimicrobial is introduced in addition to providing the enzyme supplement.

Dogs who have been diagnosed with EPI should never be fed high-fat or high-fiber diets. Fat and fiber is difficult to digest and may result in digestive problems in your dog.

Breeds Prone to Developing EPI

German Shepherds and Rough-Coated Collies are known to develop Endocrine Pancreatic Insufficiency more than other dog breeds. Research has often found young adult dogs are most prone to developing this condition.

EPI Requires Ongoing Treatment

Dogs with EPI can begin to lead a normal life following treatment. However, this is a condition which will require ongoing treatment and observation. Preventing it is difficult as it may occur at any age. However, if you know your female dog has Exocrine Pancreatic Insufficiency you should not allow her to have puppies. Monitoring your dog to ensure you ‘catch’ the condition early is also critical to ensure optimal health and quick recovery for your dog.

Affiliations

• 1 Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy, [email protected]
• 2 Digestive and Liver Disease Unit, Sant’Andrea Hospital, Sapienza University, Rome, Italy.

• PMID: 30962702
• PMCID: PMC6432881
• DOI: 10.2147/CEG.S168266

Free PMC article

Authors

Affiliations

• 1 Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy, [email protected]
• 2 Digestive and Liver Disease Unit, Sant’Andrea Hospital, Sapienza University, Rome, Italy.

• PMID: 30962702
• PMCID: PMC6432881
• DOI: 10.2147/CEG.S168266

Abstract

Exocrine pancreatic insufficiency (EPI) is a condition caused by reduced or inappropriate secretion or activity of pancreatic juice and its digestive enzymes, pancreatic lipase in particular. EPI can result in clinical manifestation and biochemical alterations causing reduced quality of life and life-threating complications. EPI is common in pancreatic disorders, where it should be suspected and actively investigated, and in many extrapancreatic conditions. There are various tests available to diagnose EPI, with indirect, noninvasive ones, such as concentration of fecal elastase being more commonly employed. Administration of pancreatic enzymes replacement therapy remains the mainstay of EPI treatment. The present review article will discuss current evidence regarding the prevalence of EPI, the available tests to diagnose it and its treatment.

Keywords: chronic pancreatitis; diagnosis; elastase; exocrine pancreatic insufficiency; malnutrition; pancreatic cancer; therapy.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Exocrine pancreatic insufficiency (EPI) is a condition characterized by deficiency of the exocrine pancreatic enzymes, resulting in the inability to digest food properly, or maldigestion.

Who gets EPI?

EPI is associated with certain diseases and conditions that affect the pancreas. Some of these diseases you are born with, like cystic fibrosis, while others may occur later in life, as is the case with chronic pancreatitis.

EPI may be associated with chronic pancreatitis and cystic fibrosis. If you have one of these conditions and symptoms of EPI, we recommend that you talk to your doctor.

Chronic Pancreatitis

Chronic pancreatitis (CP) is the most common cause of EPI in adults. Over the course of years the inflammation can lead to irreversible damage to the pancreas, including the cells that secrete pancreatic digestive enzymes and the cells that produce insulin leading to diabetes.

Cystic fibrosis

Cystic fibrosis (CF) is an inherited genetic condition that leads to chronic disease that mainly affects the lungs and digestive and reproductive systems. In patients with CF, a thick, sticky mucus is produced in certain organs throughout the body, most commonly in the lungs and digestive system, including the pancreas. Many people living with CF are unable to properly digest food because they may also have EPI.

Diagnosing EPI

If you have exocrine pancreatic insufficiency (EPI), your body cannot properly digest fats, proteins, and carbohydrates in the food you eat. In addition to preventing adequate digestion, EPI produces uncomfortable gastrointestinal (GI) symptoms.

Only your doctor can tell if your GI symptoms are due to EPI or another digestive condition. That is why it is so important to talk to your doctor about your medical history and all of your medications including all vitamins and supplements you take. And make sure to open up and share all of your symptoms at your next visit.

Living with EPI

Getting nutrition from food

The food you eat contains 3 main nutrients—fat, protein, and carbohydrates. Your body uses these nutrients to help give you energy to function.

FAT is found in foods like nuts and cheese.

PROTEIN comes from foods like meat, poultry and fish.

CARBOHYDRATES can be found in bread and pasta. Carbohydrates are broken down into sugars.

If you have EPI, your pancreas cannot properly break down foods, resulting in poor digestion of nutrients—especially fats. Eating healthy is important for all of us. But it’s especially important that people with EPI eat a nutrient-rich diet—along with taking pancreatic enzyme replacement therapy with every meal and snack—since EPI interferes with nutrient absorption.

If you have been diagnosed with EPI, you should work with your doctor or nutritionist to make sure that all your dietary needs are being met.

Pancreatic enzyme replacement therapies

Your doctor may start you on a prescription treatment called pancreatic enzyme replacement therapy, or PERT. PERTs are the main treatment for EPI—they replace the digestive enzymes that your pancreas isn’t producing anymore. When taken with food, PERTs help break down the nutrients in food.

Vitamins and supplements

If you have exocrine pancreatic insufficiency (EPI), your body may not absorb the nutrients from the food you eat. Your doctor may prescribe vitamin and mineral supplements to help you maintain proper levels of the fat-soluble vitamins A, D, E, and K.

Eating healthy with EPI and cystic fibrosis (CF)

A high-calorie diet with adequate amounts of fat is especially important to help patients with CF grow, develop, and thrive. Patients with CF should work with their dietitian or nutritionist to make sure their proper nutrition needs are met.

Ano ang EPI?

Tulad ng iba pang mga bihirang kondisyon, madalas na mahirap diagnosis ang exocrine pancreatic insufficiency (lalo na kung nakakaranas ka lamang ng mild to moderate symptoms).

Panatilihin ang pagbabasa upang matuto nang higit pa tungkol sa proseso ng pagsusuri at kung anong mga pagsubok ang maaari mong asahan.

Paano Nasuri ang EPI? Maaaring magsimula ang diagnosis ng EPI sa iyong doktor na gumaganap ng isang pisikal na eksaminasyon at nagtatanong tungkol sa iyong medikal na kasaysayan. Ang iyong medikal na kasaysayan ay magbibigay ng mahalagang mga pahiwatig para sa pag-diagnose ng EPI. Halimbawa, ang EPI ay mas karaniwan sa mga taong nagkaroon ng digestive tract surgery o may kasaysayan ng pancreatic disease. Ang iyong doktor ay magtatanong din tungkol sa kasaysayan ng iyong pamilya.

Susubukan din ng iyong doktor na maiwasan ang iba pang mga kondisyon na maaaring maging sanhi ng mga katulad na sintomas tulad ng:

• irritable bowel syndrome
• pancreatic cancer
• Crohn’s disease > ulcerative colitis
• Kung mayroon kang mga sintomas ng malubhang EPI, tulad ng mataba, matitigas na dumi, hindi maipaliwanag na pagtatae at pagbaba ng timbang, ang ilang mga doktor ay maaaring magpatingin sa iyo batay sa iyong pisikal na eksaminasyon at medikal na kasaysayan lamang. Mas malamang, magkakaroon ka rin ng mga tukoy na diagnostic na pagsusulit upang matulungan ang iyong doktor na makilala ang anumang nakapailalim na kondisyon na nagiging sanhi ng iyong EPI, tulad ng pancreatitis o pancreatic cancer.

Ang CT scan ay isang espesyal na uri ng X-ray na ginagamit upang suriin ang soft tissue para sa pinsala o abnormalidad, tulad ng mga masa at mga tumor.

Endoscopic Ultrasound

Sa pagsusulit na ito isang pagsisiyasat ay ipinasok sa iyong bibig, pababa sa iyong esophagus, at sa iyong tiyan, hanggang sa maabot ng probe ang unang bahagi ng iyong maliit na bituka. Nagbibigay ito ng detalyadong larawan ng pancreas at hinahayaan ang iyong doktor na makahanap ng pancreatitis, pancreatic tumor, at cyst.

Kung kailangan ng karagdagang impormasyon tungkol sa hitsura ng iyong pancreas, maaaring gamitin ng iyong doktor ang isang MRI sa halip na isang CT scan upang maghanap ng pancreatic cancer.

Tiyan X-ray

Ang isang X-ray ay maaaring magamit upang hanapin ang pinsala sa pancreas.

Pancreatic Function Test

Bilang karagdagan sa mga pagsusuri sa imaging, maaari mo ring asahan na sumailalim sa mga pagsubok sa laboratoryo na sumusukat sa pag-andar ng iyong pancreas.

Stool Test

Taba sa dumi ng tao ay isa sa mga unang palatandaan ng EPI. Ito ay maaaring masukat o tumingin sa ilalim ng mikroskopyo.

Ang pagsusulit ng Van de Kamer ay sumusukat sa dami ng taba sa dumi at itinuturing na isa sa mga pinaka sensitibong paraan upang masuri ang EPI. Gayunpaman, ang pagsusulit ay mahirap makumpleto dahil nangangailangan ito ng pagkolekta ng mga sample na dumi para sa tatlong araw at pagpapanatili ng mahigpit na sukat ng iyong paggamit ng taba. Ang pagsubok ay mahirap na gawin at ang malaking dami ng mga sample na dumi ay hindi kasiya-siya para sa mga kawani ng pasyente at laboratoryo.Dahil dito, bihirang gamitin ito ng mga doktor.

Isang pagsubok na tinatawag na fecal elastase

ay malawakang ginagamit para sa EPI. Sinusukat nito ang mga antas ng enzyme elastase sa dumi ng tao, na ang mga tao na may EPI ay may mas maliit na halaga. Bagaman madaling gamitin, maaasahan lamang ito para sa pag-detect ng katamtaman sa malubhang EPI.

