Diabetes Stomach Troubles? Maybe It’s Exocrine Pancreatic Insufficiency (EPI)

Diabetes, sadly, goes hand in hand with abdomen issues, for a lot of totally different causes. Type 1 diabetes has a widely known connection to celiac illness, and each varieties improve the incidence of thyroid situations that may trigger digestive issues. Gastroparesis, a sort of very uncomfortable partial abdomen paralysis, is a frequent complication of long-term diabetes. Some of one of the best kind 2 diabetes medicines, together with metformin and semaglutide (Ozempic), are broadly identified for his or her disagreeable gastrointestinal results.

If you’ve been combating stomach points, and none of these situations above appear to suit, right here’s one other situation to contemplate: exocrine pancreatic insufficiency (EPI). Though EPI will not be generally related to diabetes, a brand new examine means that it’s way more prevalent in folks with diabetes than most endocrinologists and medical doctors notice.

What is Exocrine Pancreatic Insufficiency (EPI)?

According to Everyday Health, EPI is a situation by which the pancreas doesn’t secrete sufficient digestive enzymes, which causes meals to cross by way of your system with out being totally digested. This ends in uncomfortable signs like diarrhea, oily stools, and lack of urge for food. EPI could cause malnutrition and may be very unhealthy on your well being.

EPI is notoriously tough to determine, main often to “misdiagnosis and suboptimal treatment,” in accordance with a 2019 assessment. The drawback is that its signs overlap with these of many different widespread situations, and the assessments obtainable for EPI are “generally difficult to perform, inaccurate, or non-specific.” It can take sufferers years to correctly determine the reason for their troubles. A machine studying mannequin has estimated that just one in twelve folks with EPI has truly been identified with the situation.

EPI is most strongly related to situations which might be identified to wreck the pancreas, resembling cystic fibrosis and continual pancreatitis. Yet even in sufferers with these situations and the signature signs of EPI, “diagnostic testing is rarely performed.”

How Often Do People with Diabetes Develop EPI?

Diabetes, after all, can be a illness of the pancreas. In kind 1 diabetes, the physique launches an auto-immune assault on the pancreatic Beta cells, which may utterly get rid of the flexibility to secrete the very important hormone insulin. In kind 2 diabetes, insulin resistance causes the identical pancreatic cells to overwork and finally fail. It is unknown precisely how diabetes would possibly trigger exocrine pancreatic insufficiency, or vice versa, however each are attainable.

A brand new examine argues that these mysteriously associated two situations coexist extra usually than virtually anybody realizes. The paper is the work of a affected person advocate with kind 1 diabetes named Dana Lewis. Lewis is well-known throughout the small however extremely influential neighborhood of “loopers” — she led the event of the world’s first open-source do-it-yourself synthetic pancreas. In 2021, Lewis discovered that she additionally had EPI.

After diving into the medical literature to study extra about her situation, Lewis says that she “was a little dismayed that it was so clearly prevalent in diabetes, yet I had never ever heard of it. How can there be such a disconnect? Is there anything I can do about it?”

Published in Diabetes Technology & Therapeutics, Lewis’ examine is a scientific assessment of the present literature protecting the connections between diabetes and EPI. (Though the paper is behind a paywall, Lewis shared an earlier draft on her weblog.)

There have been many research to look at pancreatic enzyme operate in folks with kind 1 and kind 2 diabetes, beginning as early because the 1960s. Most research employed the fecal elastase-1 (FE-1) check, which measures stool for a specific digestive enzyme that survives the passage by way of the intestine, in accordance with Mayo Clinic Laboratories. People with EPI have secrete much less FE-1 after they eat, and have much less FE-1 of their feces.

