Also Known As
Exocrine pancreatic insufficiency
EPI
This article was last reviewed on
This article waslast modified on July 15, 2019.
What is pancreatic insufficiency?

Pancreatic insufficiency is a condition in which the pancreas is not able to produce and/or transport enough digestive enzymes to break down food in the intestine. This condition is also known as exocrine pancreatic insufficiency or EPI.

The pancreas is a narrow, flat gland about six inches long located deep in your abdominal cavity, behind the stomach and below the liver. It has head, middle, and tail sections. Its head section connects to the first part of the small intestine (duodenum).

  • Inside the pancreas, small ducts (tubes) feed digestive enzymes and bicarbonate produced by the pancreas into the pancreatic duct. This large duct carries the digestive enzymes and bicarbonate down the length of the pancreas, from the tail to the head section, and into the duodenum.
  • The common bile duct also runs through the head section of the pancreas, carrying bile from the liver and gallbladder into the small intestine.
  • The bile duct and pancreatic duct usually join just before entering the duodenum and share a common opening into the small intestine.

The pancreas consists of two kinds of tissues that perform different functions:

  • The exocrine pancreas makes, stores and releases powerful enzymes to digest fats, proteins, and carbohydrates in the small intestine. The enzymes normally are produced and carried in an inactive form to the small intestine, where the enzymes are activated as needed. Exocrine tissues also make and release bicarbonate that neutralizes stomach acids and allows for the activation of pancreatic enzymes.
  • The endocrine pancreas produces hormones, including insulin and glucagon, and releases them into the blood. These hormones regulate sugar (glucose) transport into the body's cells, where it is used for energy and to help maintain normal blood sugar levels.

In adults, pancreatic insufficiency typically occurs as a result of ongoing (progressive) pancreatic damage that may be caused by repeated bouts of acute pancreatitis or by chronic pancreatitis due to a variety of conditions.

In children, it is most frequently associated with cystic fibrosis (CF) or Shwachman-Diamond Syndrome (SDS). SDS is the second most common cause of inherited pancreatic insufficiency, after CF. All those with SDS have some degree of pancreatic insufficiency that begins when they are infants.

People with the following conditions may also develop EPI:

Zollinger-Ellison syndrome is a rare condition caused by a tumor of the pancreas that stimulates the cells of the stomach to release excess acid. This excess acid may cause temporary pancreatic insufficiency. Once the excess acid is treated, the pancreatic insufficiency usually goes away.

Some surgical procedures that affect the function of the digestive tract or the pancreas can lead to EPI.

Accordion Title
About Pancreatic Insufficiency
  • Signs and Symptoms

    The most common signs and symptoms of exocrine pancreatic insufficiency include:

    • Frequent gas and/or abdominal bloating
    • Abdominal pain, cramps (the pain is sometimes referred to as "epigastric" because it occurs in the upper middle part of the abdomen)
    • Unexplained weight loss (inability to gain weight in children)
    • Fatigue (tiredness)
    • Frequent diarrhea
    • Greasy, foul-smelling stools that sometimes float


    People with EPI may experience malabsorption, malnutrition and vitamin deficiencies. Laboratory evaluation is often necessary to diagnose pancreatic insufficiency because symptoms may not be evident or may be similar to those of other digestive tract disorders.

  • Tests

    Laboratory tests that may be used to detect pancreatic insufficiency include:

    • Stool elastase—this test measures the level of elastase (an enzyme made by the pancreas) in a sample of your stool. The amount of this enzyme is reduced in pancreatic insufficiency. This test is more effective at detecting moderate to severe EPI than milder cases.
    • Chymotrypsin—this test measures chymotrypsin (a pancreatic enzyme that breaks down proteins) in your stool. With EPI, chymotrypsin is absent in the stool.
    • Immunoreactive trypsinogen (IRT)—this is a blood test that measures trypsinogen, an inactive precursor produced by the pancreas that is converted to the enzyme trypsin. Trypsin is the pancreatic enzyme that digests proteins. IRT may be elevated with pancreatitis, which may cause EPI.
    • Fecal fat (fat in the stool)—this test detects excess fat in your stool, often the first sign of EPI. Because the stool elastase test (see above) is easier to perform, it has largely replaced this test.
    • 13C-mixed triglyceride breath test—this is a newer method of diagnosing moderate pancreatic insufficiency, but it is not widely used and not commonly available. The test may also be used to evaluate the effectiveness of enzyme therapy on fat digestion in people with EPI.