Test ng BreathAng isang pagsubok sa paghinga ay ang pinaka maaasahan at praktikal na paraan upang masuri ang katamtaman EPI. Ang pagsusulit na ito ay nagsasangkot ng pagkain ng pagkain na may espesyal na kemikal na pirma dito. Pagkatapos mong mahuli ang pagkain at huminga ng isang air sample, ang mga kemikal sa hangin ay nasusukat upang makita kung gaano ang lagda ang nananatiling. Ang halaga ng lagda na huminga nang palabas ay nauugnay sa kung gaano kahusay ang gumagana ng iyong pancreas.

Ang pagsubok ng hininga ay ang tanging pagsubok na maaaring masukat ang tagumpay ng therapy upang palitan ang iyong pancreatic enzymes. Gayunpaman, ang pagsubok na ito ay hindi pa gaanong magagamit dahil sa gastos nito.

Habang ang secretin test ay isang direktang pagsukat ng kung gaano kahusay ang iyong mga pancreas ay gumagana, ito ay nangangailangan ng pagpasok ng isang tubo sa maliit na bituka. Dahil ito ay kaya nagsasalakay, ito ay bihirang ginagamit kumpara sa iba pang mga pagsusulit.

Mga Pagsubok ng Dugo

Maaaring mag-order ang iyong doktor sa isang pagsusuri ng dugo upang matukoy ang mga kakulangan ng nutrient o mga palatandaan ng malnutrisyon na dulot ng EPI.

Ang Takeaway

Kung mayroon kang mga sintomas ng EPI mahalaga na makipag-usap ka sa iyong doktor. Ang pag-diagnose ng EPI at anumang mga kondisyong nasa ilalim ng maaga ay makakatulong na mapabuti ang iyong kalidad ng buhay at maiwasan ang mga karagdagang komplikasyon.

Exocrine pancreatic insufficiency (EPI) occurs when your pancreas can’t make or release enough digestive enzymes to break down food and absorb nutrients. Fat digestion is impacted the most. As your body tries to expel partially digested fat, your gut will feel upset.

You’ll likely experience symptoms like bloating, flatulence, abdominal pain, and diarrhea. Severe EPI can lead to weight loss, fatty diarrhea, and malnutrition.

EPI is rare, and its symptoms and root causes overlap with other digestive disorders. For these reasons, it can be overlooked during diagnosis.

The symptoms of EPI overlap with other conditions affecting the digestive system. These include:

• celiac disease
• irritable bowel syndrome
• Crohn’s disease
• ulcerative colitis
• pancreatic cancer

The symptoms of EPI often go unnoticed. Some of the most common symptoms include:

• stomach pain
• weight loss due to malnutrition
• symptoms of vitamin deficiency such as vision problems, muscle spasms, and osteoporosis
• abnormally fatty and bulky stools due to reduced fat uptake in the intestine
• diarrhea

The pancreas is an organ about 6 inches long located behind your stomach. It has two main jobs: making hormones and digestive chemicals.

As part of the endocrine system, the pancreas makes hormones, such as insulin, that help control your blood sugar. The pancreas also plays an important role in your digestive system by releasing chemicals that help digest your food.

When enzymes from your pancreas enter the upper part of your small intestine, they break down proteins, fats, and carbohydrates into forms your body can absorb. This is known as the exocrine function of the pancreas.

If you’re diagnosed with EPI, your treatment will focus on relieving your symptoms and helping your body absorb nutrients normally.

Diet and lifestyle changes

Treatment often requires a combination of diet and other lifestyle changes to encourage smoother digestion. This means getting a healthy, balanced diet, which contains the right fats and doesn’t include other things, like high-fiber foods.

Medications and supplements

You may also need to take vitamin supplements because EPI makes it harder for your body to absorb certain vitamins. Your doctor may prescribe enzyme supplements to replace the ones your pancreas isn’t making.

Anything that interrupts the normal process of digestive enzymes leaving the pancreas can cause EPI. There are a variety of conditions that can create that disruption.

Pancreatitis that doesn’t improve with time and cystic fibrosis are the most common causes. Other conditions that cause EPI may be inherited, caused by other bowel disorders, or be the side effect of surgery.

Conditions associated with EPI:

• cystic fibrosis
• chronic pancreatitis
• pancreatic or stomach surgery
• diabetes
• celiac disease
• inflammatory bowel diseases like Crohn’s disease
• autoimmune pancreatitis
• pancreatic cancer
• Zollinger-Ellison syndrome

EPI is commonly associated with other conditions. Most people with chronic pancreatitis develop EPI. Heavy, continual alcohol use increases your chances of developing ongoing pancreatitis. Chronic pancreatitis can also run in families. In other cases, there’s no known cause for ongoing pancreatitis.

Cystic fibrosis is an inherited condition, so if you carry the gene your children are more likely to have it.

Since the symptoms of EPI are similar to other digestive conditions there’s no single symptom that confirms an EPI diagnosis. Your doctor will likely use a variety of techniques to diagnose EPI and detect its underlying causes.

History and physical exam

Sometimes, doctors diagnose severe EPI based on your medical history and the presence of several hallmark symptoms including fatty stools, diarrhea, and weight loss.

Imaging tests

Imaging tests including an X-ray, CT scan, or an MRI will help your doctor look for evidence of damage to your pancreas.

Laboratory testing

Laboratory tests will check the amount of fat in your stools to see if it’s not being digested properly. A breath test measures fat digestion indirectly by looking for certain chemicals when you exhale.

Testing for related conditions

You’ll be given additional tests to see if a related condition like pancreatitis or diabetes is the root cause of your EPI.

There’s often no way to prevent EPI, especially if it’s the result of an inherited condition like cystic fibrosis. To decrease your likelihood of developing pancreatitis, and associated EPI, avoid heavy alcohol consumption, eat a balanced diet, and avoid smoking.

Only about half of people with exocrine pancreatic insufficiency have fat digestion levels return to normal. Severe exocrine pancreatic insufficiency can be especially difficult to resolve.

If you have symptoms that suggest EPI, discuss them with your doctor. The symptoms may be a sign of underlying conditions like pancreatitis or diabetes.

Treating EPI is important because it can improve your quality of life, prevent further damage to your pancreas, and prevent serious complications from malnutrition. Following your treatment plan and positive lifestyle changes can improve your chances of returning to normal digestion and improve your quality of life.

Exocrine pancreatic insufficiency (EPI) is a medical condition that is marked by a deficiency of the exocrine pancreatic enzymes. This leads to an inability to digest food properly. Cystic fibrosis, on the other hand, is an inherited disorder that leads to body fluids becoming thick and sticky instead of being thin and runny as it should be. This leads to problems with the lungs and the digestive system. People who have cystic fibrosis develop breathing problems since the thick mucus clogs the lungs, making them susceptible to infections. This thick mucus also obstructs the pancreas, disrupting the release of digestive enzymes. Nearly 90 percent of people with cystic fibrosis go on to develop EPI. Read on to find out if there is a connection between exocrine pancreatic insufficiency and cystic fibrosis.

Causes & Risk Factors of Cystic Fibrosis

Cystic fibrosis is an inherited condition that is caused by a mutation or defect in the CFTR gene. A mutation in the CFTR gene leads to the cells to start producing thick and sticky fluids. A majority of people with cystic fibrosis are typically diagnosed at quite a young age. (1)

As cystic fibrosis is an inherited disease, if either of your parents has the condition, then you are also at an increased risk of developing this disease.

A person with cystic fibrosis has inherited two mutated genes, one from each parent. If you only have one copy of the mutated gene, you will not develop the disease, but you will still be a carrier of the disease.

It has also been observed that people of Northern European descent are at a higher risk of getting cystic fibrosis.

Exocrine Pancreatic Insufficiency and Cystic Fibrosis – Is There a Connection?

Exocrine pancreatic insufficiency (EPI) is known as a major complication of cystic fibrosis. Cystic fibrosis is, in fact, the second most common cause of Exocrine pancreatic insufficiency (EPI), with chronic pancreatitis being the leading cause. (2)

This happens because the thick mucus from your pancreas blocks the pancreatic enzymes from entering into the small intestine.

The lack of pancreatic enzymes means that your gastrointestinal tract has to process partially undigested food. Proteins and fats are particularly difficult for people with Exocrine pancreatic insufficiency (EPI)to digest.

The partial absorption and digestion of food can cause:

Even if you eat a healthy amount of food, but having cystic fibrosis makes it challenging to maintain a healthy weight, and it may often lead to malnutrition.

Treatments for Exocrine Pancreatic Insufficiency

While there is no cure for Exocrine pancreatic insufficiency (EPI), your doctor will work together with you to find the best possible treatment to manage and ease your symptoms.

A healthy and balanced diet and lifestyle can help you to a great extent in managing Exocrine pancreatic insufficiency (EPI). This also means that you will have to restrict your alcohol intake, quit smoking, and at the same time, consume a healthy diet that is rich in fresh vegetables, fruits, and whole grains.

A majority of people with cystic fibrosis are able to eat a regular diet in which 35 to 45 percent of the calories are derived from fats. (3)

You also need to be taking enzyme replacements along with all your meals and even snacks in order to improve and boost your digestion. The use of supplements may also help make up for the vitamins the medical condition of Exocrine pancreatic insufficiency (EPI) prevents your body from absorbing naturally.

If you are unable to achieve and maintain a healthy weight, then your doctor may also suggest the use of a feeding tube in the night to help prevent malnutrition from Exocrine pancreatic insufficiency (EPI).

It is very important that your doctor monitor the functioning of your pancreas very carefully, even if you presently do not have a decreased pancreatic function as it can easily decline in the future. Monitoring of your pancreatic functioning will help make your condition more manageable, and you will also be able to reduce the chances of causing any further damage to your pancreas.

Conclusion

Traditionally in the past, it had been observed that people with Exocrine pancreatic insufficiency (EPI) and cystic fibrosis had a very short life expectancy. Today, however, nearly 80 percent (3) of all people with cystic fibrosis successfully reach adulthood and have a good life expectancy. This is because of the many significant advancements in the treatment of the condition. So even though there is no cure for cystic fibrosis and Exocrine pancreatic insufficiency (EPI), there are still many ways of managing both the conditions effectively.

