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ROGELIO SILVA, MD: If you don’t think about EPI, you won't make the diagnosis. You have to connect the dots.
INTERVIEWER: Dr. Silva, tell me a little bit about the types of patients you see in your practice.
ROGELIO SILVA, MD: Well, I'm a gastroenterologist, so we see patients with all sorts of GI conditions, you know. I typically see a patient with EPI at least once a week. Actually my last patient was yesterday.
INTERVIEWER: And do you ever see EPI patients who have been previously misdiagnosed with something else?
ROGELIO SILVA, MD: Yes. Unfortunately EPI can be misdiagnosed. One of the things that makes EPI diagnosis difficult is that the symptoms can overlap with many other conditions: IBS-D, Crohn's disease, ulcerative colitis, and celiac disease.
INTERVIEWER: EPI and IBS-D can look alike. How do you differentiate between these 2 conditions?
ROGELIO SILVA, MD: So, making the distinction between IBS-D and EPI usually requires some questioning. So, if somebody with IBS-D is having unexplained weight loss, I think EPI should be considered. If they have an associated condition, that should raise the suspicion for the diagnosis. Conditions that are associated with EPI include chronic pancreatitis, pancreatectomy, and sometimes there could be patients with diabetes type I or IIIC, patients with pancreatic cancer, or previous gastric surgery.
INTERVIEWER: Thanks for the background, Dr. Silva. How do you make an EPI diagnosis?
ROGELIO SILVA, MD: EPI can be diagnosed clinically. Gathering the patient's history is important. If a patient has the signs and symptoms of EPI and they also have those other associated conditions, then it's a red flag for me. But if a confirmation is needed, we can do a fecal elastase test or we can do a qualitative fecal fat.
INTERVIEWER: When do you run a fecal elastase test?
ROGELIO SILVA, MD: So, that's an interesting question. So, we choose to use fecal elastase testing in patients where the diagnosis is not clear. For example, the patient might have signs and symptoms of EPI but doesn’t have clear-cut, associated conditions.
INTERVIEWER: I know steatorrhea is a classic clinical sign of EPI. Can't a physician simply rely on steatorrhea when diagnosing EPI?
ROGELIO SILVA, MD: Steatorrhea is a symptom of EPI, but usually it's a sign of advanced disease. So we can't use steatorrhea as our only diagnostic indicator. Patients can certainly have EPI without steatorrhea, so if you wait until the patient has steatorrhea to make the diagnosis, you've waited too long.
INTERVIEWER: What are the other telltale signs and symptoms?
ROGELIO SILVA, MD: One of these signs and symptoms can mean EPI: gas, bloating, abdominal pain, diarrhea, or unexplained weight loss.
INTERVIEWER: Makes sense. Now let's switch gears a bit, Dr. Silva, and talk about the impact of EPI.
ROGELIO SILVA, MD: The most important health impact of EPI is the malabsorption of nutrients, particularly fat absorption. When a patient cannot absorb their fats particularly, they also cannot absorb their vitamins that are fat-soluble. The patients need to get those vitamins because they're vital for multiple organ systems.
INTERVIEWER: With that in mind, it sounds like diagnosing EPI in a timely manner is very important.
ROGELIO SILVA, MD: Absolutely important. You want to catch these patients much earlier in the process, start treating them. The earlier we make the diagnosis, the better for the patient.
INTERVIEWER: I imagine that living with ongoing symptoms can be tough. Can you talk a little bit about the social and emotional impacts of EPI?
ROGELIO SILVA, MD: Patients may have symptoms for many months before they see their physician. Sometimes they can have accidents and have trouble making it to the bathroom in time. That could lead to some emotional problems and patients may want to isolate themselves and not go out with their family. Patients with EPI have symptoms that are sometimes uncomfortable to talk about. Talking about having chronic loose stools or steatorrhea, bloating, and gassiness could be embarrassing.
INTERVIEWER: So is there a good approach to help patients open up about their GI symptoms?
ROGELIO SILVA, MD: Ask them what their stool characteristics are. What's the stool frequency? How often are they going to the bathroom? What their bowel movements look like. Is there an oiliness in the stools? Are they floating? Do they have a particular foul odor? Have they had some weight loss? Where is the abdominal pain? Do they have bloating and gassiness?
INTERVIEWER: Great advice, Dr. Silva. Do you have any final thoughts to share about EPI?
ROGELIO SILVA, MD: I think the most important thing for a clinician would be to keep the diagnosis in mind. If you keep the diagnosis in mind, you'll make the diagnosis earlier. The earlier we make the diagnosis, the better for the patient.
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