Your doctor may start you on a prescription treatment called pancreatic enzyme replacement therapy, or PERT. When taken with food, PERTs help break down the nutrients in food. If you have exocrine pancreatic insufficiency EPI , your body may not absorb the nutrients from the food you eat.

Your doctor may prescribe vitamin and mineral supplements to help you maintain proper levels of the fatsoluble vitamins A, D, E, and K.

A high-calorie diet with adequate amounts of fat is especially important to help patients with CF grow, develop, and thrive. Patients with CF should work with their dietitian or nutritionist to make sure their proper nutrition needs are met.

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Those symptoms include: Oily diarrhea Steatorrhea see below Bloating Gas Fatigue Cramps Pain in the center of the stomach that radiates to the back Loss of muscle Muscle cramps Pain in the bones Signs of vitamin deficiency brittle nails, hair loss and skin problems Diarrhea in people with EPI is referred to as steatorrhea.

Steatorrhea produces stools that are: Watery Pale or gray Bulky Frothy Greasy Extremely foul smelling Because these stools contain oily droplets and consist of large amounts of undigested fat, they often stick to the toilet bowl or float on top of the water, making them hard to flush.

Medical conditions and diseases that can cause EPI are: Chronic pancreatitis Cystic fibrosis A history of stomach, pancreas, or small bowel resection during surgery Pancreatic duct obstruction Shwachman-Diamond syndrome Because EPI symptoms are similar to symptoms of other diseases of the stomach and intestine, the condition tends to be underdiagnosed.

Tests to confirm the diagnosis include: Stool samples for laboratory analysis Blood tests to look for for fat deposits and vitamin deficiencies The doctor may also request a CT scan to examine the underlying causes of EPI.

Alcohol can make it even harder for your body to absorb fat, and can damage your pancreas over time. Eat a well-balanced diet. Eat healthy fats only, and eat smaller, more frequent meals to aid digestion.

Take vitamin supplements. However, do this only on the advice of a physician fat-soluble vitamins A, D, E, and K. Pancreatic Enzyme Replacement Therapy PERT Pancreatic enzyme replacement therapy is medication designed to take over the role of the pancreas by replacing the digestive enzymes that the pancreas is no longer producing.

Others at risk include people with: Celiac disease Stomach ulcers Cystic fibrosis Shwachman-Diamond syndrome Chronic pancreatitis Pancreatic cancer Those who have had past surgeries on the stomach, pancreas or gallbladder may also be at risk. Both are tightly regulated by negative feedback mechanisms.

Secretin is released from the duodenal mucosa in response to the presence of acid in the duodenum figure 1. Secretin primarily stimulates the release of bicarbonate and water from the interlobular duct cells and causes a gradual rise in the flow of pancreatic fluid through the ducts and a typical pattern of electrolyte secretion figure 2.

CCK is released from gut endocrine cells in response to the entry of fat and protein into the proximal intestine figure 3. CCK acts directly and through vagal afferents to stimulate pancreatic acinar cells to release digestive proenzymes.

See "Overview of nutrient absorption and etiopathogenesis of malabsorption", section on 'Fat' and "Physiology of cholecystokinin" and "Secretin". Chronic pancreatitis — Chronic pancreatitis is the most common cause of exocrine pancreatic insufficiency in adults.

Progressive inflammatory changes in the pancreas in chronic pancreatitis results in permanent structural damage, which can lead to impairment in exocrine function.

See "Etiology and pathogenesis of chronic pancreatitis in adults", section on 'Pathogenesis'. Why UpToDate? Product Editorial Subscription Options Subscribe Sign in. Learn how UpToDate can help you. Select the option that best describes you.

View Topic. Font Size Small Normal Large. Exocrine pancreatic insufficiency. Formulary drug information for this topic.

It has many causes, but chronic alcohol abuse is the most common one in western countries. Chronic pancreatitis and subsequent insufficiency can also run in families hereditary pancreatitis and cystic fibrosis.

Patients with chronic pancreatitis may not have any symptoms. However, with ongoing destruction of the gland and loss of its function, symptoms of malabsorption may develop.

Chronic pancreatitis can also manifest with abdominal pain, and diabetes. Pancreatic insufficiency is suspected in a patient who develops diabetes, upper abdominal pain and features of malabsorption. Bowel movements classically are bulky, loose and foul smelling; because of their oily nature, they may float in the toilet bowl, and are difficult to flush.