When Lewis tallied up all the info, she discovered that about 33 % of individuals with kind 1 diabetes and 29 % of individuals with kind 2 diabetes have lowered ranges of FE-1, indicating some stage of enzyme secretion abnormality. These outcomes don’t essentially imply that some 30 % of individuals with diabetes have full-blown EPI — that might imply 100 million new sufferers in a single day. There is a few proof that diabetes results in deceptively low FE-1 outcomes, and most of the sufferers studied reported that that they had no gastrointestinal signs. But Lewis’ paper will not be the one latest work to argue that there’s an underdiscussed connection between the 2 situations:

  • A 2020 assessment known as EPI “highly prevalent in type 1 diabetes and common in type 2 diabetes,” though it’s usually symptomatic.
  • A 2021 evaluation concluded that EPI is, the truth is, extra widespread in kind 1 diabetes, however that EPI testing and remedy have to be restricted to sufferers with overt signs.

Advocating for Yourself

Lewis defined that when she took the FE-1 check, her outcomes have been in an indeterminate “mild-to-moderate” vary — under the common wholesome stage, however above the “severe range” that routinely signifies a necessity for enzyme remedy. The customary check is much less correct on this grey space, and the severity of a affected person’s signs could not match the examined enzyme deficiency.

This unsure check, Lewis explains, “has been considered to be indicative of how severe the symptoms are, when in reality, somebody like me can be on the upper end of that test and have severe symptoms. There’s no standardized measure of symptom severity, there’s just this test and this loose categorization.”

After two years of trying to find solutions to her signs, Lewis wasn’t about to surrender. She satisfied her cautious physician to prescribe medication for EPI; when the medication made “a remarkable difference,” it confirmed her analysis.

“But without my personal advocacy, I wouldn’t have necessarily gotten the treatment.”

Living with Diabetes and EPI

Readers that already handle diabetes are in a very good place to grasp the immense wrestle of dwelling with EPI. Exocrine pancreatic insufficiency is primarily handled with Pancreatic Enzyme Replacement Therapy (PERT), which delivers enzymes straight to the digestive system within the type of a tablet. Patients swallow drugs, typically a really massive variety of them, immediately with the meals that they eat.

It’s not straightforward to dial PERT remedy in. Patients want totally different quantities of enzymes relying on what they’re consuming; taking too little is ineffective, and taking an excessive amount of is wasteful. Just like insulin remedy, it takes quite a lot of follow to get administration proper. And similar to insulin remedy, PERT might be extraordinarily costly.

Lewis believes that PERT is much more difficult to dose correctly than insulin, and has gone as far as to design an iPhone app to assist optimize dosing.


Exocrine pancreatic insufficiency (EPI) is a situation by which the pancreas doesn’t make sufficient digestive enzymes, resulting in gastrointestinal misery and even malnutrition. Though EPI is believed to be uncommon, it could possibly be way more prevalent than most clinicians notice, particularly in folks with kind 1 and kind 2 diabetes. If you’ve had digestive points that appear unrelated to widespread diabetes points resembling celiac illness or gastroparesis, it might be price asking your physician or endocrinologist about taking a diagnostic check for EPI.

Radlinger B, Ramoser G, Kaser S. Exocrine Pancreatic Insufficiency in Type 1 and Type 2 Diabetes. Curr Diab Rep. April 2020.

Hahn JU, Kerner W, Maisonneuve P, Lowenfels AB, Lankisch PG. Low fecal elastase 1 ranges don’t point out exocrine pancreatic insufficiency in type-1 diabetes mellitus. Pancreas. April 2008.

Pancreatic Elastase [Test in Focus]. Mayo Clinic Laboratories. January 2021.

Perbtani Y, Forsmark CE. Update on the analysis and administration of exocrine pancreatic insufficiency. F1000 Research. 2019.

Pyenson B, Alston M, Gomberg J, Han F, Khandelwal N, Dei M, Son M, Vora J. Applying Machine Learning Techniques to Identify Undiagnosed Patients with Exocrine Pancreatic Insufficiency. J Health Econ Outcomes Res. February 2019.

Struyvenberg MR, Martin CR, Freedman SD. Practical information to exocrine pancreatic insufficiency – Breaking the myths. BMC Med. February 2017.

The Connection Between EPI and Diabetes. Everyday Health. May 2022.

The Consumer’s Guide to Pancreatic Enzyme Replacement Therapy (PERT). Everyday Health. February 2023.


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