    Non-laboratory tests used in diagnosing pancreatic insufficiency may include:

    • Computed tomography (CT) scan: can be used to detect inflammation or scarring of the pancreas
    • Endoscopic retrograde cholangiopancreatography (ERCP): an endoscope (a hollow tube) is guided through your mouth, down your throat and stomach to your small intestine. A smaller tube (catheter) is inserted through the endoscope to inject contrast dye into the pancreatic and bile ducts. Abdominal x-rays are taken to examine the pancreas, gallbladder, and the ducts that carry digestive enzymes from those organs to the small intestine. ERCP can be used look for blockages or damage to the ducts.
    • Magnetic resonance cholangiopancreatography (MRCP): a specific type of magnetic resonance imaging (MRI) that uses powerful magnets and radio waves to create images of the pancreas, pancreatic duct, and bile ducts. It is often used before or instead of ERCP to look for abnormalities in the pancreas because it is faster and non-invasive. It is also useful in distinguishing pancreatitis from pancreatic cancer.
    • Ultrasound: may be used to create and send images of your pancreas to a video monitor. An endoscopic ultra sound is an exam that involves a thin, flexible tube that is used to view inside the digestive tract and is more accurate than an abdominal ultrasound.


    For more on imaging studies, see RadiologyInfo.org.

  • Treatment

    Management of pancreatic insufficiency may include:

    • Taking enzyme supplements (pancreatic enzyme replacement therapy, PERT) to replace the enzymes your pancreas isn't making any more
    • Eating a healthy, balanced diet; you might need guidance from a nutritionist to create a diet that meets your needs.
    • Taking vitamin supplements (especially vitamins A, D, E, and K) if needed
    • Making lifestyle changes, such not drinking alcohol and not smoking


    Treatment of EPI also involves managing or resolving the underlying cause when possible.

    In Shwachman-Diamond Syndrome (SDS), unlike in cystic fibrosis, production of pancreatic lipase (an enzyme that digests fats) often increases with age. The reasons for this are not yet known, but about 50% of children with SDS will experience improvements in pancreatic function and fat absorption as they get older and will no longer require enzyme replacement therapy.

    For more information on other, less common conditions involving the pancreas, see Genetic and Rare Diseases Information Center.

View Sources

Sources Used in Current Review

(January 10, 2019) Al-Kaade S, Khardori R. Exocrine pancreatic insufficiency. Available online at https://emedicine.medscape.com/article/2121028-overview. Accessed March 25, 2019.

Struyvenberg M, Martin CR, Freedman SD. Practical guide to exocrine pancreatic insufficiency—breaking the myths. BMC Medicine. (2017) 15:29. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5301368/pdf/12916_2017_Article_783.pdf. Accessed March 25, 2019.

(October 25, 2016) American Gastroenterological Association press release. Largest analysis examining barriers to EPI diagnosis finds patients with digestive health issues overlook their symptoms. Available online at https://www.gastro.org/press-release/largest-analysis-examining-barriers-to-epi-diagnosis-finds-patients-with-digestive-health-issues-overlook-their-symptoms. Accessed March 27, 2019.

Lindkvist B. Diagnosis and treatment of pancreatic exocrine insufficiency. World Journal of Gastroenterology, 2013. 19(42):7258-7266. Available online at http://www.wjgnet.com/1007-9327/full/v19/i42/7258.htm. Accessed March 27, 2019.

(May 21 2014). Johnson DA. Exocrine pancreatic insufficiency: seen but not recognized? Available online at https://www.medscape.com/viewarticle/825138_1. Accessed March 27, 2019.

(September 14, 2015) Keller J, Layer P. Diagnosis of pancreatic exocrine insufficiency in chronic pancreatitis. Available online at https://www.pancreapedia.org/sites/default/files/DOI%20V3.%20Formatted%20Keller%20and%20Layer%209-04-15.pdf. Accessed March 27, 2019.

Medical University of South Carolina Digestive Disease Center. Pancreatic insufficiency. Available online at http://ddc.musc.edu/public/diseases/pancreas-biliary-system/pancreatic-insufficiency.html. Accessed March 23, 2019.

