Exocrine Pancreatic Insufficiency (EPI) is a condition that occurs when the pancreas fails to deliver adequate amounts of digestive enzymes to the small intestines. These enzymes are essential for breaking down food, especially fats, proteins, and carbohydrates. EPI, if not diagnosed or treated, can lead to malnutrition, digestive discomfort, and a variety of associated symptoms.
Most people think of the pancreas as an organ that, when it goes awry, causes conditions like Diabetes mellitus. However, hormone modulation is only about 5% of the pancreas’s role in the body. The other 95% is involved with exocrine function, aka enzyme production.
In this article, I break down EPI from a clinical perspective, including risk factors, symptoms, and treatments.
What is Exocrine Pancreatic Insufficiency (EPI)?
EPI is a condition where the pancreas fails to secrete and/or deliver enough digestive enzymes,
such as lipase, amylase, and protease, needed to break down food in the digestive system. This deficiency results in the incomplete digestion of food, leading to malabsorption and subsequent nutritional deficiencies.
With the improper breakdown of food particles, bacteria, and other microorganisms can metabolize and ferment these nutrients. The symptoms of fermentation gas can be gas, bloating, distention of the abdomen, diarrhea, and sometimes constipation.
EPI can be associated with various gastrointestinal disorders, such as chronic pancreatitis, cystic fibrosis, or pancreatic cancer. Still, it can also occur due to other often unknown causes.
Historical Overview of EPI in the Medical Community
Historically, EPI has been recognized as a complication of chronic pancreatitis, but its broader implications have only recently been explored. Initially, EPI was viewed as a disease of the pancreas, with treatment focusing solely on pancreatic enzyme replacement therapy (ERT).
However, with growing interest in Naturopathic medicine, the understanding of EPI has expanded to include its connection with conditions like SIBO and its role in gut health.
Who Can Get EPI? What Are the Risk Factors?
EPI can affect individuals of all ages, though certain groups are at higher risk:
- Chronic pancreatitis: Individuals with chronic inflammation of the pancreas are at a high risk of developing EPI.
- Cystic fibrosis: This genetic disorder causes thick mucus that blocks pancreatic enzyme production.
- Pancreatic cancer: Tumors in the pancreas can impair enzyme secretion.
- Aging: As people age, pancreatic function can naturally decline, sometimes leading to EPI.
- Gallbladder dysfunction: Conditions that affect bile production may exacerbate digestive issues linked to EPI.
- Alcohol abuse: Chronic alcohol consumption is a well-known risk factor for chronic pancreatitis and EPI.
The risk of EPI increases with the severity and duration of these conditions, but lifestyle factors such as diet, stress, and gut health may also play a role.
Symptoms of Exocrine Pancreatic Insufficiency (EPI)
The symptoms of EPI arise from the body’s inability to digest food properly due to insufficient enzyme production or delivery to the first part of the small intestines, known as the duodenum.
Common symptoms include:
- Greasy, foul-smelling stools (steatorrhea), often difficult to flush
- Bloating, abdominal distention, or discomfort after meals
- Frequent diarrhea or loose stools
- Unexplained weight loss despite normal or increased food intake
- Nutrient deficiencies, particularly in fat-soluble vitamins (A, D, E, K)
- Fatigue or weakness due to malabsorption
- Constipation depending on what type of microorganisms are fermenting the undigested food
EPI can also lead to vitamin deficiencies, as the inability to absorb nutrients like fats and proteins can result in a lack of essential vitamins, contributing to broader health issues.
How is EPI Diagnosed?
Diagnosing EPI involves several steps and tests. The most common methods include:
- Fecal Elastase Test: This stool test measures fecal elastase level, an enzyme secreted by the pancreas. Low levels indicate insufficient enzyme production and a potential EPI diagnosis.
- Secretin Stimulation Test: This is a more invasive test where secretin is injected to stimulate pancreatic enzyme production. It is used less frequently but can provide accurate insights.
- Imaging: Imaging studies, such as CT scans or MRI, may be used to identify underlying conditions (e.g., chronic pancreatitis, tumors).
- Small Bowel Imaging: In some cases, testing for SIBO (Small Intestinal Bacterial Overgrowth) or other related conditions may be part of the diagnostic workup, as these conditions can mimic or contribute to EPI symptoms.
Learn more about our in-house SIBO testing.
Treatments for EPI
Conventional treatment for EPI primarily focuses on replacing the missing enzymes in the intestines to help with digestion. While effective for symptom relief, these treatments do not address the root causes of EPI, and they may require long-term management.
A naturopathic medical approach to treating EPI looks beyond enzyme replacement therapy by focusing on healing the entire digestive system and addressing underlying causes.
