Exocrine pancreatic insufficiency (EPI) is “defined by a deficiency in exocrine pancreatic enzymes resulting in an inability to maintain normal digestion.”1 This deficiency leads to inadequate digestion of nutrients. In particular it leads to fat malabsorption, which occurs when intraduodenal levels of lipase fall below 5% to 10% of normal enzyme output.1 The results of deficiency include pancreatic steatorrhea, weight loss, and decreased quality of life.

When EPI is due to cystic fibrosis (CF) or chronic pancreatitis, the decreased bicarbonate output causes lower intestinal pH, thereby precipitating bile salt acids, impairing micelle formation of fats, and resulting in fat maldigestion.

Many physicians experience “significant confusion” regarding dosing and administration of pancreatic enzymes in patients with this condition, and which tests for EPI are the best to use in diagnosis. A recent opinion piece by Struyvenberg et al “aims to address the existing myths, remove the current confusion, and function as a practical guide to the diagnosis and treatment of EPI.”1


EPI occurs only with >90% loss of exocrine pancreatic function.

Expert Opinion

EPI represents a graded response rather than a precise cut-off in pancreatic function and thus patients may benefit from early testing.

Chronic pancreatitis is a leading cause of EPI. In addition, there are a host of other pancreatic and non-pancreatic causes, including a history of extensive necrotizing acute pancreatitis, pancreatic cancer, pancreatic surgery, CF, celiac disease, diabetes mellitus, Crohn’s disease, gastric surgery, short bowel syndrome, and Zollinger-Ellison syndrome.

Symptoms of EPI include steatorrhea (ie, clay-colored, loose, greasy, foul-smelling large stools), abdominal discomfort, bloating, and weight loss. The authors state that floating stools are not indicative of steatorrhea. On the other hand, stools that stick to the toilet bowl are a more specific sign.

The authors note that infants—especially formula-fed preterm infants—represent the largest population of individuals with EPI.