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Exocrine pancreatic insufficiency: prevalence, diagnosis, and management

Accepted for publication 5 February 2019

Published 21 March 2019 Volume 2019:12 Pages 129—139

Checked for plagiarism Yes

Review by Single-blind

Peer reviewer comments 2

Editor who approved publication: Prof. Dr. Wing-Kin Syn

Gabriele Capurso, 1 Mariaemilia Traini, 1 Matteo Piciucchi, 2 Marianna Signoretti, 2 Paolo Giorgio Arcidiacono 1

1 Pancreato-Biliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, San Raffaele Scientific Institute, Vita Salute San Raffaele University, Milan, Italy; 2 Digestive and Liver Disease Unit, Sant’Andrea Hospital, Sapienza University, Rome, Italy

Abstract: Exocrine pancreatic insufficiency (EPI) is a condition caused by reduced or inappropriate secretion or activity of pancreatic juice and its digestive enzymes, pancreatic lipase in particular. EPI can result in clinical manifestation and biochemical alterations causing reduced quality of life and life-threating complications. EPI is common in pancreatic disorders, where it should be suspected and actively investigated, and in many extrapancreatic conditions. There are various tests available to diagnose EPI, with indirect, noninvasive ones, such as concentration of fecal elastase being more commonly employed. Administration of pancreatic enzymes replacement therapy remains the mainstay of EPI treatment. The present review article will discuss current evidence regarding the prevalence of EPI, the available tests to diagnose it and its treatment.

Keywords: exocrine pancreatic insufficiency, chronic pancreatitis, pancreatic cancer, elastase, malnutrition, diagnosis, therapy

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Affiliations

• 1 Beth Israel Deaconess Medical Center, 330 Brookline Ave., Dana 501, Boston, MA, 02215, USA.
• 2 Beth Israel Deaconess Medical Center, 330 Brookline Ave., Dana 501, Boston, MA, 02215, USA. [email protected]

• PMID: 28183317
• PMCID: PMC5301368
• DOI: 10.1186/s12916-017-0783-y

Free PMC article

Authors

Affiliations

• 1 Beth Israel Deaconess Medical Center, 330 Brookline Ave., Dana 501, Boston, MA, 02215, USA.
• 2 Beth Israel Deaconess Medical Center, 330 Brookline Ave., Dana 501, Boston, MA, 02215, USA. [email protected]

• PMID: 28183317
• PMCID: PMC5301368
• DOI: 10.1186/s12916-017-0783-y

Abstract

Background: Exocrine pancreatic insufficiency (EPI) is characterized by a deficiency of exocrine pancreatic enzymes, resulting in malabsorption. Numerous conditions account for the etiology of EPI, with the most common being diseases of the pancreatic parenchyma including chronic pancreatitis, cystic fibrosis, and a history of extensive necrotizing acute pancreatitis. Treatment for EPI includes dietary management, lifestyle changes (i.e., decrease in alcohol consumption and smoking cessation), and pancreatic enzyme replacement therapy.

Discussion: Many diagnostic tests are available to diagnose EPI, however, the criteria of choice remain unclear and the causes for a false-positive test are not yet understood. Despite multiple studies on the treatment of EPI using exogenous pancreatic enzymes, there remains confusion amongst medical practitioners with regard to the best approach to diagnose EPI, as well as dosing and administration of pancreatic enzymes. Appropriate use of diagnostics and treatment approaches using pancreatic enzymes in EPI is essential for patients. This opinion piece aims to address the existing myths, remove the current confusion, and function as a practical guide to the diagnosis and treatment of EPI.

Keywords: Exocrine pancreatic insufficiency; Fat malabsorption; Lipase; Pancreatic enzyme replacement therapy; Pancreatic enzymes; Steatorrhea.

The pancreas is an important intra-abdominal organ, which lies behind the stomach and adjacent to the first part of the small intestine. It is about six inches long and has a head and a tail. Its most important functions are to produce hormones that help regulate blood sugar levels and pancreatic juices that aid in digestion. These are known as its endocrine and exocrine functions respectively.

Pancreatic insufficiency occurs when the exocrine function is deficient so that the pancreas does not produce enough pancreatic enzymes that help digest food.

What Is Pancreatic Insufficiency?

Exocrine pancreatic insufficiency is a condition that occurs when your pancreas cannot make enough enzymes the body needs to digest the food in your small intestine. This leads to problems in digestion and nutrition intake because the body cannot break down food into nutrients that can be absorbed by the cells.

Enzymes are chemicals that speed up natural reactions in the body. Pancreatic enzymes help break down food in the small intestine to make nutrients available for absorption into the cells. A lack of digestive enzymes causes poor digestion and malabsorption of proteins, fats, starches and other important nutrients likevitamins and minerals from food. This can lead to bloating, gas, fatty stools, weight loss, and abdominal pain.

Initially, you may not have symptoms, but later on, you may experience symptoms like:

• abdominal pain/tenderness
• feelings of fullness
• loss of appetite
• weight loss
• foul-smelling bowel movements
• diarrhea
• abnormal bleeding, if you do not get enough vitamin K
• bone pain, if you do not get adequate amounts of vitamin D

What Causes Pancreatic Insufficiency?

Damage to the pancreas can lead to pancreatic insufficiency, resulting in low levels of pancreatic enzymes. This leads to malabsorption of food, which is not properly used as energy by the body.

Your pancreas may be damaged by:

• chronic inflammation
• pancreatic surgery
• cancer
• genetic factors that may cause cystic fibrosis or Shwachman-Diamond Syndrome

Other factors that increase your risk for pancreatic insufficiency include:

• chronic pancreatitis
• chronic alcohol abuse

How to Diagnose Pancreatic Insufficiency

There are several tests used to diagnose pancreatic insufficiency. Evaluation of this medical condition also includes some blood tests to check for any vitamin deficiencies. Tests to determine the underlying cause for your condition also include tests for celiac disease and other conditions.

A “3-day fecal test,” which involves collection of stool samples for three days may be needed to assess the amount of fat in your stools. Another test called “fecal elastase-1” may also be done to look for the presence of an important digestive enzyme in your stool.

Other tests that may help find out if you have pancreatic damage or inflammation include:

• CT scan, which uses powerful X-ray to take detailed pictures of your body.
• MRI, which uses powerful magnetic and radio waves to examine the internal organs of your body.
• Endoscopic ultrasound, which uses sound waves to make images of your digestive system.

Genetic testing may also be recommended to see if you have genes responsible for certain conditions that can lead to pancreatic insufficiency.

How to Treat Pancreatic Insufficiency

Fortunately, pancreatic insufficiency is treatable. One option treatment consists of replacing pancreatic enzymes with supplements that aid in digestion. This type of treatment helps improve absorption and prevent vitamin deficiencies. It also improves weight gain. Other options include home remedies like dietary modifications and pancreatic cell transplantation.

1. Medical Treatment

Pancreatic enzyme replacement therapy is the main treatment used for pancreatic insufficiency. It consists of regular intake of enzyme pills to replace deficient enzymes. These enzymes break down food for easy digestion and absorption. They are taken during meals for best results.

You may also need to take antacids to prevent premature break down of the pancreatic enzymes in the stomach before they start to work.

FDA-approved pancreatic enzymes that you can obtain with a doctor’s prescription include the following:

However, not all patients who have pancreatic insufficiency need these digestive enzymes. Some people who have milder forms of the disease can reduce their symptoms just by eating a healthy, low-fat diet.

For severe pancreatic insufficiency, vitamin supplements are necessary part of your treatment to treat vitamin deficiencies.

You may also need medication to treat abdominal pain. Doctors usually advise taking nonsteroidal anti-inflammatory drugs (NSAID) like ibuprofen, but if this does not bring relief, stronger pain relievers, such as oxycodone and hydrocodone may be prescribed.

2. Home Remedies

It is important for you to take care of yourself by modifying your lifestyle to prevent symptoms. Choosing the right types of food with the help of a dietitian is always advised. This will help prevent symptoms of malabsorption and at the same time provide enough energy and nutrition your body needs.

• Eating frequent small meals rather than big meals to improve digestion.
• Avoiding alcohol, which can damage your pancreas over time and make it more difficult for your body to absorb fat.
• Taking vitamins A, D, E, and K to replace those that your system is not able to absorb from the diet. Consult your doctor before taking supplements.

Exocrine Pancreatic Insufficiency

What is exocrine pancreatic insufficiency?

The pancreas has 2 functional parts. The endocrine part secretes insulin and glucagon, which are essential for the metabolism of carbohydrates. The exocrine part consists of units called acini that produce and secrete enzymes essential for the digestion of protein, into the small intestine.

With exocrine pancreatic insufficiency (EPI), there is gradual wasting away (atrophy) of the acini. Clinical signs do not develop until most of the acini are gone. As dogs lose the ability to digest protein, they progressively lose weight despite a voracious appetite.

What breeds are affected by exocrine pancreatic insufficiency?

There is a genetic predisposition to this disorder in the German shepherd . It also occurs sporadically in dogs of other breeds.

For many breeds and many disorders, the studies to determine the mode of inheritance or the frequency in the breed have not been carried out, or are inconclusive. We have listed breeds for which there is a consensus among those investigating in this field and among veterinary practitioners, that the condition is significant in this breed.

What does exocrine pancreatic insufficiency mean to your dog & you?

Affected dogs lose weight despite voracious appetites, and usually pass large amounts of semi-formed feces. They often eat their own stools, or other inappropriate substances.

Some dogs with this condition do not show these typical signs, and may experience intermittent watery diarrhea or vomiting.

How is exocrine pancreatic insufficiency diagnosed?

The clinical signs of weight loss and increased appetite may occur with malabsorption of nutrients due to a variety of causes. Routine diagnostic tests will eliminate some of these as possibilities. Once EPI is suspected, there are specific laboratory tests that will diagnose this disorder.