Here’s a look at all of the tools we use when appropriate:
Pancreatic Enzyme Replacement Therapy (ERT)
The most common treatment for EPI is prescription enzyme supplementation. These supplements contain lipase, amylase, and protease, which assist in the digestion of fats, proteins, and carbohydrates. These medications can often be covered by insurance and provide enzymes activated/used by the body in a pH of around 6-8.
These medications (commonly including Creon and Zenpep) are measured or dosed out in units of lipase. The dose that you might need can vary. This therapy should always be prescribed and monitored by your doctor.
It is important to note that some of these enzymes are derived from animal sources, including porcine (pigs). Like with any treatment, there are potential side effects of lipase supplementation, including a rare condition called fibrosing colonopathy.
Dietary Modifications
When treating EPI, patients are often advised to reduce fat intake, as fats are the most difficult to digest in cases of EPI.
While this is recommended for many, it is important to confirm with your doctor if this dietary modification is right for you, and that other conditions, such as BAM (Bile Acid Malabsorption), Bile Acid reflux, Gilbert’s Syndromes are all ruled out as the gallbladder and liver make and store bile which helps emulsify and concentrate bile, which is used for the emulsification of fats in your food.
To address deficiencies caused by malabsorption, individuals may need testing and natural medications/supplements containing fat-soluble vitamins (A, D, E, K), along with minerals like calcium and magnesium.
Digestive Enzyme Supplements
In addition to conventional enzyme replacements, vegetarian/vegan digestive enzyme supplements (e.g., protease, lipase, and amylase) may support digestion and reduce bloating and discomfort.
I use this approach to work more holistically with the prescription enzymes as the pH window is much broader. Most vegan/vegetarian enzymes work in a pH between 2-12. This allows any food particles that make it past the first part of the small intestine to the jejunum and illium to be broken down, reducing unwanted fermentation and thus helping to reduce those pesky IBS symptoms.
HCl Supplementation
Hydrochloric acid (HCl) supplementation can help improve stomach acidity, aiding in digestion and enzyme activation—a word of warning that not everyone should be on HCL enzymes. Ideally, test for achlorhydria or hypochlorhydria before starting HCL.
As a general rule, over 80% of Blood type As and Blood Type ABs have low stomach acid, and this population might benefit from HCL. I generally do not recommend the HCL challenge test, which is when one keeps taking HCL until they feel a warming/burning sensation in their stomach. Instead, if a blood type A has EPI, I would generally recommend a full spectrum enzyme with HCL and Ox bile to supplement the prescription enzymes.
Ox Bile
Ox bile can also be added to an EPI treatment protocol to help with the emulsification and absorption of fats. Bile generally tends to be low in most blood types As and ABs, and adding ox bile in with ERT is usually beneficial.
I generally prefer a full-spectrum enzyme with ERT. Full spectrum usually means vegan enzymes with HCL and Ox bile for most.
Please note that you should speak to a doctor before starting Ox Bile as this can worsen other digestive tract symptoms, such as BAM or Bile acid malabsorption.
Gut Health Support
The use of probiotics, prebiotics, and postbiotics can help restore a healthy balance of gut flora. But, I recommend testing the microbiome starting. Herbal antimicrobials like oregano oil or berberine may be used to treat gut imbalances and infections/overgrowths like SIBO or SIFO that could exacerbate EPI. But EPI is usually the cause of SIBO, not the other way around
Anti-inflammatory Herbs
Turmeric (curcumin) and fish oil are commonly used to reduce inflammation in the pancreas and improve digestive health.
Liver and Gallbladder Support
Milk thistle, dandelion root, and bitter herbs like artichoke support bile production, which is essential for the digestion of fats.
Natural therapies should be used in conjunction with allopathic treatments under the guidance of a healthcare professional.
The EPI and SIBO Connection
EPI and SIBO (Small Intestinal Bacterial Overgrowth) often coexist. SIBO occurs when excessive bacteria grow in the small intestine, interfering with digestion and nutrient absorption. SIBO can exacerbate EPI symptoms by creating an environment where digestion is further impaired, leading to increased malabsorption and inflammation.
Treating SIBO with herbal antimicrobials or prescription antibiotics (e.g., Rifaximin) can help reduce bacterial overgrowth and alleviate some of the digestive burden caused by EPI. Furthermore, addressing SIBO may enhance pancreatic function over time.
Overall, I find that around 70% of my patients with EPI who undergo proper treatment and management are able to stop all ERT and other EPI treatments after 3-12 months.
Our Personalized Approach to EPI Treatment
At our practice, we recognize that EPI treatment is not one-size-fits-all. We’ve developed a unique, personalized EPI management approach beyond conventional treatments.
