One such problem is exocrine pancreatic insufficiency (EPI). “EPI occurs when the pancreas fails to produce sufficient digestive enzymes, which results in inefficient absorption of nutrients from the diet and loss of nutrients in the stool,” explains Mark E. Lowe, MD, PhD, vice chair of pediatrics clinical affairs and strategic planning and a professor of gastroenterology, hepatology, and nutrition at Washington University School of Medicine in St Louis. Here’s what you should know about the link between EPI and gut health.
How Does EPI Affect Gut Health?
There’s no understating the importance of pancreatic enzymes. Your body needs them to digest fat, protein, and carbohydrates, as well as absorb many micronutrients, vitamins, and antioxidants. “These things are vital for gut function,” says Tamas Gonda, MD, chief of endoscopy and director of the pancreatic disease program at NYU Langone Health’s Tisch Hospital in New York. Without sufficient amounts of these enzymes, your gut flora (also called microbiota or microbiome), which include bacteria, viruses, fungi, and other organisms that live inside your gastrointestinal tract, can change for the worse. In one study published in March 2019 in the journal Gastroenterology, researchers at the University of Greifswald, in Germany, determined that changes in the level of elastase — one of the digestive enzymes made by the pancreas — was associated with greater changes in gut microbiota composition. Changes in gut flora have been linked to various illnesses and disorders, including inflammation, cancer, obesity, type 2 diabetes, and asthma. Another study, by researchers at the University of Greifswald published in March 2021 in the journal Gut, looked at fecal samples of healthy people and noted that, in general, negative changes to the microbiome (such as a reduced diversity in the organisms) were associated with fatty liver disease, diabetes, and other unhealthy outcomes. The study found that certain factors, including well-functioning production of pancreatic enzymes, was linked to the greatest long-term stability of microbiota. Small intestinal bacterial overgrowth (SIBO) is another condition directly linked to EPI and its effects on the microbiome. SIBO occurs when the microorganisms in the gut are knocked out of balance, causing bacteria to grow out of control. These sections of bacterial overgrowth force food to “skip” parts of the small intestine and can lead to blind loop syndrome, a condition where nutrients bypass sections of the intestine and aren’t absorbed. This eventually leads to changes in the flora, Dr. Gonda says. “It’s well understood that chronic pancreatitis or any condition that results in pancreatic insufficiency can elicit bacterial overgrowth.” A review of studies published in the September 2019 issue of Clinical and Translational Gastroenterology confirms that EPI is associated with a higher prevalence of SIBO in people with chronic pancreatitis and that receiving treatment for SIBO led to a marked reduction in symptoms.
How EPI and Gut Changes May Impact Your Overall Health
The myriad health problems that can arise from or be exacerbated by EPI are mostly connected to the malnutrition caused by your body’s inability to absorb enough nutrients, according to both Dr. Lowe and Gonda. These conditions include weight loss, osteoporosis, bleeding disorders, vision issues, susceptibility to certain infections, and even neurological problems. “EPI can lead to problems that are related to the malabsorption of fat-soluble vitamins — namely, vitamins A, D, E, and K,” Lowe explains, including:
Problems with bone health from low vitamin DVision problems from a vitamin A deficiencyBleeding problems from a lack of vitamin KNeurological issues, called peripheral neuropathies or tingling sensations in your extremities, from low levels of vitamin E
According to Gonda, there is a direct connection between vitamin and antioxidant deficiencies and neurological dysfunction, as well as a secondary connection between neurological issues and changes in the microbiome caused by EPI. Changes to the gut flora also make EPI patients more susceptible to infections such as C. diff, helicobacter pylori, and the flu.
How to Give Your Gut TLC When You Have EPI
While doctors don’t know for sure whether treating EPI will resolve gut issues — or have a direct effect on EPI — Gonda and Lowe say there are ways to alleviate your symptoms and improve your quality of life. Your first line of defense is to treat your EPI. Currently, the only treatment is pancreatic enzyme replacement therapy (PERT), which contains the enzymes your pancreas is not producing. These include lipase (for digesting fats), protease (for digesting proteins), and amylase (for digesting carbs). Next, you should address the vitamin and nutritional deficiencies that result from EPI. “As an adjunct to PERT, gut health, whether it is altering the microbial flora or adding certain micronutrients, has an important role,” Gonda says. Lowe recommends eating a healthy, moderate-fat diet and taking supplements that contain the fat-soluble vitamins A, D, E, and K, if necessary. Work with your doctor to ensure you’re adjusting your diet and vitamin dosage as needed. It’s also important to know if you have SIBO and ensure that it’s being properly managed. SIBO is typically diagnosed through a breath test or endoscopy, and treatment involves a course of antibiotics. There is still a lot to be understood about the relationship between EPI and gut health and how, in turn, that affects your overall well-being. But taking PERT, using supplements, and eating a healthy diet has shown a lot of promise in helping people with EPI live normal lives and avoid the illnesses associated with EPI-related malnutrition and an unhealthy gut.
