Exocrine pancreatic insufficiency (EPI) is an underrecognized yet clinically significant condition that can profoundly affect digestive health and nutritional status. Characterized by inadequate pancreatic enzyme activity, EPI often presents with nonspecific gastrointestinal symptoms that overlap with more common disorders, making it easy to miss in routine practice.
In a recent discussion, Sarah Enslin, PA-C, and Jennifer Geremia, PA-C, highlighted the evolving understanding of EPI, emphasizing the growing awareness of the condition, the challenges that continue to delay diagnosis, and the critical need for more effective testing and treatment strategies to improve patient outcomes.
Both experts pointed to the need for greater clinical awareness and improved diagnostic strategies for EPI, a condition they say is often overlooked despite its significant impact on patients.
Reflecting on trends in clinical practice, Enslin noted that EPI is not a new diagnosis, but rather one that clinicians are recognizing more frequently as awareness improves. In her view, the condition has likely been underdiagnosed for years, only now gaining broader attention as providers become more attuned to its presentation and associated risk factors.
Geremia echoed this sentiment, stressing that EPI should remain firmly in the differential diagnosis for patients with compatible symptoms and comorbidities. Both underscored that missing the diagnosis can have meaningful consequences, including poor quality of life and nutritional deficiencies.
The speakers highlighted the nonspecific nature of EPI symptoms as one of the greatest barriers to diagnosis. As Enslin explained, patients commonly present with vague complaints such as chronic diarrhea, bloating, and abdominal discomfort, all of which are symptoms that can easily be attributed to more common gastrointestinal disorders. While clinicians often associate EPI with chronic pancreatitis or cystic fibrosis, both experts emphasized the importance of broadening that perspective, pointing to additional at-risk populations, including patients with pancreatic cancer, intraductal papillary mucinous neoplasms, or a history of pancreatic surgery.
Geremia expanded this discussion beyond classic pancreatic disease, noting that EPI may also be missed in patients with less obvious pancreatic abnormalities, such as cysts or atrophy. They further emphasized that certain non-pancreatic conditions, such as prior gastric bypass surgery, inflammatory bowel disease, and celiac disease, should also prompt consideration of EPI, as it may coexist and go unrecognized.
Diagnostic challenges also remain a key issue. Enslin described the gold standard 72-hour fecal fat test as impractical for most patients, while the more commonly used fecal elastase test, though convenient, has notable limitations in accuracy. Both experts suggested that newer approaches, including breath or serum-based testing, could help address these gaps if validated and adopted more widely.
When discussing management, both experts pointed to pancreatic enzyme replacement therapy (PERT) as the cornerstone of treatment. As Enslin explained, therapy is individualized based on symptom improvement, with goals centered on reducing stool frequency, improving consistency, and alleviating bloating to enhance overall quality of life. However, they also identified important unmet needs, including the lack of non-porcine enzyme formulations for patients with dietary restrictions.
Ultimately, both experts agreed that while progress has been made in recognizing EPI, delays in diagnosis remain common. They stressed that continued efforts to improve awareness, refine diagnostic tools, and expand treatment options will be essential to improving outcomes for patients.
Editors’ note: Enslin reports no relevant disclosures. Geremia reports relevant disclosures with Madrigal, Ipsen, Pfizer, AbbVie, and others.
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