How is exocrine pancreatic insufficiency treated?

Although this disorder can not be cured, management is generally fairly straightforward. Powdered pancreatic enzyme extract is mixed in with each meal. Within a few days, your dog’s appetite and stools should become more normal, and s/he will begin to gain weight. Your veterinarian will work with you to determine the best regime (what dose of extract, 1 or 2 feedings per day) to keep your dog free of clinical signs. Enzyme supplementation of your dog’s food will be necessary for life.

Some dogs fail to gain weight despite treatment, and this may be due to chronic bacterial overgrowth. A course of antibiotic therapy and probiotic may be useful in these dogs.

FOR MORE INFORMATION ABOUT THIS DISORDER, PLEASE SEE YOUR VETERINARIAN.

by Hilary Kiell

Anytime you hear your pet is sick, or needs treatment it is a scary confusing time. EPI dogs can continue to live a full life and do all the activities they did before, EPI, in and of itself, when treated , does not shorten a dog’s lifespan, The key is successful management. Pictured to the left is Maia. Maia, now 7 1/2 years old, was diagnosed with EPI when she was about a year old. She is a joy and we can’t imagine our family without her. She has mentored GSD fosters who have come in and out of our home – teaching them the ropes of life in a loving home. Her EPI care is routine for us. She gets love, toys and ice cubes in lieu of most treats, although she enjoys a dried tripe stick or probiotic treat, on occasion. She gets a combination of powdered enzyme and fresh frozen pancreas with each meal and thrives on this diet. At more than 90 lbs, we actually have to watch her weight, now that she is getting older. Maia’s idea of a great day includes chasing squirrels, hiking in the park and going for a car ride.

The information below is not intended to replace advice or guidance from veterinarians or other pet care professionals. It is being shared to assist you in understanding the disease and identifying the right questions to ask your veterinarian.

What is EPI?

EPI is a digestive disorder which impacts a dog’s ability to produce the pancreatic enzyme needed to digest his/her food. It may also be referred to as pancreatic acinar atrophy (PAA). Without supplemental pancreatic enzyme added with each meal, dogs with EPI are not able to digest their food and show symptoms of starvation, including weight loss, loose stools, and increased appetite. While currently there is no cure, EPI is readily treated by adding appropriate pancreatic enzyme supplements to each meal.

Symptoms

The most common symptoms include:

• Weight loss
• Chronic diarrhea (may include foul-smelling, yellowish, greasy stools from cow-pie to watery consistency)
• Ravenous appetite
• Coprophagia (stool eating) and pica (eating non-food items)
• Failure to gain weight or thrive

Diagnosis

The definitive test for EPI is cTLI (canine Trypsin-like Immunoreactivity ). A blood sample is sent to a specialized lab for testing. A single test is required. In addition, the Cobalamin/Folate test for B12 deficiency is recommended. This test may be repeated after treatment commencement to confirm that the B12 level is appropriate. As some veterinarians are not familiar with EPI, you may need to be your dog’s advocate. If you have any reason to believe your dog might have EPI, ask for these tests!

Treatment

Treatment consists of supplementation with pancreatic enzymes. Your vet may provide guidance on how much to use, based on the results of the cTLI test, however, there is often quite a bit of experimentation involved to get the amount just right, and to find the right food. The enzyme must be added with each meal (it does not stay in the body but is digested with the food). Without the enzyme, your dog is starving as s/he passes anything it eats through her/his system – basically undigested. Hence, the large cow-pie poops and the weight loss.

Food

Dogs with EPI require a highly digestible diet for their entire lives. This does not have to be a prescription diet if a high quality, highly digestible over-the-counter pet food is used. Some dogs do best with a raw diet; others with a grain free diet. At the beginning of treatment, the dog’s daily food intake may be divided into several meals per day. As the diarrhea resolves and weight gain begins, the number of meals may be reduced to two per day. Enyzme supplements must be added with each meal, regardless of how many meals per day. Remember, your dog can not digest his food, without the additional enzyme (this goes for treats, too)!

The optimal food should be based on:

Optimal

Protein

Fat

Fiber

quality enzymes economically,

What Is Exocrine Pancreatic Insufficiency?

Exocrine pancreatic insufficiency (EPI) is the inability to break down and digest food properly. Normally, the pancreas produces three digestive enzymes, which move into your small intestine to help the body break down food into the nutrients you need. If you have EPI, your pancreas cannot properly break down foods, resulting in poor digestion of nutrients—especially fats.

What Are The Symptoms?

The symptoms of EPI, caused by undigested food moving through your system, can vary.

If you are experiencing any of these symptoms, talk with your gastroenterologist.

• Diarrhea
• Gas and bloating
• Stomach pain or tenderness
• Foul-smelling, greasy stools
• Weight loss

What Causes EPI?

Exocrine pancreatic insufficiency normally occurs when there has been some kind of damage to the pancreas, which reduces its ability to produce the necessary enzymes for proper digestion. Pancreatitis (inflammation of the pancreas), can lead to EPI. Pancreatitis can be caused by alcohol, immune system disorders or inherited diseases, like cystic fibrosis. Surgery of the pancreas may also cause EPI.

How Is Exocrine Pancreatic Insufficiency Diagnosed?

Your gastroenterologist may recommend several tests to help diagnose EPI. The first may be blood tests to determine vitamin and nutrient levels, to see how well your pancreas is processing foods. Additionally, your doctor may order a fecal test.

There are two main types of fecal tests. A fecal elastase test measures the amount of elastase, an enzyme produced by the pancreas, in your stool. A deficiency of elastase could be an indicator of EPI. The second is a fecal fat test, which requires eating a prescribed diet and collecting stool samples over 3 days. This test can help determine how much fat your body is not absorbing.

What Treatments Are Available?

A healthy diet, along with pancreatic enzyme replacement therapy (PERT) is the main treatment for exocrine pancreatic insufficiency. There are a number of prescription medicines that replace the enzymes your pancreas can’t make. Your doctor may also prescribe taking fat-soluble vitamins A, D, E, and K supplements to replace ones that aren’t getting absorbed from your diet.

Some patients find that eating smaller, more frequent meals, aids in the digestion and proper breakdown of nutrients. Avoid drinking alcohol, since it can damage your pancreas and make it even harder for your body to absorb fat. In some cases, patients need to take an antacid to keep the stomach from breaking down pancreatic enzymes before they can start to work.

Undiagnosed Complications of Exocrine Pancreatic Insufficiency, Dyserythropoietic Anemia, And Calvarial Hyperostosis

As part of Exocrine Pancreatic Insufficiency, Dyserythropoietic Anemia, And Calvarial Hyperostosis diagnosis, consider whether any of these Exocrine Pancreatic Insufficiency, Dyserythropoietic Anemia, And Calvarial Hyperostosis complications may have been overlooked:

• Infant death due to severe jaundice
• More complications »

Undiagnosed Diseases

Read our premium medical health articles on topics related to undiagnosed conditions in general, not necessarily specific to Exocrine Pancreatic Insufficiency, Dyserythropoietic Anemia, And Calvarial Hyperostosis:

• Failure to Diagnose
• Under-Diagnosed Diseases
• How Common is Failure to Diagnose?
• Conditions by Undiagnosed Prevalence
• More premium medical articles . »

About undiagnosed conditions:

One possible misdiagnosis is the failure to correctly diagnose Exocrine Pancreatic Insufficiency, Dyserythropoietic Anemia, And Calvarial Hyperostosis leading to a person remaining with undiagnosed Exocrine Pancreatic Insufficiency, Dyserythropoietic Anemia, And Calvarial Hyperostosis. Any condition can potentially be missed and stay undiagnosed. For a general overview of diseases that are often undiagnosed, see Failure to Diagnose or Under-Diagnosed Diseases.

Exocrine pancreatic insufficiency in German Shepherds is a lot more common than you think. About 70% of dogs diagnosed with the condition are German Shepherds. The disease, also known as EPI, is characterized by the pancreas’ inability to produce enough enzymes to help the body digest and absorb food nutrients.

What is the function of the pancreas?

The pancreas is an integral part of the digestive system. Aside from releasing insulin, the organ is also responsible for supplying digestive enzymes to the stomach and the digestive tract. These enzymes help break down food into digestible ingredients that the body can absorb.

What happens inside your German Shepherd’s body if he has exocrine pancreatic insufficiency?

When a dog has exocrine pancreatic insufficiency disorder, his pancreas fails to secrete the adequate amount of digestive enzymes. Without sufficient enzymes in the digestive system, the consumed food remains undigested and your German Shepherd’s body is unable to absorb nutrients. Even if a dog with EPI consumes adequate food, he could suffer from malnourishment, have organ failures, and starve to death. This disease can also contribute to bacterial overgrowth in the intestine.

What causes exocrine pancreatic insufficiency in German Shepherds?

Idiopathic pancreatic acinar atrophy (PAA) is the most common cause of EPI in German Shepherds. With PAA, there is a progressive destruction of the acinar cells, which are involved with enzyme production. The damage to these cells causes the inadequate production of enzymes and bicarbonate essential in digesting foods.

On the other hand, chronic pancreatitis is the second leading cause of exocrine pancreatic insufficiency in German Shepherds. When pancreatitis is the cause of EPI, there is a very high chance that your pet may suffer from diabetes.

What are the signs of exocrine pancreatic insufficiency in German Shepherds?

Common signs of EPI in dogs include:

• gray or yellow stool that may look fatty
• coprophagia (eating of stool)
• weight loss
• muscle atrophy
• increased appetite
• poor coat quality
• large amounts of stool
• frequent defecation
• chronic diarrhea
• excessive drinking

These symptoms may either come over a long period of time or set in within a week or two.

How is EPI in dogs diagnosed?

