Exocrine Pancreatic Insufficiency: Symptoms, risk factors, and the value of Pancreatic Elastase testing

TRANSCRIPT for Podcast Episode with the title Exocrine Pancreatic Insufficiency: Symptoms, risk factors, and the value of Pancreatic Elastase testing

Voiceover [00:00:02]:

Welcome to The Results Are In from Quest Diagnostics, conversations with diagnostics industry leaders who enable optimized care pathways for patients.

Jen Jenkins [00:00:18]:

I'm your host, Jen Jenkins, a Senior Marketing Manager on the Clinical Solutions marketing team at Quest Diagnostics. Today we're diving into an important but often underrecognized condition, exocrine pancreatic insufficiency or EPI.

We'll explore what it is, the clinical symptoms providers should watch for, and which patients are most at risk. We'll also talk about why pancreatic elastase testing is such a valuable tool to help identify EPI and how early diagnosis can lead to life-changing treatment with pancreatic enzyme replacement therapy.

Jen Jenkins [00:00:55]:

Joining me to discuss this important topic is Dr. Elif Nahas, Associate Director of Pathology at Quest Diagnostics. Dr. Nahas, welcome to the show.

Dr. Elif Nahas [00:00:59]:

Thank you so much for having me, Jen. It's great to be here.

Jen Jenkins [00:01:02]:

To start us off today, can you share a bit about your role at Quest and the work you do as an Associate Director of Pathology?

Dr. Elif Nahas [00:01:08]:

I am an anatomic and clinical pathologist with fellowship training in gastrointestinal and liver pathology. Currently, I serve as the Medical Director of the clinical laboratory at two hospitals in the Las Vegas area and I am the Chair of Quest's National Gastrointestinal and Liver Resource Committee.

Jen Jenkins [00:01:27]:

We're so excited to have you. Today, let's dive into the topic. What exactly is exocrine pancreatic insufficiency and what's happening in the body when someone develops this condition?

Dr. Elif Nahas [00:01:37]:

In a nutshell, exocrine pancreatic insufficiency, or EPI, is when the pancreas fails to deliver an adequate amount of digestive enzymes to the intestines. This could be due to an impaired pancreatic function or due to an obstruction that blocks the flow of pancreatic enzymes to the gut. Whatever the cause might be, the consequence is a reduced ability to digest food and reduced absorption of fat-soluble vitamins like A, D, E, and K as well as other micronutrients. This impaired ability to digest and absorb nutrients can lead to malnutrition with muscle wasting, weight loss, failure to thrive, vision problems, bone fractures, osteoporosis, and an increase in mortality.

Jen Jenkins [00:02:22]:

Those are some significant impacts. What are some of the key symptoms that might signal EPI, especially ones that a primary care physician or maybe a pediatrician should be aware of?

Dr. Elif Nahas [00:02:32]:

The clinical symptoms really depend on the severity of EPI. Mild early cases could be completely asymptomatic. In these cases, one might consider testing based upon clinical risk factors, which we'll talk about shortly.

Otherwise, the symptoms patients might experience are mostly gastrointestinal in nature and could include excessive fat in the stools known as diatorrhea, which can occur with or without diarrhea. There can also be other nonspecific symptoms, including bloating, flatulence, and unintended weight loss.

Jen Jenkins [00:03:06]:

In addition to identifying patients based on those symptoms, I understand that EPI can be a complication of other conditions. Can you walk us through some of the patient populations at highest risk?

Dr. Elif Nahas [00:03:16]:

Patients who are at the highest risk for EPI include those with chronic pancreatitis risk, recurrent acute pancreatitis, pancreatic cancer, cystic fibrosis, and those who have had prior pancreatic surgery. Moderate risk factors for EPI include long standing diabetes mellitus, intestinal diseases like celiac disease, prior intestinal surgery, and other conditions like Zollinger-Ellison syndrome.

Jen Jenkins [00:03:43]:

Knowing that symptoms alone aren't always enough to make the diagnosis, why is laboratory testing so critical in confirming EPI and ruling out other conditions with similar symptoms like IBS or celiac disease?

Dr. Elif Nahas [00:03:56]:

Laboratory testing is so critical because there are many other medical conditions that can have symptoms that overlap with the symptoms of EPI. Patients with intestinal disorders such as celiac disease, small intestinal bacterial overgrowth, long standing diabetes mellitus, inflammatory bowel disease like Crohn's disease, infections like Giardiasis, et cetera, can have a similar clinical presentation.

Although these patients might have symptoms that overlap with the symptoms of EPI, they probably wouldn't respond to pancreatic enzyme replacement therapy as those with EPI would. These patients would probably benefit more from correcting the underlying issue.

Jen Jenkins [00:04:38]:

And speaking of differential diagnosis, let's talk about pancreatic elastase testing, specifically. How does this test work and why is it considered such a reliable option for evaluating pancreatic function?

