woman at work clutching her stomach

Pancreatic Exocrine Insufficiency

Helping you understand and live with pancreatic exocrine insufficiency (PEI).

Pancreatic Exocrine Insufficiency (PEI) is a condition that causes problems in how you digest food. Your pancreas doesn’t make enough of the enzymes that your body needs to break down and absorb nutrients.

Enzymes speed up chemical reactions in the body. The enzymes made by the pancreas move into the small intestine, where they help break down the food that you have eaten.

When you have PEI, you don’t get the nutrition you need because your body can’t absorb fats and some vitamins and minerals from foods.

There are drugs that work for this condition that give you much needed supply of enzymes. Besides taking medicine, you can manage your symptoms by making sure you follow the right diet. Your doctor will recommend foods that will help you get enough nutrients and protein that you might be missing.

Signs & Symptoms of pancreatic exocrine insufficiency (PEI)

You may not have any symptoms at first. But once your pancreas gets so damaged that it starts to negatively affect your ability to absorb fats, you may experience the following:

  1. Pain or tenderness in your belly
  2. Foul-smelling bowel movements
  3. Diarrhea
  4. Gas and bloating
  5. Feeling full

You might also lose weight among other things, because your body doesn’t absorb enough vitamins. For instance, you could develop a bleeding disorder if you’re not getting enough vitamin K. Or you could get bone pain if you don’t get enough vitamin D.

Risk Factors of pancreatic exocrine insufficiency (PEI)

Your doctor will investigate a diagnosis of PEI If you have a new diagnosis of pancreatic disease or a new diagnosis of a condition that may predispose to PEI or malabsorption, including:

  • Chronic Pancreatitis (CP)
  • Type 1 Diabetes
  • Unresponsive celiac disease
  • If you are current or former smokers
  • Longstanding history of alcohol abuse (defined as >5 drinks/day)
  • The last two risk categories interact, such that risk of PEI with alcohol abuse is heightened among current smokers

PEI will be investigated if you have any of the unexplained suggestive symptoms, even in the absence of the conditions just mentioned.

PEI is occasionally confused with some other GI conditions, such as peptic ulcers, Crohn’s and IBS, since they have many of the same symptoms. If you’re showing some of these symptoms, it is important to speak to your doctor to determine whether you have PEI or another GI condition.

Treating pancreatic exocrine insufficiency (PEI)

  • PERTs: Apart from a healthy diet, the main treatment for PEI is pancreatic enzyme replacement therapy (PERT). You take prescription pills that replace the enzymes your pancreas isn’t making. These enzymes break down your food so you can more easily digest and absorb it. You must take them during or immediately after your meals. If you take them before you eat, the replacement enzymes may move through your stomach before your food gets there.
  • Antacid: You may also need to take an antacid – called a proton-pump-inhibitor – to keep your stomach from breaking down pancreatic enzymes before they can start to work. This is only needed for certain types of PERT; check with your pharmacist if you are unsure. Together with your doctor, you should be able to come up with a treatment plan that works for you, so you can get back to living your life, your way!

Managing pancreatic exocrine insufficiency (PEI)

The right diet is very important for managing PEI. Your doctor and/or dietician can help you choose the foods that keep your energy level up and give you the nutrition you need. Here are a few tips:Don’t do this:

  • DON’T drink alcohol: It can make it even harder for your body to absorb fat, and can damage your pancreas over time.
  • DON’T smoke
  • DON’T Go on a low-fat diets – because you are at risk of malnourishment.

Do this:

  • DO eat six small meals per day, instead of the traditional three. A big meal might not be appealing if you have digestion troubles from PEI.
  • DO take vitamins. You may need to take vitamins A, D, E, and K to replace ones that aren’t getting absorbed from your diet.
  • DO talk with your family and friends to get the support you need while you’re getting treatment.
  • Pancreatic exocrine insufficiency (PEI) is an under diagnosed digestive disease where the pancreas does not produce the necessary amount of enzymes to digest food.
  • The prevalence of PEI is unknown. This condition is underdiagnosed because its main symptoms such as diarrhea and weight loss are similar to other digestive illnesses.
  • The most common causes of PEI are chronic pancreatitis in adults and cystic fibrosis in children and adolescents.
  • In chronic pancreatitis, approximately 20% of patients develop PEI over time. (Struyvenberg et al. 2017)
  • A quarter of those having acute pancreatitis will develop PEI during follow-up. (Hollemans et al. 2018)
  • About 85% of the cystic fibrosis population are affected by PEI. (Singh et al. 2017)

