Pancreatic Exocrine Insufficiency

Podcast Transcript

Dr. Scott Steele:

Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again, everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, president of main campus and colorectal surgeon here at Cleveland Clinic in beautiful Cleveland, Ohio. And today I'm super excited to have Dr. Robert Naples, a general surgeon for the Digestive Disease Institute here at the Cleveland Clinic, and he also specializes in hepatobiliary and pancreatic surgery. Rob, welcome to Butts & Guts.

Dr. Robert Naples:

Thanks for having me.

Dr. Scott Steele:

So today we're going to talk a little bit about exocrine pancreatic insufficiency, something we haven't really covered here on Butts & Guts. But first, can you give us a little bit of background for our listeners? Where are you from? Where'd you train? And how did it come to the point that you're here at the Cleveland Clinic?

Dr. Robert Naples:

So I did my general surgery training at the Cleveland Clinic. I did my HPV fellowship as well there, and then I stayed on as staff. I became interested in the pancreas because I thought it was a challenging pathology and a challenging organ to deal with.

Dr. Scott Steele:

Oh, that's fantastic, and we're lucky for that. So today, as I said, we're going to be talking a little bit about exocrine pancreatic insufficiency or what you sometimes hear as EPI. So can you start by telling our listeners what exactly is exocrine pancreatic insufficiency?

Dr. Robert Naples:

So the pancreas has two main functions. One is endocrine and one is exocrine. The endocrine function, as everybody knows, is to regulate sugars. The exocrine function is to digest our fats and foods. It creates enzymes to do that. And when someone gets exocrine pancreatic insufficiency, they're not making enough enzymes to digest those fats and foods.

Dr. Scott Steele:

So how common is this EPI and who is at most risk for this condition?

Dr. Robert Naples:

Some studies report about a prevalence of 10% in the population, but obviously, the most common patients at risk for this are patients who have pancreatitis, acute or chronic, patients with pancreatic cancer, or something called main duct IPMNs, which is a cyst of the pancreas, and patients who have had pancreatectomy, so patients who have had surgery on their pancreas.

Dr. Scott Steele:

Rob, I must admit that this is something that I actually didn't get a whole lot of press about, but recently have heard it a little bit on the radio, talking about some of these things. And so, like many listeners out there, they may have never heard of this in the past. So are there common symptoms or signs that patients should look out for, and can these symptoms be mistaken for other conditions?

Dr. Robert Naples:

So the symptoms for these are actually pretty vague: bloating, abdominal pain, diarrhea. And they're most commonly mistaken for other GI disorders, such as irritable bowel syndrome, celiac disease, and inflammatory bowel disease, such as Crohn's or ulcerative colitis. But the one that kind of distinguishes them is that they have something called steatorrhea. So their stools are fatty, greasy, oily. A lot of patients don't pay attention to their stool, so I would say that they miss that symptom.

Dr. Scott Steele:

So if somebody's got floating stools or foam along with their stools, is that what you mean by greasy or oily?

Dr. Robert Naples:

Yes.

Dr. Scott Steele:

Okay, fantastic. So, how is EPI diagnosed, and what tests should patients be expected to get if they are thought to have this?

Dr. Robert Naples:

So the most common test to diagnose it is a stool sample. It's called fecal elastase. It measures that enzyme in the stool. And if that's low, you're diagnosed with EPI. There is another invasive test, which is a secretin stimulation test, but they have to go endoscopically and grab some fluid from your bowel. Typically, that's not done.

Dr. Scott Steele:

So Rob, what makes exocrine pancreatic insufficiency so challenging to diagnose? And is it sometimes misdiagnosed and why is that?

Dr. Robert Naples:

The most reason that it's challenging is because they have vague abdominal symptoms and they usually go down the workup of functional GI disorders and other workups. And I can't say that a fecal elastase is usually part of the normal workup for these vague symptoms.

Dr. Scott Steele:

It just seems like diarrhea goes along with so many different things that... Is it the chronicity of the diarrhea? Is it something about that with the stools and their appearance that lead one to suspect? Or is this typically a diagnosis where you've done a traditional workup for all other sorts and somebody says, "Hey, maybe it's EPI?"

Dr. Robert Naples:

It's usually a diagnosis of exclusion. And like I said, a lot of the people don't really pay attention to their stools. They just know that they have diarrhea. So I would say they go down other workups and they really don't say that they have those pale, greasy colored stools that would maybe trigger somebody to test them for it.

Dr. Scott Steele:

And so is this something that you have to go to your doctor in order to do or can you just give a stool sample at home and drop it off or put it in the mail or whatever the deal is?

Dr. Robert Naples:

A physician would have to order it and then actually once you get the stool sample, you'll drop it off at the lab.

Dr. Scott Steele:

Okay. So walk me through a little bit of any other kind of workup that you might have, so a patient that is either suspected to have that or the test comes back positive and they come see you. What can listeners out there expect to get in that visit with you?

Dr. Robert Naples:

Obviously, the things I think of are like I talked about before, pancreatitis, pancreatic cancer, the cyst of the pancreas, or patients who had prior pancreatic surgery. So I find out their history and usually I would get some sort of imaging. I think an MRI is kind of the best imaging to look at the pancreas, see if anything's going on, if there's cancer or a cyst that would trigger you to that.

