Underlying Conditions and
Procedures

EPI can result from various etiologies

Exocrine Pancreatic Insufficiency (EPI) is caused by inadequate production, delivery, or activity of the pancreatic enzymes needed for digestion.1

Image conveying decreased production of pancreatic enzymes in pancreas

Decreased production of pancreatic enzymes2,3

Loss of functional pancreatic parenchyma or reduced endogenous stimulation of the pancreas can result in decreased production of enzymes.

Image conveying decreased delivery of pancreatic enzymes to the duodenum

Decreased delivery of pancreatic enzymes to the duodenum2,3

An obstruction in the duct can cause a decrease in the delivery of pancreatic enzymes to the duodenum.

Image conveying decreased activity of pancreatic enzymes

Decreased activity of pancreatic enzymes2,3

Activity of enzymes can be reduced due to postcibal asynchrony or intraluminal activation.

EPI may be present in patients with the following underlying conditions or procedures:

Other underlying conditions and procedures in which EPI has been reported include:

References: 1. Lindkvist B. Diagnosis and treatment of pancreatic exocrine insufficiency. World J Gastroenterol. 2013;19(42):7258-7266. 2. Durie P, Baillargeon J-D, Bouchard S, Donnellan F, Zepeda-Gomez S, Teshima C. Diagnosis and management of pancreatic exocrine insufficiency (PEI) in primary care: consensus guidance of a Canadian expert panel. Curr Med Res Opin. 2018;34(1):25-33. 3. Pezzilli R, Andriulli A, Bassi C, et al; Exocrine Pancreatic Insufficiency collaborative Group. Exocrine pancreatic insufficiency in adults: a shared position statement of the Italian Association for the Study of the Pancreas. World J Gastroenterol. 2013;19(44):7930-7946. 4. Keller J, Layer P. Human pancreatic exocrine response to nutrients in health and disease. Gut. 2005;54(suppl 6):vi1-vi28. 5. Borowitz D, Baker SS, Duffy L, et al. Use of fecal elastase-1 to classify pancreatic status in patients with cystic fibrosis. J Pediatr. 2004;145(3):322-326. 6. Kempeneers MA, Ali UA, Issa Y, et al; for Dutch Pancreatitis Study Group. Natural course and treatment of pancreatic exocrine insufficiency in a nationwide cohort of chronic pancreatitis. Pancreas. 2020;49(2):242-248. 7. Layer P, Yamamoto H, Kalthoff L, Clain JE, Bakken LJ, DiMagno EP. The different courses of early- and late-onset idiopathic and alcoholic chronic pancreatitis. Gastroenterology. 1994;107(5):1481-1487. 8. Sandhu BS, Hackworth WA, Stevens S, Bouhaidar DS, Zfass AM, Sanyal AJ. Recurrent flares of pancreatitis predict development of exocrine insufficiency in chronic pancreatitis. Clin Gastroenterol Hepatol. 2007;5(9):1085-1091. 9. Matsumoto J, Traverso LW. Exocrine function following the Whipple operation as assessed by stool elastase. J Gastrointest Surg. 2006;10(9):1225-1229. 10. Yuasa Y, Murakami Y, Nakamura H, et al. Histological loss of pancreatic exocrine cells correlates with pancreatic exocrine function after pancreatic surgery. Pancreas. 2012;41(6):928-933. 11. Phillips ME. Pancreatic exocrine insufficiency following pancreatic resection. Pancreatology. 2015;15(5):449-455. 12. Sabater L, Ausania F, Bakker OJ, et al. Evidence-based guidelines for the management of exocrine pancreatic surgery. Ann Surg. 2016;264(6):949-958. 13. Partelli S, Frulloni L, Minniti C, et al. Fecal elastase-1 is an independent predictor of survival in advanced pancreatic cancer. Dig Liver Dis. 2012;44(11):945-951. 14. Sikkens ECM, Cahen DL, de Wit J, Looman CWN, van Eijck C, Bruno MJ. A prospective assessment of the natural course of the exocrine pancreatic function in patients with a pancreatic head tumor. J Clin Gastroenterol. 