Sources Used in Previous Reviews

Everhart, J. Digestive Diseases and Diabetes. Chapter 21 [pp 474-476]. NIDDK [On-line information]. PDF available for download at http://www.niddk.nih.gov/health/diabetes/dia/chpt21.pdf.

Merck. Malabsorption Syndromes, [General]. The Merck Manual of Diagnosis and Therapy [On-line information]. Available online at http://www.merck.com/pubs/mmanual/section3/chapter30/30a.htm.

National Digestive Diseases Information Clearinghouse. ERCP (Endoscopic Retrograde Cholangiopancreatography). Available online at http://digestive.niddk.nih.gov/ddiseases/pubs/ercp/.

Durie PR. Inherited and congenital disorders of the exocrine pancreas. Gastroenterologist. Sep 1996;4(3):169-87.

Mack DR, Forstner GG, Wilschanski M, Freedman MH, Durie PR. Shwachman syndrome: exocrine pancreatic dysfunction and variable phenotypic expression. Gastroenterology. Dec 1996;111(6):1593-602.

Spoto-Cannons, Antoinette C. Shwachman-Diamond Syndrome. Emedicine.com. Article Last Updated: Aug 12, 2008. Available online at http://www.emedicine.com/ped/TOPIC2060.HTM.

Sharma, G. (Updated 2010 December 3). Cystic Fibrosis. eMedicine [On-line information]. Available online at http://emedicine.medscape.com/article/1001602-overview. Accessed January 2011.

Spoto-Cannons, A. et. al. (Updated 2009 September 30). Shwachman-Diamond Syndrome. eMedicine [On-line information]. Available online at http://emedicine.medscape.com/article/958476-overview. Accessed January 2011.

Delgado, J. et. al. (Updated 2010 November). Malabsorption. ARUP Consult [On-line information]. Available online at http://www.arupconsult.com/Topics/Malabsorption.html?client_ID=LTD#tabs=0. Accessed January 2011.

Pagana, K. D. & Pagana, T. J. (© 2011). Mosby's Diagnostic and Laboratory Test Reference 10th Edition: Mosby, Inc., Saint Louis, MO. Pp 441-442.

RadiologyInfo.org. Endoscopic retrograde cholangiopancreatography (ERCP). Avaiable online at http://www.radiologyinfo.org/en/glossary/glossary1.cfm?gid=805. Accessed January 2012.

Al-Kaade, Samer, et. al. (Updated Jan. 29, 2013.) Exocrine Pancreatic Insufficiency. Medscape. Available online at http://emedicine.medscape.com/article/2121028-overview#aw2aab6b2b4. Accessed March 2014.

Dominguez-Munoz, JE. (March 2011.) Pancreatic Exocrine Insufficiency: Diagnosis and Treatment. PubMed. Available online at http://www.ncbi.nlm.nih.gov/pubmed/21323992. Accessed March 2014.

Lohr, J-Matthias, et. al. (Jan. 7, 2013.) Synopsis of Recent Guidelines on Pancreatic Exocrine Insufficiency. United European Gastroenterology Journal. Available online at http://ueg.sagepub.com/content/1/2/79. Accessed April 2014.

Dominguez-Munoz, JE, et. al. (April 2007.) 13C-Mixed Triglyceride Breath Test to Assess Oral Enzyme Substitution Therapy in Patients with Chronic Pancreatitis. PubMed. Available online at http://www.ncbi.nlm.nih.gov/pubmed/17445754. Accessed April 2014.

Secretin Stimulation Test. (Updated Oct. 8, 2012.) MedlinePlus. Available online at http://www.nlm.nih.gov/medlineplus/ency/article/003892.htm. Accessed April 2014.

Exocrine Pancreatic Insufficiency. (Updated Apr. 1, 2014.) Aptalis. Available online at http://www.aptalispharma.com/epi. Accessed April 2014.

Philip D. Hardt and Nils Ewald. Exocrine Pancreatic Insufficiency in Diabetes Mellitus: A Complication of Diabetic Neuropathy or a Different Type of Diabetes? Experimental Diabetes Research, Volume 2011, Article ID 761950.

Gregory C. Sephel PhD FACB MT(ASCP). Lab Tests Online adjunct board member. Director Clinical Pathology, VA TN Valley Healthcare System; Associate Professor Pathology, Microbiology, Immunology, Vanderbilt University School of Medicine.