Occasionally, the pancreas becomes so chronically inflamed that a scarred mass may develop which can be difficult to distinguish from pancreatic cancer.

There are reports of the use of antioxidants selenium, vitamin A, vitamin C, and vitamin E to reduce ongoing inflammation. In terms of maldigestion from chronic pancreatitis, enzyme supplements are usually prescribed.

These supplements are in the form of pills which contain pancreatic enzymes. The pills are taken before and during each meal. Depending on the type of supplements, an antacid may also be prescribed, as some pancreatic supplements are broken down by gastric acid.

Dietary changes are also suggested; a low fat diet 30g fat per day will reduce the amount of steatorrhea and sometimes abdominal pain associated with chronic pancreatitis. Since fat can be so significantly malabsorbed, supplements of fat soluble vitamins vitamin D, A, E, and K may be prescribed.

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Digestive Diseases. Small Intestine. Digestive Organs. Chronic Pancreatitis Surgery. Laparoscopic Surgery. Rectal Surgery. Medical Tests. Abdominal Scans. Barium Radiology. Function Studies. Interventional Radiology. Symptoms and Conditions. The most reliable enzyme to measure is a protease called elastase Elastase-1 is not broken down as it travels through the gut and it concentrates in the poo.

This test is called the faecal elastase-1 test or FE The levels of elastase-1 found in the poo can indicate whether pancreatic function is normal or how severe the PEI is.

It is relatively convenient to test faecal elastase in poo as it does not require blood tests or invasive examinations. However, the test can fail to pick up cases of mild to moderate PEI. It can also sometimes give false positive results in other causes of diarrhoea.

There are other tests that measure, directly or indirectly, the function of the pancreas. These tests are not usually carried out in routine clinical practice and are not routinely available in the UK. Sometimes the history, examination, scans and faecal elastase test agree, in which case the diagnosis is clear.

Sometimes however, there is a disagreement between the different tests, or between the tests and the history. When that happens, further tests, for example an endoscopic ultrasound or tests for other digestive diseases may be necessary if there is no clear evidence of pancreatic disease.

An experienced clinician will weigh up all these factors to arrive at a diagnosis and explain any other testing that might be needed.

Pancreatic enzymes are taken by mouth to compensate for the low levels produced by the pancreas in PEI. This is known as Pancreatic Enzyme Replacement Therapy PERT , and it is the standard treatment for PEI. When taken properly PERT can improve fat, protein and carbohydrate absorption.

PERT also reduces symptoms of fatty stools, wind and belly pain, increases body weight, and improves nutritional status and quality of life. People with PEI take capsules containing pancreatic enzymes lipase, amylase and proteases with food. The capsules come in varying strengths; the dose can then be adjusted to suit the different requirements of people with PEI.

They are taken with meals, snacks and milky drinks and release the enzymes in the top of the small bowel. This allows the food to be digested.

PERT should be a part of a nutrition plan developed and managed by a specialist dietitian, who is a vital team member. The enzymes are extracted from animal sources pork as being the closest in function to human pancreatic enzymes.

If you have religious reasons to avoid pork products there are dispensations for medicines and medical conditions where they are essential for health and no suitable alternative is available.

As there are no alternatives, the use is deemed acceptable by the Chief rabbi and most Muslim groups. Discuss this with your religious leader for support. They have variable training and may give poor or dangerous advice. The British Dietetic Association can provide more information on the differences between a dietitian, a nutritionist, and other roles.

The digestive enzymes that are promoted by health food shops and nutritional therapists contain tiny amounts of enzymes. Even though they are often marketed as vegan or vegetarian, unfortunately they are not likely to be effective.

The only effective enzymes are those prescribed by a doctor, a nurse or a prescribing dietitian. Often people with PEI taking PERT have a poor appetite. Eating smaller meals more often can help. It is important to ensure that the PERT dose is adequate and spread out throughout larger meals.

There is no need to restrict fat routinely. Occasionally people with pancreatic conditions can develop difficulty tolerating fat. If this is the case the PERT dose should be reviewed and possibly increased. If this does not help symptoms, other conditions should be investigated such as bile acid diarrhoea , small bowel bacterial overgrowth and coeliac disease.

Some people also need vitamin and mineral supplements, and this can be discussed with the dietitian. Instead, request a review of your digestive enzyme medicine from your doctor if you are having problems. This recommendation does not account for the size of the meal or cater for snacks or nutritious fluids such as milky coffee or hot chocolate.