If signs of EPI are discernible in your pet, take him to the veterinarian without any delay. Blood tests and x-rays help rule out other diseases. Exocrine pancreatic insufficiency in German Shepherds is confirmed by measuring of blood trypsinogen levels through trypsin-like immunoreactivity (TLI).

Is there a way to treat EPI in German Shepherds?

To treat exocrine pancreatic insufficiency in German Shepherds, the pancreatic enzymes must be reinvigorated. Enzymes supplements are available in the market in both tablet and powdered forms. They can be either mixed with your dog’s meal or be given separately before his meals. These manufactured enzymes help dogs with EPI to break down the food they eat and allow for proper digestion and absorption of its nutrients. Improvement becomes visible within a week of starting this treatment.

It is a must to observe your German Shepherd’s condition – especially the texture and color of his stool – in the first few weeks of treatment to figure out the correct amount of enzymes he needs. Your pet may also start to gain weight.

EPI relapse is a threat. So observe your German Shepherd to see if signs of EPI are coming back. Generally, dogs who suffered from EPI can still live a normal and happy life as long as the recommended diet and enzyme supplements are given. In most cases, stopping the enzyme supplementation results in the recurrence of the disease.

It is recommended to feed your German Shepherd with several small meals daily instead of giving him one big meal. The ideal diet for dogs with EPI is low in fat, fiber, and carbohydrates.

If the EPI in your German Shepherd is caused by an underlying condition, such as pancreatitis, that condition must be dealt with first.

How to prevent exocrine pancreatic insufficiency in German Shepherds?

There is no sure way to prevent exocrine pancreatic insufficiency in German Shepherds. Symptoms of the disease usually do not appear until there are signs of pancreatic damage or inadequate enzyme production. Because it is common to diagnose EPI in German Shepherds, there are studies suggesting that the disease can be inherited. For this reason, removing dogs with EPI from breeding programs are recommended. The disorder caused by pancreatitis can be prevented with proper diet and care.

How to promote pancreas healing and beat pancreatitis

Exocrine Pancreatic Insufficiency, often called pancreatic insufficiency, is the inability of your digestive system to break down and properly digest the foods you eat.

Exocrine Pancreatic Insufficiency or EPI is characterized by the pancreas NOT producing enough pancreatic enzymes (protease, amylase, lipase) to promote normal digestion and the need for pancreatic enzyme supplementation.

This condition can be mild or severe.

What Causes Exocrine Pancreatic Insufficiency?

There are more causes for pancreatic insufficiency than most people think. Some of the conditions that cause EPI are:

• chronic pancreatitis
• cystic fibrosis
• obstructions of the pancreatic duct (cancer, tumors)
• Shwachman-Diamond syndrome (SDS)
• Celiac disease
• Crohn disease
• Autoimmune pancreatitis: This is often caused by immunoglobulin G4 (IgG4)-related disease and can progress to EPI.
• Zollinger-Ellison syndrome
• GI and pancreatic surgical procedures

What Are The Symptoms of Pancreatic Insufficiency?

When trying to discover whether your symptoms may match those of pancreas insufficiency one has to remember that you may not have the exact same symptoms that Tom, Dick or Harriet experience. In fact …

Only your licensed physician will know (hopefully anyway) for sure whether you have pancreatic insufficiency or parasites (example only).

These are the symptoms most often found to be relevant to exocrine pancreatic insufficiency:

Frequent diarrhea. EPI can cause problems with the digestion process. As a result undigested food can move too quickly through the digestive tract.

Not all people experience this symptom.

There are many causes of diarrhea so just because you have a couple of days of it does not mean you have pancreatic insufficiency.

However, if you do have (been diagnosed) with any of the above conditions that can cause EPI it would be prudent to ask your doctor to test you (especially if you have some of the following symptoms as well).

Weight loss. People with EPI cannot digest fats, proteins, and carbohydrates found in the food they eat, which can result in weight loss.

I’m not talking just a pound or two or even 10 that one may lose on a low fat diet. I’m talking severe weight loss that doesn’t stop even though you are eating two or three healthy meals per day.

If the malabsorption is severe enough you could become skin and bone.

IF your doctor has been oblivious, you need to bring it to his/her attention because severe malabsorption issues could be caused by EPI and you need to get a handle on it.

Gas and bloating. People with EPI cannot properly digest the food they eat, which can result in uncomfortable symptoms like gas and bloating.

Stomach pain. The gas and bloating caused by maldigestion in people with EPI will frequently result in stomach pain.

Foul-smelling, greasy stools (steatorrhea). Steatorrhea is a type of bowel movement that is oily, floats, smells really bad, and is difficult to flush.

People with EPI are not able to absorb all of the fat that they eat, so undigested fat is excreted, resulting in stools that look oily or greasy.

Not all people experience this symptom.

Talk to your doctor if you notice oil droplets floating in the toilet bowl or stools that float or stick to the sides of the bowl and are hard to flush because these may be signs that you have EPI.

Does your poop float, sink or actually swim around the toilet bowl doing the backstroke? Maybe one day it floats, the next it sinks or maybe it even “bobs” up and down?

Are you the type of person who NEVER checks out your poop?

Yes you do! You look don’t you?

I like to play a game I call “Pilot to Bombardier.”

Of course I have to look and view the bomb damage! And it is important to check out what that poo actually looks like.

What color is it?

Is it rock solid or nice and soft?

Oh wow it’s floating and looks like a battle cruiser!

And if you’re like me you have probably wondered what makes my poop float?

If you asked your mom when you were a kid “Hey mom why does my poop float?” She might have come up with a very brainy answer like “It floats son because it’s full of fiber. And fiber floats.” And …

Was she right or wrong?

Scientifically she’s wrong. But who knew right? It probably sounded good to her at the time! But you probably still wondered, even as a kid, why some poop floats and why some sinks, right?

If you are concerned about exocrine pancreatic insufficiency this discussion about poop may help because knowing your poop can actually save your life (in some cases). Yes, I am venturing off the path a bit, talking about stool appearance but bear with me and things will come out fine.

Ask Yourself “Is My Poop Looking Healthy?”

Your poop can actually tell you how healthy you are; at least to some degree. If your stool looks like a nice sized snake (not a skinny little devil suffering from starvation), is easily evacuated and looks like #4, in the following Bristol stool chart (yes the folks at the University of Bristol actually did a poop study and then published the study in the Scandinavian Journal of Gastroenterology), then chances are you probably have a well, oiled, finely tuned intestinal tract.

What are the chances that you’ll now be looking at and rating your poop?

You’ll do it all the time!

If you ever happen to see that your poop looks like a nightcrawler (big long worm) as seen in the next chart top row, far right, rather than a nice sausage-shaped candy bar with peanuts #3 or a smooth healthy snake #4 you may want to make an appointment with your doctor.

Stools that look like an emaciated snake or a long, big worm may signal a colon tumor or polyps.

I think we’ve covered most of the important, basic information regarding exocrine pancreatic insufficiency and poop. If you think you have exocrine pancreatic insufficiency you should schedule an appointment with your doctor and get evaluated. Should you be diagnosed with EPI your doctor will likely prescribe pancreatic enzymes (Creon, etc) to help regulate your digestion.

A full malabsorption workup comprising numerous tests is required to differentiate exocrine pancreatic insufficiency from other causes of malabsorption. This workup may include fat absorption tests, a D-xylose test, a carbohydrate absorption test, a bile salt absorption test, a three-stage Schilling test, and the carbon 14 D-xylose breath test.

Stool tests can be useful to determine the levels of fecal elastase and chymotrypsin (two proteases produced by the pancreas) to help distinguish between pancreatic and intestinal causes of malabsorption. However, in the absence of testing a formed stool, routinely checking for exocrine pancreatic insufficiency in patients with chronic diarrhea using fecal elastase levels is unreliable. In patients with mild exocrine pancreatic insufficiency, diagnostic testing using fecal elastase levels has a lower sensitivity and specificity, which may result in an underestimation of exocrine pancreatic insufficiency.

Pancreatic function can be measured indirectly. For example, qualitative fecal fat analysis via microscopic examination of random stool samples can be used as a screening test only, and the measurement of fecal elastase and fecal chymotrypsin levels may serve as an indirect indicator of pancreatic function. Typical findings in exocrine pancreatic insufficiency are increased fecal fat and decreased enzyme levels.

The most sensitive approach for assessing exocrine pancreatic function is direct pancreatic function testing using endoscopy or the Dreiling tube method after stimulation with secretin or cholecystokinin. This is normally performed at specialized centers.

Learn more about the workup of exocrine pancreatic insufficiency.

No of Tables: 60

No of Figures: 220

Global Exocrine Pancreatic Insufficiency (EPI) Therapeutics and Diagnostics Market By Type (Therapeutics, Diagnostics), Therapeutic Drugs (Creon, Zenpep, Pancreaze, Ultresa, Viokace, Others), Geography (North America, South America, Europe, Asia-Pacific, Middle East and Africa) – Industry Trends & Forecast to 2026

Market Analysis: Global Exocrine Pancreatic Insufficiency (EPI) Therapeutics and Diagnostics Market

Global Exocrine Pancreatic Insufficiency (EPI) Therapeutics and Diagnostics Market is expected to rise from its initial estimated value of USD 3.96 billion to a projected value of USD 7.09 billion by 2026, registering a CAGR of 7.57% in the forecast period of 2019-2026. This rise in market value can be attributed to the large number of therapies and drugs in the pipeline of major pharmaceutical companies currently present in the market.

Market Definition: Global Exocrine Pancreatic Insufficiency (EPI) Therapeutics and Diagnostics Market

Exocrine pancreatic insufficiency is a disorder which causes the pancreas to behave improperly resulting in the lack of generation of digestive enzymes required for the proper digestion of food. It is majorly caused in humans suffering from cystic fibrosis. The therapeutics currently prevalent in the market includes lifestyle changes, management of nutritional intake enzyme replacement. The diagnostics procedures include testing the blood sample, various diagnostic imaging procedures and others.