Obviously, if they have pancreatitis or a history of that, talk about their alcohol and smoking for cessation and to treat that. And that's usually kind of where we go. And then I get a little bit into how much for the treatment, it's pancreatic enzyme replacement therapy. Usually, that's with Creon. There are other pills out there as well, but Creon, and we talk about that in terms of treatment.

Dr. Scott Steele:

So you mentioned Creon, you mentioned the replacement that's out there, but are there any other current treatment options available for patients with EPI?

Dr. Robert Naples:

Not right now. It's just pancreatic enzyme replacement therapy. Zenpep is another big one. And then if patients are on tube feeds, RELiZORB is the one that goes along with tube feeding.

Dr. Scott Steele:

And is there any specific diets that you would recommend for patients that have issues associated with EPI, even if they're on replacement or they're not?

Dr. Robert Naples:

Yeah. Low-fat diet, obviously, these are the pancreatic enzymes to digest fatty foods. So anytime you have fats, that's when you're going to need the pancreatic enzyme replacement. If you don't have any fat in your diet, then you don't need that pancreatic enzyme replacement therapy and you won't have any of those symptoms.

Dr. Scott Steele:

Rob, how important is early detection and treatment and the prognosis of EPI? And maybe conversely, let's just say I'm out there and I'm like, listen, I don't mind having diarrhea occasionally now and then. What might happen if it was left untreated?

Dr. Robert Naples:

Yeah. So I mean, it's important to diagnose it early, number one, for the malnutrition. And mainly that's because of the fat-soluble vitamins A, D, E, and K. So anything malnutrition associated with those, osteoporosis, some vision loss, stuff like that, that's why you would want to treat it. And that's what happens when it's left untreated. And the main thing, really a lot of the times you don't get to see that stuff, but the main complaint is weight loss and malnutrition.

Dr. Scott Steele:

So truth or myth, truth or myth, exocrine pancreatic insufficiency can be caused by genetic factors.

Dr. Robert Naples:

That is true. It can be caused by cystic fibrosis is one of the genetic factors that can cause pancreatic insufficiency.

Dr. Scott Steele:

So Rob, for listeners out there, is there anything that can be done to reduce risk of exocrine pancreatic insufficiency?

Dr. Robert Naples:

There's really not. The only thing that I'll say is pancreatitis can cause it. And so the most common is alcohol use here in America, so alcohol cessation, and then smoking contribute to pancreatitis as well, so smoking cessation. So alcohol and smoking are the two big ones to kind of prevent it from a pancreatitis standpoint.

Dr. Scott Steele:

So let's look into the future. Are there any advancements on the horizon when it comes to either the diagnosis or the treatment of EPI, or is there any promising clinical trials that are in the works?

Dr. Robert Naples:

Yeah, I haven't heard of any new kind of advancements in terms of pancreatic enzyme replacement therapy. There are new formulas coming out and they're still trying to work out which is the best. I would say the one exciting thing, not necessarily clinical trial related, but Creon is an expensive medication to buy. So one of the things that we've been working with is trying to reduce that medication with plans through AbbVie and the Creon supplier. So I think that is exciting for the patients.

Dr. Scott Steele:

So, Rob, you are, as we said initially, a specialist in hepatobiliary and pancreatic surgery. So is there any role for pancreatic transplant for this particular disease?

Dr. Robert Naples:

Actually, good question. I don't do pancreas transplants myself, but I have not heard of any pancreas transplants for pancreatic insufficiency. Most of the pancreas transplants are done for the endocrine function and that has to deal with insulin. The exocrine function, I'm not too sure of.

Dr. Scott Steele:

Fantastic. And so now it's time for our quick hitters, a chance to get to know our guests a little bit better. So first of all, are you a salt or sweet guy?

Dr. Robert Naples:

Sweet.

Dr. Scott Steele:

What was your first car?

Dr. Robert Naples:

Mercury Mariner.

Dr. Scott Steele:

What color was it?

Dr. Robert Naples:

Black.

Dr. Scott Steele:

In what year?

Dr. Robert Naples:

It was in early 2000s.

Dr. Scott Steele:

Fantastic.

Dr. Robert Naples:

2004 maybe.

Dr. Scott Steele:

Spinning rims and jacked-up wheels. Number three, if you could have one, your superhero power you would like to have?

Dr. Robert Naples:

That I could make a meal or food in front of me without having to actually make it.

Dr. Scott Steele:

That's the first time I've ever heard that. If you could go back to your 18-year-old self ready to go off to college, what advice would you give to yourself?

Dr. Robert Naples:

I would tell myself just to relax and not be so high stressed and life will be fine.

Dr. Scott Steele:

Fantastic. And so give us a final take-home message to our listeners regarding EPI.

Dr. Robert Naples:

EPI is an important thing to know about. It's an important thing to get diagnosed, and it's an important thing to treat even though many people miss it. People suffer with these symptoms for a long time going undiagnosed and I think that getting the diagnosis right and treating these patients can go a long way to helping them.

Dr. Scott Steele:

Fantastic advice. So for more information on the Digestive Disease Institute, DDI, here at the Cleveland Clinic, please call 216.444.7000. That's 216.444.7000. You can also visit clevelandclinic.org/digestive. For more information, that's clevelandclinic.org/digestive. Rob, thanks so much for joining us on Butts & Guts.

Dr. Robert Naples:

Yeah, thanks so much for having me, Dr. Steele.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.