Customized Enzyme Therapy Based on Individual Factors
Unlike standard approaches that rely solely on prescription enzymes, our treatment protocols are tailored to each patient’s unique biochemistry, including genetic factors like blood type:
- Blood Type A and AB Patients often benefit from our full-spectrum enzyme therapy that includes targeted supplementation with ox bile and/or HCl to optimize protein and fat breakdown.
- Blood Type O and B Patients may respond differently, requiring customized enzyme formulations that support their specific digestive patterns.
The Dual-Enzyme Advantage
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Our clinical experience has shown that combining prescription enzymes with plant-based enzymes offers superior results for many patients:
- Prescription Enzymes (Creon, Zenpep) work efficiently within the narrow pH window of the duodenum (first part of small intestine)
- Vegetarian Enzymes function across a broad pH spectrum from the mouth to the colon, providing comprehensive digestive support throughout the entire digestive tract
This dual approach ensures complete food breakdown and maximizes nutrient absorption, addressing the root cause of EPI symptoms rather than just managing them.
Our Comprehensive EPI Treatment Philosophy
We believe effective EPI management must address:
- Enzyme Replacement – Customized to your specific digestive needs and genetic factors
- Underlying Causes – Identifying and treating related conditions like SIBO that exacerbate EPI
- Nutritional Rehabilitation – Targeted supplementation to correct deficiencies caused by malabsorption
- Gut Microbiome Balance – Optimizing intestinal flora to support proper digestion and absorption
- Lifestyle Modifications – Practical dietary and stress management strategies that support pancreatic function
This multi-faceted approach allows us to achieve superior outcomes compared to conventional enzyme replacement therapy alone.
EPI Frequently Asked Questions (FAQs)
What causes Exocrine Pancreatic Insufficiency (EPI)?
EPI can result from chronic pancreatitis, cystic fibrosis, pancreatic cancer, gallbladder disease, or a decline in pancreatic function associated with aging. Gut imbalances like SIBO or SIFO can also contribute to EPI.
Can EPI be treated naturally?
Yes! EPI treatments are natural, including prescription enzyme replacements. Additional natural treatments also include digestive enzymes, HCl supplementation, gut healing with probiotics, and the use of anti-inflammatory herbs like turmeric and omega-3s.
How does SIBO contribute to EPI?
SIBO can increase inflammation in the small intestine, causing malabsorption or what some call a leaky gut. Removing the overgrowth of bacteria allows the body to heal, reducing malabsorption. Reducing malabsorption can take pressure off the pancreas and reduce the need for more enzymes to break down and absorb the nutrients from your foods, thus giving the pancreas more time to heal and prepare for the next meal.
In my practice, I find that curing SIBO doesn’t typically also cure EPI, but it often helps. If EPI is still present after SIBO and IMO have been cured, treating the remaining EPI is that much easier.
How is EPI diagnosed?
EPI is diagnosed using tests like fecal elastase, secretin stimulation, and imaging studies. At the office, we generally prefer the widely available pancreatic elastase test as our primary diagnostic tool. Secretin stimulation tests are only performed at a handful of health centers, are invasive and costly, and are used mainly for research. Doctors may also test for related conditions like SIBO or SIFO.
Can EPI be reversed?
While EPI caused by chronic damage (e.g., from pancreatitis) may not be fully reversible, treatment can manage symptoms and improve quality of life. A holistic approach, including enzyme replacement and gut health support, can offer substantial relief. I find that most of my patients can stop or reduce ERT and supplementation for EPI after 12 months.
Conclusion
Exocrine Pancreatic Insufficiency (EPI) is a serious condition that affects digestion and nutrient absorption, leading to malnutrition and a range of uncomfortable symptoms. Although enzyme replacement therapy is important for symptom management, a holistic approach that addresses underlying causes offers significant potential for long-term relief.
Individuals with EPI can restore digestive health and improve their overall well-being by integrating naturopathic medical treatments and addressing lifestyle factors.
Dr. Brody is a Naturopathic Physician specializing in gastroenterology and digestive health. He is a Fellow of the American Board of Naturopathic Gastroenterology. With extensive experience treating complex digestive disorders, Dr. Brody combines conventional medical diagnostics with evidence-based natural medicine to address the root causes of gastrointestinal conditions. His integrated approach has helped countless patients overcome challenging digestive issues, including EPI, SIBO, IMO, and other functional gastrointestinal disorders.
For personalized care and treatment of digestive conditions including Exocrine Pancreatic Insufficiency, visit www.brodynd.com or call our office to schedule a consultation.
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