Diabetes Abdomen Troubles? Perhaps It’s Exocrine Pancreatic Insufficiency (EPI)

Diabetes, sadly, goes hand in hand with abdomen issues, for a lot of completely different causes. Type 1 diabetes has a widely known connection to celiac illness, and each sorts improve the incidence of thyroid circumstances that may trigger digestive issues. Gastroparesis, a sort of very uncomfortable partial abdomen paralysis, is a frequent complication of long-term diabetes. A number of the greatest sort 2 diabetes medicines, together with metformin and semaglutide (Ozempic), are extensively recognized for his or her disagreeable gastrointestinal results.

When you’ve been scuffling with stomach points, and none of these circumstances above appear to suit, right here’s one other situation to think about: exocrine pancreatic insufficiency (EPI). Although EPI shouldn’t be generally related to diabetes, a brand new research means that it’s way more prevalent in individuals with diabetes than most endocrinologists and docs understand.

What’s Exocrine Pancreatic Insufficiency (EPI)?

Based on On a regular basis Well being, EPI is a situation wherein the pancreas doesn’t secrete sufficient digestive enzymes, which causes meals to go via 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 dangerous to your well being.

EPI is notoriously tough to establish, main often to “misdiagnosis and suboptimal therapy,” in keeping with a 2019 overview. The issue is that its signs overlap with these of many different frequent circumstances, and the assessments accessible for EPI are “typically tough to carry out, inaccurate, or non-specific.” It could actually take sufferers years to correctly establish the reason for their troubles. A machine studying mannequin has estimated that just one in twelve individuals with EPI has really been recognized with the situation.

EPI is most strongly related to circumstances which can be recognized to break the pancreas, resembling cystic fibrosis and power pancreatitis. But even in sufferers with these circumstances and the signature signs of EPI, “diagnostic testing isn’t carried out.”

How Usually Do Folks with Diabetes Develop EPI?

Diabetes, in fact, can be a illness of the pancreas. In sort 1 diabetes, the physique launches an auto-immune assault on the pancreatic Beta cells, which might utterly remove the flexibility to secrete the very important hormone insulin. In sort 2 diabetes, insulin resistance causes the identical pancreatic cells to overwork and ultimately fail. It’s unknown precisely how diabetes may trigger exocrine pancreatic insufficiency, or vice versa, however each are doable.

A brand new research argues that these mysteriously associated two circumstances coexist extra typically than nearly anybody realizes. The paper is the work of a affected person advocate with sort 1 diabetes named Dana Lewis. Lewis is well-known throughout the small however extremely influential group 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 be taught extra about her situation, Lewis says that she “was somewhat dismayed that it was so clearly prevalent in diabetes, but I had by no means ever heard of it. How can there be such a disconnect? Is there something I can do about it?”

Revealed in Diabetes Expertise & Therapeutics, Lewis’ research is a scientific overview of the prevailing literature overlaying the connections between diabetes and EPI. (Although 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 individuals with sort 1 and sort 2 diabetes, beginning as early because the Sixties. Most research employed the fecal elastase-1 (FE-1) check, which measures stool for a selected digestive enzyme that survives the passage via the intestine, in keeping with Mayo Clinic Laboratories. Folks with EPI have secrete much less FE-1 once they eat, and have much less FE-1 of their feces.

When Lewis tallied up all the information, she discovered that about 33 % of individuals with sort 1 diabetes and 29 % of individuals with sort 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 may imply 100 million new sufferers in a single day. There may be some proof that diabetes results in deceptively low FE-1 outcomes, and most of the sufferers studied reported that they’d no gastrointestinal signs. However Lewis’ paper shouldn’t be the one latest work to argue that there’s an underdiscussed connection between the 2 circumstances:

  • A 2020 overview referred to as EPI “extremely prevalent in sort 1 diabetes and customary in sort 2 diabetes,” though it’s typically symptomatic.
  • A 2021 evaluation concluded that EPI is, in actual fact, extra frequent in sort 1 diabetes, however that EPI testing and remedy must be restricted to sufferers with overt signs.

Advocating for Your self

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

This unsure check, Lewis explains, “has been thought of to be indicative of how extreme the signs are, when in actuality, any person like me could be on the higher finish of that check and have extreme signs. There’s no standardized measure of symptom severity, there’s simply this check and this free 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 exceptional distinction,” it confirmed her analysis.

“However with out my private advocacy, I wouldn’t have essentially gotten the therapy.”

Residing with Diabetes and EPI

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

It’s not simple to dial PERT remedy in. Sufferers want completely different quantities of enzymes relying on what they’re consuming; taking too little is ineffective, and taking an excessive amount of is wasteful. Identical to insulin remedy, it takes quite a lot of follow to get administration proper. And identical to insulin remedy, PERT could 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 wherein the pancreas doesn’t make sufficient digestive enzymes, resulting in gastrointestinal misery and even malnutrition. Although EPI is believed to be uncommon, it could possibly be way more prevalent than most clinicians understand, particularly in individuals with sort 1 and sort 2 diabetes. When you’ve had digestive points that appear unrelated to frequent diabetes points resembling celiac illness or gastroparesis, it might be value 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. Replace on the analysis and administration of exocrine pancreatic insufficiency. F1000 Analysis. 2019.

Pyenson B, Alston M, Gomberg J, Han F, Khandelwal N, Dei M, Son M, Vora J. Making use of Machine Studying Strategies to Establish Undiagnosed Sufferers with Exocrine Pancreatic Insufficiency. J Well being Econ Outcomes Res. February 2019.

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

The Connection Between EPI and Diabetes. On a regular basis Well being. Might 2022.

The Client’s Information to Pancreatic Enzyme Substitute Remedy (PERT). On a regular basis Well being. February 2023.


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