People with PEI may also be advised to take a part of their dose at the start, halfway through and at the end of the meal. PERT works directly on food, so it is important the capsules are in the stomach at the same time as food.

Taking PERT on an empty stomach will not be effective. Some meals take longer to eat dining out in a restaurant, for instance and ensuring that PERT is taken with each course will help the capsules mix with the food more effectively. Heat also damages the enzymes so do avoid leaving the capsules in direct sunlight, near radiators or in trouser pockets.

Establishing successful PERT therapy requires a partnership between the person with PEI and their dietitian. PERT is often prescribed with a proton pump inhibitor PPI medicine — examples are omeprazole, lansoprazole and esomeprazole, there are several options. In PEI the top of the small bowel may be more acidic than it should be.

In an acidic environment, pancreatic enzymes cannot work. As a result, the coating on PERT capsules prevents the enzymes from being activated in an acidic environment.

The PPI medicine lessens the quantity of acid from the stomach reaching the small bowel and improves the action of PERT. The NICE guideline for pancreatitis recommends that people with chronic pancreatitis are offered monitoring of their pancreatic exocrine function and their nutritional status.

This should be done at least every 12 months or every 6 months in people under This should be done by clinical assessment and blood tests, to be agreed with a specialist pancreatic centre.

Any treatment of vitamin and mineral deficiencies received by the person with PEI should be adjusted according to the results of the assessments. Adults with chronic pancreatitis should also be offered monitoring of their HbA1c level, a test for diabetes, at least every 6 months.

Plus, a bone density assessment every two years. People diagnosed with PEI can also develop diabetes. Eight in 10 people with chronic pancreatitis may develop diabetes within 20 years of diagnosis.

One in 3 people with cystic fibrosis over 16 years of age will be treated for diabetes. Diabetes can also happen with other causes of PEI but the number of people it affects is unknown.

People with PEI often learn to manage the food they eat to help their symptoms and improve their nutritional status. You will know if your treatment is working as your symptoms of runny poo should improve, pain may be better controlled, and your weight should start to stabilise.

PEI might seem complicated but working with your healthcare team it is possible to have a good quality of life with PEI. References available on request.

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Please read our Privacy Polic y for more details. Skip to content Search Menu Donate. Pancreatic Exocrine Insufficiency PEI and Pancreatic Enzyme Replacement Therapy PERT Download printable version. Overview 2. Causes 3. Pancreas and digestion 4. Symptoms 5. Treatment 6. What is Pancreatic Exocrine Insufficiency?

What causes PEI? As people get older, there are more people diagnosed with PEI. Pancreas and digestion. What is the role of the pancreas? In summary, pancreatic enzymes help convert: Starchy carbohydrates to glucose.

Proteins to peptides and amino acids. Fats to fatty acids and glycerol. How does PEI affect digestion? What other roles does the pancreas have? Endocrine function The other role of the pancreas is called its endocrine function.

What are the signs and symptoms of PEI? Symptoms can include: Belly discomfort or pain. Fatty stools. Weight loss. Poo can also float and be difficult to flush away and may stain the toilet bowl. See the chart here. Type 6 to type 7 is defined as runny poo diarrhoea. Low levels of these vitamins can give the following symptoms: Bone problems — osteoporosis.

Poor wound healing. Increased infections. Sight problems particularly in the dark. Neurological nerve symptoms. Muscle weakness. How is PEI diagnosed? How is PEI managed and what is the role of Pancreatic Enzyme Replacement Therapy PERT?

There are four different types of enzyme medicine available: Creon® Pancrease® Nutrizym® Pancrex® They are available in either capsule or powder form. Religious and ethical: The enzymes are extracted from animal sources pork as being the closest in function to human pancreatic enzymes.

NICE guidelines: The NICE guideline for pancreatitis recommends that people with chronic pancreatitis are offered monitoring of their pancreatic exocrine function and their nutritional status.

Symptoms of possible diabetes which should be discussed with your doctor include: Unintentional weight loss.

Feeling very thirsty. Peeing more frequently than normal, particularly at night. Blurred vision. Craving sugary drinks and foods. What to ask your doctor? Talk to your doctor if you feel you have PEI or have questions about: Your prescribed enzyme medicine dose.

If you suspect an allergy to your enzymes, for example a skin rash, which is an uncommon reaction.