2014;(48)5:e43-e46. 15. Subramaniam S, Nobar N, Besherdas K. Pancreatic enzyme replacement therapy in chronic pancreatitis and pancreatic cancer – are we getting it right? Gut. 2015;64:A307-A308. doi:10.1136/gutjnl-2015-309861.664. 16. Belyaev O, Herzog T, Chromik AM, Meurer K, Uhl W. Early and late postoperative changes in the quality of life after pancreatic surgery. Langenbecks Arch Surg. 2015;64:A307-A308. 17. Sikkens ECM, Cahen DL, de Wit J, Looman CWN, van Eijck C, Bruno MJ. Prospective assessment of the influence of pancreatic cancer resection on exocrine pancreatic function. Br J Surg. 2014;101(2):109-113. 18. Halloran CM, Cox TF, Chauhan S, et al. Partial pancreatic resection for pancreatic malignancy is associated with sustained pancreatic exocrine failure and reduced quality of life: a prospective study. Pancreatology. 2011;11(6):535-545. 19. Roeyen G, Jansen M, Ruyssinck L, et al. Pancreatic exocrine insufficiency after pancreaticoduodenectomy is more prevalent with pancreaticogastrostomy than with pancreaticojejunostomy. A retrospective multicentre observational cohort study. HPB (Oxford). 2016;18(12):1017-1022. 20. Tran TCK, van ‘t Hof G, Kazemier G, et al. Pancreatic fibrosis correlates with exocrine pancreatic insufficiency after pancreatoduodenectomy. Dig Surg. 2008;25(4):311-318. 21. Hollemans RA, Hallensleben NDL, Mager DJ, et al; for Dutch Pancreatitis Study Group. Pancreatic exocrine insufficiency following acute pancreatitis: systematic review and study level meta-analysis. Pancreatology. 2018;18(3):253-262. doi:10.1016/j.pan.2018.02.009 22. Huang W, de la Iglesia-Garcia D, Baston-Rey I, et al. Exocrine pancreatic insufficiency following acute pancreatitis: systematic review and meta-analysis. Dig Dis Sci. 2019;64(7):1985-2005. doi:10.1007/s10620-019-05568-9 23. Capurso G, Traini M, Piciucchi M, Signoretti M, Arcidiacono PG. Exocrine pancreatic insufficiency: prevalence, diagnosis, and management. Clin Exp Gastroenterol. 2019;12:129-139. doi:10.2147/CEG.S168266 24. Xu Y, Wu D, Zeng Y, Wang X. Pancreatic exocrine function and morphology following an episode of acute pancreatitis. Pancreas. 2012;41(6):922-927. 25. Singh VK, Haupt ME, Geller DE, Hall JA, Quintana Diez PM. Less common etiologies of exocrine pancreatic insufficiency. World J Gastroenterol. 2017;23(39):7059-7076. 26. Jasdanwala S, Babyatsky M. Crohn’s disease and acute pancreatitis: a review of literature. J Pancreas (Online). 2015;16(2):136-142. doi:10.6092/1590-8577/2951 27. Alkaade S, Vareedayah AA. A primer on exocrine pancreatic insufficiency, fat malabsorption, and fatty acid abnormalities. Am J Manag Care. 2017;23(12)(suppl):S203-S209. 28. Piciucchi M, Capurso G, Archibugi L, Delle Fave MM, Capasso M, Delle Fave G. Exocrine pancreatic insufficiency in diabetic patients: prevalence, mechanisms, and treatment. Int J Endocrinol. 2015:1-7. 29. Chaudhary A, Domínguez-Muñoz JE, Layer P, Lerch MM. Pancreatic exocrine insufficiency as a complication of gastrointestinal surgery and the impact of pancreatic enzyme replacement therapy. Dig Dis. 2020;38(1):53-68. doi:10.1159/000501675 30. Zhang J, Hou J, Liu D, et al. The prevalence and characteristics of exocrine pancreatic insufficiency in patients with type 2 diabetes: a systematic review and meta-analysis. Int J Endocrinol. 2022;2022:7764963. doi:10.1155/2022/7764963 31. Radlinger B, Ramoser G, Kaser S. Exocrine pancreatic insufficiency in type 1 and type 2 diabetes. Curr Diab Rep. 2020;20(6):18. doi:10.1007/s11892-020-01304-0