EPI is largely a clinical diagnosis

Have an open discussion with your patients1,2

Encourage patients who may be experiencing GI symptoms to be open and discuss all of their symptoms with you. Some patients may feel embarrassed or uncomfortable talking about GI symptoms, but you can help make it easier by letting them know that you're comfortable listening to them. Make sure to discuss the following with your patients:

  • When the symptoms started
  • Frequency and severity of symptoms
  • Any differences in stools and bowel movements
  • Any unexplained weight loss
  • Patient diet and eating habits
  • Medications or herbal supplements the patient may be taking

It is key to take a history in your patients suspected of having EPI since not all patients will present with typical signs and symptoms of EPI as some patients will limit fat intake because of symptoms.

EPI should be suspected in patients who present with symptoms including frequent diarrhea, unexplained weight loss, fatty stools, flatulence, bloating, or abdominal pain, especially if they have also have been diagnosed with a condition that has been associated with EPI.

Help your patients open up about their GI symptoms.

Laboratory tests that evaluate fat malabsorption help to confirm a diagnosis of EPI1,2

There are a number of direct and indirect tests that can be performed to confirm a diagnosis of EPI. Once a diagnosis of EPI has been confirmed, you can help patients manage the symptoms and ensure a normal nutritional status.


Quantitative fecal fat
The 72-hour fecal fat collection is the standard for indirect testing, expressed as the coefficient of fat absorption (CFA). This test is the current standard for measuring fat absorption in clinical trials with EPI patients. By measuring the stool fat and knowing the fat content of the diet, researchers can determine the CFA – the percentage of fat in the diet that is absorbed. Normal CFA is approximately 93%. Steatorrhea is classically defined as at least 7 g of fecal fat over 24 hours, in the context of a 72-hour stool test while on 100 g of fat daily. Quantification of fecal fat can be inconvenient and difficult for both patients and laboratory personnel.

Qualitative fecal fat
Qualitative fecal fat analysis by microscopic examination of random stool samples can be used as a screening test.

Fecal elastase
The fecal elastase concentration, or FEC, measures the concentration of pancreatic enzyme elastase. Its sensitivity is limited to moderate or severe disease (lower sensitivity with milder steatorrhea), and it can give false positive results when diluted by watery stools. It is, however, done on a single stool sample, and it is used in clinical practice.


Direct stimulation test
Direct measurements of pancreatic function such as the secretin or cholecystokinin stimulation test are the standard for assessment of the exocrine function of the pancreas. This test includes direct duodenal intubation, stimulation with secretin and cholecystokinin, and collection of pancreatic secretions for pH, bicarbonate, and enzyme analysis. These tests are invasive and usually only performed by gastroenterologists at specialized centers.

References: 1. Fieker A, Philpott J, Armand M. Enzyme replacement therapy for pancreatic insufficiency: present and future. Clin Exp Gastroenterol. 2011;4:55-73. 2. Domínguez-Muñoz JE. Pancreatic enzyme therapy for pancreatic exocrine insufficiency. Curr Gastroenterol Rep. 2007;9(2):116-122. 3. Leeds JS, Oppong K, Sanders DS. The role of fecal elastase-1 in detecting exocrine pancreatic disease. Nat Rev Gastroenterol Hepatol. 2011;8(7):405-415. 4. Hammer HF. Pancreatic exocrine insufficiency: diagnostic evaluation and replacement therapy with pancreatic enzymes. Dig Dis. 2010;28(2):339-343. 5. Domínguez-Muñoz JE. Pancreatic exocrine insufficiency: diagnosis and treatment. J Gastroenterol Hepatol. 2011;26(suppl 2):12-16. 6. Augarten A, Ben Tov A, Madgar I, et al. The changing face of the exocrine pancreas in cystic fibrosis: the correlation between pancreatic status, pancreatitis and cystic fibrosis genotype. Eur J Gastroenterol Hepatol. 2008;20(3):164-168.
7. Weintraub A, Blau H, Mussaffi H, et al. Exocrine pancreatic function testing in patients with cystic fibrosis and pancreatic sufficiency: a correlation study. J Pediatr Gastroenterol Nutr. 2009;48(3):306-310. 8. Cohen JR, Schall JI, Ittenbach RF, et al. Fecal elastase: pancreatic status verification and influence on nutritional status in children with cystic fibrosis. J Pediatr Gastroenterol Nutr. 2005;40(4):438-444.