Market Drivers

Increase in the prevalence of diabetes globally which is one of the major factors behind the generation of cystic fibrosis which ultimately causes EPI; this factor is expected to drive the market growth

Increasing expenditure incurred on healthcare and development of healthcare infrastructure along with increasing prevalence of the disorders are expected to positively affect the market growth

Market Restraints

Presence of strict regulations regarding the approval and commercialization of therapies across the various regions is expected to restrain the market growth

Lack of advancements in technology and innovations for the treatment of disorders is expected to restrain the market growth

Segmentation: Global Exocrine Pancreatic Insufficiency (EPI) Therapeutics and Diagnostics Market

Pancreatic Enzyme Replacement Therapy (PERT)

Magnetic Resonance Imaging (MRI)

Computed Tomography (CT) Scanning

Endoscopic Ultra-Sonography (EUS)

By Therapeutic Drugs

Rest of South America

Rest of Asia Pacific

Middle East & Africa

United Arab Emirates

Rest of Middle East & Africa

Key Developments in the Market:

In May 2018, VIVUS Inc. announced that, they had agreed to acquire the product rights for “PANCREAZE (pancrelipase)” from Janssen Global Services, LLC for the United States and Canada region. This acquisition will significantly improve the financial standpoint of the company and will improve the product offerings for the gastrointestinal disorders market.

In December 2016, ALLERGAN announced that, they had received a positive opinion for marketing authorization of “ENZEPI® (pancrelipase)” in the European region from Committee for Medicinal Products for Human Use (CHMP). The product is a therapeutic PERT (Pancreatic Enzyme Replacement Therapy) for patients suffering from Exocrine Pancreatic Insufficiency (EPI). This positive opinion is a big step in bringing this therapy into the market for the European region.

Competitive Analysis: Global Exocrine Pancreatic Insufficiency (EPI) Therapeutics and Diagnostics Market

Global exocrine pancreatic insufficiency (EPI) therapeutics and diagnostics market is highly fragmented and the major players have used various strategies such as new product launches, expansions, agreements, joint ventures, partnerships, acquisitions, and others to increase their footprints in this market. The report includes market shares of exocrine pancreatic insufficiency (EPI) therapeutics and diagnostics market for global, Europe, North America, Asia-Pacific, South America and Middle East & Africa.

Key Market Competitors: Global Exocrine Pancreatic Insufficiency (EPI) Therapeutics and Diagnostics Market

Few of the major competitors currently working in the exocrine pancreatic insufficiency (EPI) therapeutics and diagnostics market are Eli Lilly and Company; AbbVie Inc.; VIVUS Inc.; Mayoly Spindler; ALLERGAN; Nordmark Arzneimittel GmbH & Co. KG; Janssen Global Services, LLC; PDL BioPHARMA; Cilian AG; Digestive Care, Inc.; Anthera and AzurRx.

Research Methodology: Global Exocrine Pancreatic Insufficiency (EPI) Therapeutics and Diagnostics Market

Data collection and base year analysis is done using data collection modules with large sample sizes. The market data is analysed and forecasted using market statistical and coherent models. Also market share analysis and key trend analysis are the major success factors in the market report. To know more please Request an Analyst Call or can drop down your inquiry.

The key research methodology used by DBMR Research team is data triangulation which involves data mining, analysis of the impact of data variables on the market, and primary (industry expert) validation. Apart from this, other data models include Vendor Positioning Grid, Market Time Line Analysis, Market Overview and Guide, Company Positioning Grid, Company Market Share Analysis, Standards of Measurement, Top to Bottom Analysis and Vendor Share Analysis. To know more about the research methodology, drop in an inquiry to speak to our industry experts.

Primary Respondents

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Supply Side: Product Managers, Marketing Managers, C-Level Executives, Distributors, Market Intelligence, and Regulatory Affairs Managers among others.

Reasons to Purchase this Report

Current and future of global exocrine pancreatic insufficiency (EPI) therapeutics and diagnostics market outlook in the developed and emerging markets

The segment that is expected to dominate the market as well as the segment which holds highest CAGR in the forecast period

Regions/Countries that are expected to witness the fastest growth rates during the forecast period

The latest developments, market shares, and strategies that are employed by the major market players

Customization of the Report:

All segmentation provided above in this report is represented at country level

All products covered in the market, product volume and average selling prices will be included as customizable options which may incur no or minimal additional cost (depends on customization)

Since exocrine pancreatic insufficiency isn’t necessarily the first thing that someone decides to look up while “surfing the web”, we can naturally assume that you either suspect something might be wrong with your dog or your dog has already been diagnosed with this condition and now you’re looking to learn a little bit more about what exocrine pancreatic insufficiency is.

Which makes perfect…

Sense to us which is why we here at IndulgeYourPet decided to write this article so that we can shed a little light on exactly what this condition is, without getting too technical so that the “average” person doesn’t lose their mind with all of the scientific mumbo jumbo.

So, without further ado, let’s dive right in.

Exocrine Pancreatic Insufficiency in Dogs Defined

Exocrine Pancreatic Insufficiency (EPI) sounds like a very complicated disease but it actually has a very simple concept. EPI in dogs is primarily caused by pancreatic acinar atrophy (PAA) which disturbs the pancreatic acinar cells that secrete enzymes in the pancreas.

This causes…

The food your pet eats to not be digested properly in the small intestine which in turn makes your pet’s body not be able to digest the food you feed them well and absorb the nutrients they need to live. Or to put in another way, your dog begins to starve even though he or she has plenty to eat!

Additionally…

The “insufficiency” also allows for bacterial “overgrowth” to occur, and the lining of the small intestine can begin to deteriorate which can both lead to many serious consequences for your dog down the line.

Also…

Since there are not sufficient cells to produce the pancreatic enzymes to digest starches and lipids the body cannot break down these nutrients and like we’ve already mentioned will begin to actually starve despite having access to plenty of food.

Symptoms to be aware of…

Since all this is happening on the inside of your loved one’s body, you’re not going to necessarily be able to diagnosis EPI right away. That said however there are some symptoms and clinical signs you can see on the outside as the disease progress which is nothing else will indicate that you need to have your dog checked out ASAP.

Symptoms such as:

• Large amounts of diarrhea,
• Loss in strength and energy,
• Unexplained weight loss,
• Vigorous eating like a scavenger,
• And deterioration in their coat and fur.

Although…

Even if your furry friend has all of these symptoms it may not necessarily mean they have EPI. Intestinal Parasites, Small intestinal bacterial overgrowth, and pancreatitis all have similar symptoms which further complicate the diagnosis.

It is important to note that…

It is crucial to bring your four-legged buddy in to the veterinarian as soon as possible once you begin to see signs that your dog is not doing well. This is because proper treatment is essential for having your dog make a full recover. Or to put in another way, this is not something that is going to resolve itself on its own.

Which brings us to…

A good point in this article to remind folks that we here at IndulgeYourPet are not medical professionals and we’re certainly not veterinarians. All we are is a bunch folks who are passionate about animals and want to try to help any pet owner do what’s best for his or her loved one. We want the best for your pet so we provide the information that you need to treat your furry friend.

This is why…

One of the main phrases we go by here at IndulgeYourPet is:

“When in doubt, have your vet check it out”

So, you can ensure a safe treatment for your pet. It is always better to take your pet into the veterinarian early especially in the case of EPI where the longer you wait, the more the pancreas and small intestine deteriorates.

Commonly affected dog breeds include…

This is because they are susceptible for getting pancreatic acinar atrophy (PAA), which is the disease that causes EPI. Of these breeds German Shepherd dogs are the most affected with 70% of all dogs who have EPI being a German Shepherd. For collies, 20% of all affected dogs with EPI are collies.

Now, you may be wondering…

What treatments are available for your furry friend with EPI, and the good news is that EPI is treatable, although it is not a one-time cure. The treatment is extensive and includes:

• Periodic treatment with antibiotic and anti-inflammatory drugs for treatment of the small intestinal lining,
• Continual pancreatic enzyme supplementation for life as a way of enzyme replacement,
• Low-fat diet because the pancreas does not produce the enzymes needed to digest fat,
• And supplemental oral vitamins like vitamin K and E, and cobalamin to treat vitamin and cobalamin deficiencies which stem from not being able to fully digest food.

And here lies the problem…

While it is fantastic that EPI is treatable, the cost of such treatment can really add up. First of all, the diagnostic tests to first diagnose EPI can run upwards of $500 and the constant medications can add up to $300 to $1000 a year. Not to mention the check-ups your dog will require to ensure their constant well-being, and the low-fat food they will need to eat.

This is why…

At IndulgeYourPet, we typically recommend that everyone who is considering purchasing an animal at least take a few moments and explore what it might cost to purchase a pet insurance policy.

This way…

You are not the sole person paying for your four-legged family member’s vet bills and medications and can offer them the best treatments for whatever they are enduring.

Because…

You never know what type of medical issues your pet may have throughout the course of its life time and knowing that you have an insurance policy in place that could “shield” you from costly bills is always a great feeling to have!

For more information on who we feel currently offers the “Best” pet insurance policies in the industry, feel free to check out our Best Pet Insurance Companies article.

The pancreas has 2 functional parts. The endocrine part secretes insulin and glucagon, which are essential for the metabolism of carbohydrates. The exocrine part consists of units called acini that produce and secrete enzymes essential for the digestion of protein, into the small intestine.
With exocrine pancreatic insufficiency (EPI), there is gradual wasting away (atrophy) of the acini. Clinical signs do not develop until most of the acini are gone. As dogs lose the ability to digest protein, they progressively lose weight despite a voracious appetite.

This is thought to be an autosomal recessive trait in the German shepherd.

Affected dogs lose weight despite voracious appetites, and usually pass large amounts of semi-formed feces. They often eat their own stools, or other inappropriate substances.
Some dogs with this condition do not show these typical signs, and may experience intermittent watery diarrhea or vomiting.