Hollemans RA et al. Pancreatic exocrine insufficiency following acute pancreatitis: Systematic review and study level meta-analysis. Pancreatology. 2018 Apr;18(3):253-62.
Singh VK and Schwarzenberg SJ. Pancreatic insufficiency in cystic fibrosis. J Cyst Fibros. 2017 Nov;16(2):S70-8.
Struyvenberg MR et al. Practical guide to exocrine pancreatic insufficiency – Breaking the myths. BMC Med. 2017 Feb 10;15(1):29.

Are other conditions causing my PEI?

PEI can be caused by conditions that affect your pancreas. These include conditions like:

  • Inflammation of the pancreas (pancreatitis)
  • Cystic fibrosis
  • Type 1 diabetes (juvenile diabetes)
  • Celiac disease
  • Crohn’s disease
  • Pancreatic cancer
  • Gastrointestinal surgery

Your doctor will talk to you about the underlying cause of your PEI and how it will affect your treatment.

Are there certain foods that I should avoid?

If you have pancreatic exocrine insufficiency (PEI), figuring out what to eat can be tricky. You need to make sure you’re getting enough nutrients and vitamins, but you also need to avoid foods that irritate your digestive tract. On top of this, some conditions associated with PEI, like cystic fibrosis, Crohn’s disease, Celiac disease, and diabetes, have additional special dietary requirements.

Fortunately, a balanced diet combined with enzyme replacement therapy can help ease your symptoms and improve your quality of life. Ask your doctor what kinds of foods you should avoid.

Do I need to take supplements?

If you have PEI, you may need to take vitamins to replace the ones your body is struggling to absorb. Ask your doctor what kinds of symptoms to expect if you’re malnourished, and what you can do to make sure you’re getting enough vitamins in your diet.

How can you tell that I have PEI and not another condition?

Since the symptoms of PEI overlap with many other digestive conditions, your diagnosis may seem confusing. To determine if you may have PEI, your doctor will assess your symptoms, rule-out other conditions that cause similar symptoms (such as celiac disease or irritable bowel syndrome), and may look for signs of malnutrition. Finally, you doctor may consider a trial of PERT to assess how you respond to therapy.

How much enzyme replacement should I take?

Your doctor will recommend how much enzyme replacement you should start taking. You’ll take less with snacks than at meals. You may need to take more enzyme replacement if you’re eating a high-fat meal.

How will I know if my treatment is working?

There’s no scientific agreement on how successful PEI treatment with pancreatic enzyme replacement therapy should be defined. The main measure of treatment success is improvement in symptoms, weight gain and improved nutrition. Also, you may have less abdominal pain and flatulence and you may not have to go to the bathroom as often.

Following your doctor’s and pharmacist’s recommendations and taking enzymes with every meal will improve your chances of success. Ask your doctor about how to ensure you’re getting the maximum benefit from your treatment.

What kind of diet should I follow?

In the past, doctors recommended a low-fat diet for people with PEI. That has changed with the recognition that a low-fat diet may worsen your malnutrition and that you need fat in your diet to help absorb certain vitamins. Still, some fats are better for you than others. If you’re not sure how to maintain a balanced, healthy diet, talk to your doctor and a nutritionist about planning healthy meals that will help alleviate your symptoms.

What lifestyle changes do I need to make?

If ongoing pancreatitis (Inflammation of the pancreas) is causing your PEI, certain lifestyle choices can make your condition worse. Alcohol and smoking decrease your chances of successful treatment. It’s hard to make lifestyle changes, so ask your doctor for advice on how to form new healthy habits.

What should I do if my treatment isn’t working?

If your treatment isn’t working right away, don’t give up. Improvements in symptoms may take one to two weeks. Remember, you must take your PERT with each meal and snack. Your treatment can’t work if you don’t take it.

Speak to your doctor and he or she may adjust your dose of enzyme replacement therapy. Your dose may be too low, or you may need extra medication. Remember that you have options if your symptoms aren’t improving.

When should I return for a follow-up?

It’s important that you and your doctor or gastroenterologist are working as a team and scheduling regular appointments. Regular appointments will ensure that your treatment plan can be monitored and complications of PEI can be caught early.

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