“If you have diabetes and continue to have gastrointestinal symptoms, you should talk to your doctor about screening for EPI,” advises Dr. Matiodakis. If you have diabetes, be aware of the following signs and symptoms of EPI.
- mild or severe abdominal pain
- Steatorrhea, or fatty, oily stools (a sign that pancreatic enzymes are not reaching the digestive tract to break down fats in food)
- Signs of unintentional weight loss or malnutrition
- Fat-soluble vitamin deficiencies such as vitamins A, D, E, and K
“Some people with type 1 diabetes experience large, unpredictable fluctuations in blood sugar levels,” Matiodakis says. This is colloquially known as “brittle diabetes,” but he explains that this is not an official diagnosis.
Steatorrhea is usually a sign of severe EPI. EPI associated with diabetes is often mild to moderate, and steatorrhea may not be seen in people with more severe EPI.
Matiodakis suggests that carbohydrate malabsorption may exacerbate this discrepancy. “If glucose from a meal appears in your bloodstream later than expected, the insulin you took before the meal may peak too early, causing low blood sugar initially, but then rebounding and becoming high when your intestines finally absorb the carbohydrates,” he says.
Mathioudakis suggests that in addition to EPI, other conditions that can affect carbohydrate absorption include:
- Gastroparesis, or delayed gastric emptying
- celiac disease
- crohn’s disease
- Small intestinal bacterial overgrowth (SIBO)
- Have had stomach or small intestine surgery
“Physicians most commonly see this in fully disabling diabetes, such as type 1 diabetes or diabetes after complete removal of the pancreas,” Matioudakis says. “It often reflects a mismatch between the timing and amount of insulin and the timing and amount of glucose entering the bloodstream. Some people have very high insulin sensitivity, so the slightest dosing error or delay can exaggerate the effects.” He advises that taking extra insulin when high or taking carbohydrates when a low is imminent (known as reactive dosing) can also create a yo-yo pattern.
These are one of the most common signs of EPI, but there may be other causes. In fact, many people with diabetes complain of common stomach problems, but they don’t necessarily indicate an emergency health condition.
“If you have new or worsening diabetes, as well as gastrointestinal symptoms or unexplained weight loss, we should discuss having your pancreas evaluated for EPI or other pancreatic diseases,” advises Mathioudakis.
Fortunately, Mathiodakis says technology is available to help patients with brittle diabetes. “Today, continuous glucose monitors (CGMs) and automated insulin delivery systems (insulin pumps integrated with CGMs) can reduce variability by adjusting insulin delivery as blood sugar levels rise or pulling back insulin when blood sugar levels fall,” he says.
Additionally, diagnosis of EPI is often possible with a simple test for an enzyme called fecal elastase. Treatment is simple and involves administering pancreatic enzyme replacement therapy (PERT) along with meals to replace lost enzyme function.