The clinical signs of weight loss and increased appetite may occur with malabsorption of nutrients due to a variety of causes. Routine diagnostic tests will eliminate some of these as possibilities. Once EPI is suspected, there are specific laboratory tests that will diagnose this disorder.

Although this disorder can not be cured, management is generally fairly straightforward. Powdered pancreatic enzyme extract is mixed in with each meal. Within a few days, your dog’s appetite and stools should become more normal, and s/he will begin to gain weight. Your veterinarian will work with you to determine the best regime (what dose of extract, 1 or 2 feedings per day) to keep your dog free of clinical signs. Enzyme supplementation of your dog’s food will be necessary for life.
Some dogs fail to gain weight despite treatment, and this may be due to chronic bacterial overgrowth. A course of antibiotic therapy may be useful in these dogs.

Assay of serum trypsin-like immunoreactivity (TLI), bentiromide absorption test, and quantitative assay of fecal proteolytic activity (azocasein substrate) are sensitive tests for EPI in the dog. TLI is also a specific test, and requires only 1 sample for diagnosis. (Check with your diagnostic laboratory).

Affected dogs, and in German shepherds, their parents (considered carriers) and siblings (suspect carriers) should not be used for breeding.
FOR MORE INFORMATION ABOUT THIS DISORDER, PLEASE SEE YOUR VETERINARIAN.

This database is a joint initiative of the Sir James Dunn Animal Welfare Centre at the Atlantic Veterinary College, University of Prince Edward Island, and the Canadian Veterinary Medical Association. Comments may be addressed to [email protected] Please note that we are unable to provide medical or breeding advice. Please contact your veterinarian.

Permission is granted to reprint pages from the database, provided that credit is given as follows: Crook A et al. 2011. Canine Inherited Disorders Database (CIDD).

Copyright © 2011 Canine Inherited Disorders Database.

Feline pancreatitis, or more specifically exocrine pancreatic insufficiency, is a rare but serious condition. Fortunately, this problem is fairly easy to solve, but is extremely life-threatening if left untreated.

Exocrine Pancreatic Insufficiency

Exocrine pancreatic insufficiency, also called pancreatic insufficiency and maldigestion syndrome, occurs when the pancreas fails to release the enzymes that are required to properly break down food. When a feline has this condition, the starches, proteins and fats that are required for a cat’s proper nutrition cannot be turned into pieces that are small enough to be absorbed by the intestinal tract. Therefore, the food remains undigested and passes out in the cat’s stool whole. The feline does not benefit from any nutrition the food can provide and is essentially starving, although she may be constantly eating. Chronic inflammation of the pancreas, an infestation of flukes or cancer can cause feline pancreatitis.

Symptoms of Exocrine Pancreatic Insufficiency

Cats who have feline pancreatitis often display the same symptoms and follow the same patterns. The affected cats will seem extremely hungry, even though they are constantly eating. Cats who have feline pancreatitis will lose weight and have high amounts of stool that can be loose and strong in odor. The stool may also be watery without any form at all. Because of the high amount of fat in the feces, the cat’s anal area and stool appears greasy. In addition, these cats will have poor hair coats and depending on the diet, may have large pieces of fat in their stool. Many times, cats who have exocrine pancreatic insufficiency will also have diabetes mellitus.

Diagnosis of Pancreatic Insufficiency

Typically, feline pancreatitis is initially diagnosed based on the appearance of the animal. The doctor will then perform laboratory testing that will measure the amounts of enzymes in the cat’s blood. Symptoms of exocrine pancreatic insufficiency are similar to those associated with hyperthyroidism and inflammatory bowel disease. Therefore, your cat’s veterinarian will often perform additional tests to rule out these diseases as well.

Treatment of Feline Pancreatitis

While there is treatment available for feline pancreatitis, it is often expensive and is a life-long process. In order to treat the missing pancreatic enzymes, they need to be replaced. This can be accomplished by administering medication that contains pancreatic enzymes from other sources. These medications are made using freeze-dried, ground hog and cattle pancreas and contain large amounts of the same types of enzymes that are lacking in the affected cat. The medications are available in either pill or tablet forms and should be given 30 minutes before eating. Typically, the powder variety is recommended for cats. Cats who have exocrine pancreatic insufficiency are often placed on low-fiber diets and may need vitamin supplementation.

It is not recommended to treat feline pancreatitis with products that are not specifically made for the treatment of exocrine pancreatic insufficiency. There are many supplements that are advertised to aid in digestion, however they do not contain the appropriate enzymes that cats with this condition need.

HEALTH SECTION / Exocrine Pancreatic Insufficiency

EPI is a serious disorder that occurs when pancreas produces digestive enzymes or insufficiently produced, which means that the body cannot digest food as well, causing an inadequate absorption of nutrients from food.

The EPI is a major consequence of a wide range of serious diseases that disrupt normal pancreatic function. The diseases which are associated with the EPI are:

• Acute pancreatitis (AP).
• Chronic pancreatitis (CP).
• Pancreatic cancer.
• Pancreatic Surgery.
• Gastric surgery.
• Cystic Fibrosis.
• Diabetes.

Common symptoms of the EPI are:

• Abdominal pain.
• Flatulence (in adults).
• Weight loss.
• Lack of weight gain in children.
• Depositions fats (steatorrhea).
• Fatigue or lack of energy.
• Secretin Test.
• Secretin-cerulein test.
• Lundh test.
• Serum pancreatic enzymes.
• Quantification of fecal fat.
• Pancreatic enzymes in feces.
• Test pancreolauryl.
• Breath Test with 13 C-Mixed triglycerides: Breath Test to diagnose of exocrine pancreatic insufficiency.

Treatment for EPI is the pancreatic enzyme replacement therapy (enzyme replacement treatment, TES). Addition of TES, may also be prescribed vitamins and nutritional supplements.

• Domínguez-Muñoz JE. Pancreatic enzyme replacement therapy for pancreatic exocrine insufficiency: When is it indicated, what is the goal and how to do it? Advances in Medical Sciences 2011; 56(1): 1-5. DOI:10.2478/v10039-011-0005-3.
• Domínguez-Muñoz JE. Pancreatic exocrine insufficiency: Diagnosis and treatment. Journal of Gastroenterology and Hepatology 2011; 26(2):12-16.

Chronic Fatigue Syndrome ME/CFS and
Exocrine Pancreatic Insufficiency (EPI)

There are many paths to ME/CFS. It is chronic, has a wide range of symptoms, and is very difficult to diagnose and treat. ME/CFS is short for myalgic encephalomyelitis (ME) and Chronic Fatigue Syndrome (CFS). Other names used include chronic fatigue and immunity deficiency syndrome (CFIDS), systemic exertion intolerance disorder (SEID), myalgic encephalopathy, or post viral fatigue syndrome (PVFS). It is often misunderstood, as the ‘chronic fatigue’ label almost sounds benign, or a mental state, and does not do justice to all the symptoms people are suffering from. What a misnomer really, as it is horrible and debilitating.

ME/CFS is tough to describe to those that have not experienced it either firsthand, or as a caretaker. Even close friends and family will not truly understand unless they have gone through something similar, or are taking care of you on a day-to-day basis. There are of course various levels of ME/CFS, from completely debilitated and unable to communicate, clean and feed yourself, to having no energy for life and being in a constant form of fatigue, pain and malaise, and anything in between. Sometimes you may not even look classically ill, even though you sure feel horribly ill.

Pancreas damage, specifically exocrine pancreatic insufficiency (EPI), is an under-reported and over-suffered cause of ME/CFS. EPI causes malabsorption, malnutrition and thus nutritional deficiencies. Often related issues such as small intestinal bacterial overgrowth (SIBO), Candida yeast overgrowth, acid or silent reflux exacerbate nutritional deficiencies. Over time your metabolism (chemical processes that occur within the body in order to maintain life) struggles and breaks down, and metabolic pathways no longer function properly. The body’s mitochondria have a tougher time generating energy (ATP). This can have an impact anywhere in the body, hence the wide variety of symptoms, and it causes a vicious cycle Whether the trigger for ME/CFS is viral, bacterial, toxic overload, auto-immune, trauma, genetic, unknown, or pancreas damage as in the author’s case, the result is similar.

Below are some of the classic ME/CFS symptoms, which in the author’s case were caused by exocrine pancreatic insufficiency, and treated successfully using the steps in the book:

• Post-exertional exhaustion, malaise, fatigue (PEM)
• Neurological issues such as delayed reactions, memory loss, abnormal sleep patterns, headaches, temporary dyslexia, temporary stuttering, brain fog, confusion, difficulty processing information, difficulty understanding conversations, paresthesia
• Motor impairments, poor coordination, sudden clumsiness, weakness, spasms
• Immune symptoms, non-stop flu-like malaise, difficulty healing, swollen glands
• Gastrointestinal dysfunctions
• Chronic pain, fatigue and malaise
• Cardiovascular dysfunctions
• Breathing dysfunctions
• Sensitivities to light, noise, heat, cold, smell, taste
• Blurry eyesight, night blindness
• Homebound for years and bed/couch ridden for many months

Primal Pancreas – Damage Survival Guide

Exocrine pancreatic insufficiency affects the ability of the pancreas to aid in food digestion. The pancreas is responsible for producing enzymes that help the body break down food and absorb nutrients. Problems with this process can cause digestive and general health issues. People with exocrine pancreatic insufficiency require medical treatment and lifestyle changes to process food properly.

What is Exocrine Pancreatic Insufficiency?