Dr. Elif Nahas [00:04:50]:

The gold standard for assessing pancreatic function is actually direct testing of pancreatic secretions. Direct testing is not ideal for routine use because it is invasive, time-consuming, and costly. Pancreatic elastase testing is a simple, indirect, noninvasive way of getting the same information to assess pancreatic function.

Basically, it works by measuring the concentrations of various pancreatic enzymes in the stool. These concentrations in the stool actually correlate with the concentrations seen in pancreatic secretions, making pancreatic elastase a very specific test for EPI. The specificity is actually about 88% relative to direct testing of pancreatic secretions.

Jen Jenkins [00:05:37]:

You mentioned that the test is noninvasive, which sounds like a pretty big advantage. Another advantage is that it can be used for patients already receiving pancreatic enzyme replacement therapy. Can you explain why that's the case?

Dr. Elif Nahas [00:05:49]:

Absolutely. One of the challenges in interpreting other pancreatic enzyme tests in patients being treated with pancreatic enzyme replacement therapy is that the therapy itself could affect the results of the pancreatic enzyme test, therefore making it difficult to confirm true exocrine pancreatic insufficiency.

Currently, all of the commercially available preparations of pancreatic enzyme replacement therapy are of porcine origin, not human. Since pancreatic elastase 1 targets human enzymes, we don't have this problem of cross-reactivity and therefore the use of porcine based pancreatic enzyme replacement therapy does not alter or affect pancreatic elastase 1 test results.

Jen Jenkins [00:06:31]:

Now that we've gotten a handle on clinical utility, let's talk specifics about the test. When a provider orders this test, how should they interpret the results? Can you explain what different ranges, such as normal, moderate or severe insufficiency, would mean for patient management?

Dr. Elif Nahas [00:06:48]:

The sensitivity of pancreatic elastase 1 in detecting EPI increases in more moderate to severe cases of EPI. Obviously, the results need to be correlated with the patient's clinical history and symptoms. In a nutshell, results in the normal range would suggest normal pancreatic function. Anything less than 200 micrograms per gram of stool is considered abnormal.

The American Gastroenterological Association, or AGA, suggests that levels less than 100 grams per gram of stool provide good evidence of EPI, while levels in the 100 to 200 range are indeterminate for EPI. I should also note that levels can appear to be falsely low in liquid or loose stools because of dilution. Of course, as with all lab tests, results must be interpreted in the context of the patient's clinical history.

Jen Jenkins [00:07:41]:

We know that not every practitioner is totally familiar with this test. For providers in our audience who may not routinely screen for EPI, when should they consider ordering a pancreatic elastase test?

Dr. Elif Nahas [00:07:53]:

Providers should order pancreatic elastase testing as the initial test in patients who have high and moderate risk factors for exocrine pancreatic insufficiency and/or gastrointestinal symptoms like steatorrhea and malnutrition.

Jen Jenkins [00:08:08]:

And finally, what is the clinical impact of making the right diagnosis? How can timely testing and treatment improve patient quality of life?

Dr. Elif Nahas [00:08:16]:

The benefit of being able to make the diagnosis of EPI early on is that it enables patients to receive pancreatic enzyme replacement therapy and make lifestyle and diet modifications that will help decrease symptoms and dramatically improve quality of life. Early detection and treatment also helps to reduce long-term consequences of EPI and ultimately reduces overall morbidity and mortality.

Jen Jenkins [00:08:43]:

Well, that sounds like a great reason to utilize pancreatic elastase testing. Thank you so much for joining me in this conversation today, Dr. Nahas.

Dr. Elif Nahas [00:08:51]:

Thank you, Jen, for bringing awareness to such an important topic. Exocrine pancreatic insufficiency is now easy to test for with fecal pancreatic elastase and can even be evaluated in patients taking pancreatic enzyme replacement therapy. Considering this diagnosis in specific clinical scenarios is so important to help people get the treatment that they need.

Jen Jenkins [00:09:12]:

That brings us to the end of today's episode. I'd like to extend a big thank you again to Dr. Elif Nahas for sharing her expertise on exocrine pancreatic insufficiency and the value of pancreatic elastase testing.

We learned about the symptoms in at-risk patient populations, why laboratory testing is essential, and how early detection can guide treatment with pancreatic enzyme replacement therapy.

If you enjoyed this conversation and want to stay informed about the latest advancements in diagnostic testing, make sure to subscribe to the show and leave a review. You won't want to miss our upcoming episodes where we dive into more groundbreaking research and real-world stories that impact patient care.

Thanks for tuning in. I'm Jen Jenkins and we'll see you next time on The Results Are In by Quest Diagnostics.

Voiceover [00:10:09]:

This podcast was produced in partnership with Amaze Media Labs.