Doctor Q+A: What is exocrine pancreatic insufficiency (EPI) and how is it treated?

B.S. Dietetics, Dietitian, Health Professional

_I was fortunate enough to speak with gastroenterologist Philip Hart, M.D in a phone interview. Dr. Hart is affiliated with Ohio State University (OSU) Wexner Medical Center in Columbus, OH and serves as assistant professor in Clinical Gastroenterology, Hepatology & Nutrition at OSU. _

Q: Why do so many patients put off seeing a gastroenterologist (GI)?A: That’s an important question. We recently completed a survey supported by the American Gastroenterological Association (AGA) and we found that patients wait on average four years before they discuss symptoms with a health care provider. We were surprised by how long this time was, and in those patients that reported difficulty discussing things with health care providers,** 60 percent cited embarrassment** as the primary reason for not wanting to discuss their symptoms.

Q: Do you have any suggestions that would make it easier for a patient to communicate with their doctor?

A: One of the things I can share with patients is that this is what we are here for — we’ve been through training and are very comfortable discussing these types of issues. We want patients to realize that they don’t have to suffer from these symptoms alone, but the only way we are able to provide help as health care providers is when those issues are brought to us.

Q: Exocrine pancreatic insufficiency (EPI) is one of the most under-recognized pancreatic conditions. What symptoms should alert patients to talk with their doctors?

A: In the most severe forms, symptoms that can be related to this condition are the development of greasy stools or unexplained weight loss. Symptoms that can happen in milder forms of EPI would be things like abdominal bloating and gas. The overlap with other more common GI conditions can make this sometimes difficult to tease apart.

Q: How early should someone go see a doctor when showing symptoms and why is this important?

A: To some degree that depends on the severity of the symptoms. I would encourage patients that if they are having to miss work or adjust their social schedule on account of symptoms, like avoiding meals with friends or family, those are signs to visit their health care provider.

Q: How do you diagnose EPI? And why is it so under-recognized?

A: There are probably multiple reasons that it is under-recognized. One is just the lack of awareness. In our survey, we found that only one out of five patients were able to recognize the symptoms related to EPI. As I mentioned, the symptoms can be similar to other more common GI conditions, which makes the diagnosis of EPI challenging, and many primary care providers are not familiar with it. It takes a combination of the patient’s clinical history and test results, specifically stool test results.

Q: How is EPI treated? Is treatment expensive or hard to find?

A: One of the reasons the AGA pushed for this survey is that EPI is a highly treatable condition. These patients with under-recognized EPI are suffering from their symptoms unnecessarily. The treatment consists of medication that is referred to as pancreatic enzymes. These are widely available and easy for patients to take. They take the enzymes with meals and it replaces the digestive function of the pancreas.

Q: Are there nutrition or lifestyle changes that can benefit a patient with EPI?

A: That’s an important question. Previously we would have asked patients to be on a very fat-restricted diet but it’s become more clear that that is not necessary. Aside from avoiding excessively high amounts of fat, we don’t have any other dietary restrictions for these patients.

Q: How often is EPI seen in association with other conditions (like pancreatitis)?

A: EPI is a complication of disease of the pancreas. There are a variety of these diseases that are highly associated with EPI: Chronic pancreatitiscystic fibrosis, partial or complete removal of the pancreas through surgery, and those patients with pancreatic cancer.

Q: Anything else you’d like to mention that we haven’t discussed already today?

A: Again, one of the most alarming things from our survey was this long delay between a patient’s symptoms and discussing them with a health care provider.  I want to reiterate the importance of patients having that open and honest conversation with their health care provider. If anyone is interested in learning more about these conditions, and have a lot of resources that can be helpful.

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Jennifer has a bachelor's degree in dietetics as well as graduate work in public health and nutrition.She has worked with families dealing with digestive disease, asthma and food allergies for the past 12 years.Jennifer also serves on the Board of Directors for Pediatric Adolescent Gastroesophageal Reflux Association (PAGER).