The pancreas releases enzymes into the small intestine that help break down food so the body can access the nutrients within. People with exocrine pancreatic insufficiency do not produce or release enough of these enzymes and so cannot absorb fat and certain vitamins and minerals properly from their food. This can lead to malnutrition and weight loss.

magicmine / Getty Images

Causes

Damage to the pancreas is the primary cause of exocrine pancreatic insufficiency. A condition called chronic pancreatitis can cause inflammation of the organ because it causes the enzymes to begin working early before they have left the pancreas. Alternatively, surgery of the digestive system may lead to exocrine pancreatic insufficiency. Certain inherited disorders can also cause the condition.

chudakov2 / Getty Images

Risk Factors

People who drink alcohol heavily are at a higher risk of developing exocrine pancreatic insufficiency because heavy drinking can lead to pancreatic inflammation. People with immune system disorders are also at higher risk. Cystic fibrosis raises a person’s chance of getting the condition because the body makes very thick mucus that can create blockages in the pancreas. Crohn’s disease, celiac disease, and Schwachman-Diamond syndrome also make developing exocrine pancreatic insufficiency more likely.

Common Symptoms

In mild cases, people with exocrine pancreatic insufficiency may have no symptoms. However, as the condition progresses, symptoms develop such as abdominal discomfort or pain and a feeling of excessive fullness. The individual may also feel bloated and gassy, and pass unpleasant-smelling stools. People with exocrine pancreatic insufficiency often lose weight because the body cannot adequately absorb fats and other nutrients.

Deagreez / Getty Images

Tests

The doctor will gather medical history and a description of symptoms. If symptoms are consistent with the suspected condition, the doctor will order further tests such as those that look for nutrient deficiencies and conditions associated with exocrine pancreatic insufficiency, such as Crohn’s. The doctor may also request stool samples, which a lab will analyze for digestive enzyme content to help the doctor determine if the pancreas is working properly.

bluecinema / Getty Images

Medical Imaging

The doctor may also order imaging tests that allow them to take a detailed look at the pancreas and assess whether it has become inflamed. CT and MRI scans take intricate images of the organ, or the doctor may perform an endoscopy. This procedure involves feeding a small camera through the digestive system using a catheter.

MementoImage / Getty Images

Treatment

The most common treatment for exocrine pancreatic insufficiency is pancreatic enzyme replacement therapy (PERT). Prescription medications replace the enzymes the pancreas is not producing. These need to be taken during meals to ensure the enzymes work at the right time. Some people require additional medicines to reduce acid in the stomach, an excess of which may destroy the enzymes from PERT before they can work. Painkillers can alleviate physical discomfort.

Daisy-Daisy / Getty Images

Self Help

A healthy and balanced diet can help to manage exocrine pancreatic insufficiency. Splitting food consumption into several smaller meals throughout the day can ease digestive problems. Some doctors recommend supplementary vitamins to prevent deficiencies. People with exocrine pancreatic disorder should avoid drinking alcohol, as consumption can make the pancreas more inflamed and worsen the condition. It can also make it harder for the body to absorb fat, which can make weight loss more severe.

marilyna / Getty Images

Prevention

Often, exocrine pancreatic insufficiency cannot be avoided because it has resulted from a factor outside the person’s control, such as a pre-existing health condition. However, certain steps can help prevent chronic pancreatitis, which is a leading cause of exocrine pancreatic insufficiency. Limiting or even eliminating alcohol makes developing pancreatitis far less likely. Quitting smoking, maintaining a healthy diet that’s low in fat, and regular exercise can also prevent pancreas inflammation and pancreatitis.

Tevarak / Getty Images

Prognosis

As long as a doctor promptly diagnoses and treats the condition, the outlook for people with exocrine pancreatic insufficiency is good. Although the condition is unlikely to resolve, PERP and diet can maintain good health. The biggest challenge for people living with exocrine pancreatic insufficiency long-term is maintaining a healthy body weight. It can be helpful to seek advice from a nutritionist to avoid unwanted weight loss.

Exocrine pancreatic insufficiency (EPI) is a condition that occurs then the pancreas starts to lose its ability to aid digestion.

What is the pancreas?

The pancreas is well known amongst people with diabetes as the gland that produces and releases insulin. However, this is not its only function.

The pancreas releases hormones into the blood (endocrine), but also sends some through tube like ducts (exocrine) to certain organs, mainly in the digestive system

The exocrine enzymes it releases – elastase, lipase, protease and amylase – are used in the intestines to help with digestion. It also releases bicarbonate to neutralise stomach acid.

What is exocrine pancreatic insufficiency?

Exocrine pancreatic insufficiency (EPI) is when the pancreatic functions start to falter and there are not enough exocrine enzymes released to digest food properly. As a result, the body struggles to absorb a lot of vital nutrients.

This usually happens due to tissue damage of the pancreas, or as a blockage of the ducts that transfer the enzymes into the intestines, and can lead to several symptoms and complications.

What causes EPI?

One of the most common causes of EPI is cystic fibrosis. About 90% of cystic fibrosis patients have EPI, and many will have it from birth.

However, EPI can also be caused by chronic pancreatitis (CP).

CP is an inflammation of the pancreas, caused, among other things, by alcohol or gallstones. It can stop the pancreas from producing and releasing the hormones or enzymes that it is supposed to. For this reason, it can also cause secondary diabetes

Symptoms of EPI

Because of how it affects the digestive system, the symptoms of EPI have to do with not absorbing enough nutrients from food or digesting it properly. They can include:

• Diarrhoea
• Loss of appetite
• Weight loss
• Steatorrhea (foul smelling feces caused by undigested fat)
• Flatulence
• Stomach pain

Diabetes and EPI

It is unknown exactly what causes certain cases of EPI, but it does occur often in people with insulin dependent diabetes.

Among other theories such as it being caused by a virus, EPI has been hypothesised to be as a result of an autoimmune disease attacking the pancreas, just as type 1 diabetes is.

In 2003, a study of over 1,000 diabetic patients found that insulin dependent diabetics were more likely to produce abnormally low levels of exocrine pancreatic enzymes.

Between 25% and 50% of insulin dependent diabetics were found to have developed exocrine pancreatic insufficiency.

Furthermore, another study published in 2011 found that obese women produced less elastase, one of the exocrine enzymes. A person’s development of type 2 diabetes may be related to obesity, and so they could well suffer with a form of EPI.

By Richard Asa @RickAsa

May 11, 2015

These serious symptoms are overlooked, yet they’re connected to many diseases. Here’s what you should know about exocrine pancreatic insufficiency.


Julie DuBois, 28, has willfully made herself the voice of people with exocrine pancreatic insufficiency (EPI).

A striking blonde with long, flowing hair and an athlete’s physique, Dubois is a dietitian and elite personal trainer with EPI. She has celiac disease and ulcerative colitis. But it was chronic pancreatitis that triggered the EPI.

The condition is difficult to diagnose because it’s an underlying complication of pancreatitis, irritable bowel disorder, diabetes, celiac disease, cystic fibrosis, and other autoimmune diseases.

A deficiency of the exocrine pancreatic digestive enzymes, EPI results in the inability to digest food properly. That leads to a loss of nutrients because they can’t be absorbed in the intestines.

Resulting symptoms include vitamin deficiency, bone loss, and gastrointestinal problems such as weight loss, nausea, loss of appetite, gas, bloating and steatorrhea (loose stools with unabsorbed fat).

If you have exocrine pancreatic insufficiency, you know it’s more than just unpleasant. It’s potentially dangerous. The weight loss from malnutrition has been related to an increased risk of illness and cardiovascular disease, according to a paper on EPI diagnosis and treatment.

Dubois was diagnosed with EPI in 2011 and has talked about having all the usual symptoms, building bathroom breaks into her ballet classes to avoid unfortunate consequences. It became a game changer for her lifestyle, prompting her to set aside embarrassment and see her doctor for diagnosis and treatment.

If you have chronic pancreatitis you are at the greatest risk for EPI. Over years of living with the disease, the inflammation can lead to irreversible damage to the pancreas, including the cells that secrete pancreatic digestive enzymes. If you have the symptoms that characterize EPI, don’t let them fester. Like DuBois, you are much better off discussing the unsavory side of EPI symptoms with your doctor.

Testing for diagnosis of exocrine pancreatic insufficiency is widely available. Sometimes it’s not necessary. “The probability of pancreatic exocrine insufficiency after severe necrotizing pancreatitis, gastrointestinal and pancreatic surgery, as well as in patients with cancer of the head of the pancreas, tends to be higher than 80 percent,” says the paper’s author.

That usually leads you directly to pancreatic enzyme substitution to relieve malnutrition and increase absorption of nutrients the body needs.

Dubois keeps a food journal to document what’s she’s eating and the calories those foods contain. She also records symptoms that seem to be associated with certain foods. That journal helps her, and can help you, fine-tune your diet in consultation with your doctor.

She has the advantage of being a dietician, making her more familiar with what her food options are. But you can educate yourself over time to learn that as well.

Extra measures of support for your gastrointestinal (GI) system include stress reduction and plenty of sleep. Dubois says both affect her GI symptoms, for better or worse.

Generally, you want to avoid dehydration, which can worsen EPI symptoms. Also, ease into a low-fat diet. Less fat could help lead your bowel movements back to regularity and lessen, if not eliminate, stools that are far more unpleasant than usual, to put it politely.

A study of Japanese patients with chronic pancreatitis and steatorrhea found that it occurs less and is milder in that population because their fat intake is lower than that of Americans and Europeans.

You’re still going to need some healthy fats in your diet so you can metabolize mineral supplements and fat-soluble vitamins A, D, E, and K. You need them all. That’s where your doctor or dietitian can help you choose which foods are best for you.

A high-fiber diet may be good for most of us, but for people with EPI, it could lead to more gas and flatulence, a study found. Again, if you have EPI, talk to you doctor about how much fiber you need and how much fiber you can actually ingest.

Another tip: Don’t smoke or drink. Of course, both habits are bad for your general health since they increase the risk of heart disease and cancer. They’re also not friendly to the pancreas.

EPI stays under the radar for a couple of main reasons. One, its symptoms may not seem distinct to you from the disease that causes it. Two, it’s not pretty. But, now that you know what it involves, acknowledge it and get help. Young and beautiful Julie Dubois did, and you can, too.