Title: Exocrine pancreatic insufficiency

{{short description|Inability to properly digest food due to a lack of digestive enzymes from the pancreas}}
{{More medical citations needed|date=July 2014}}
{{Infobox medical condition
| name          = Exocrine pancreatic insufficiency
| synonyms      =
| image         = Blausen_0699_PancreasAnatomy2.png
| caption       = Anatomy of the pancreas
| pronounce     =
| field         = [[Endocrinology]], [[gastroenterology]]
| symptoms      =
| complications =
| onset         =
| duration      =
| types         =
| causes        = [[Type 2 diabetes]], [[type 1 diabetes]], [[pancreatitis]], [[Coeliac disease|celiac disease]], [[cystic fibrosis]], [[IBS-D]], [[Inflammatory bowel disease|IBD]], somatostatin analogues
| risks         = older age, tobacco use, alcohol use
| diagnosis     = Fecal elastase test
| differential  =
| prevention    =
| treatment     = pancreatic enzyme replacement therapy (PERT)
| medication    = pancrelipase
| prognosis     =
| frequency     =
| deaths        =
}}

'''Exocrine pancreatic insufficiency''' ('''EPI''') is the inability to properly digest food due to a lack or reduction of [[digestive enzyme]]s made by the [[pancreas]]. EPI can occur in humans and is prevalent in many conditions&lt;ref name=&quot;Capurso et al&quot;&gt;{{cite journal |last1=Capurso |first1=Gabriele |last2=Traini |first2=Mariaemilia |last3=Piciucchi |first3=Matteo |last4=Signoretti |first4=Marianna |last5=Arcidiacono |first5=Paolo Giorgio |title=Exocrine pancreatic insufficiency: prevalence, diagnosis, and management |journal=Clinical and Experimental Gastroenterology |date=21 March 2019 |volume=12 |pages=129–139 |doi=10.2147/CEG.S168266 |pmc=6432881 |pmid=30962702 |doi-access=free }}&lt;/ref&gt; such as cystic fibrosis,&lt;ref&gt;{{cite journal |last1=Ritivoiu |first1=Mirela-Elena |last2=Drăgoi |first2=Cristina Manuela |last3=Matei |first3=Dumitru |last4=Stan |first4=Iustina Violeta |last5=Nicolae |first5=Alina Crenguţa |last6=Craiu |first6=Mihai |last7=Dumitrescu |first7=Ion-Bogdan |last8=Ciolpan |first8=Alina Angelica |title=Current and Future Therapeutic Approaches of Exocrine Pancreatic Insufficiency in Children with Cystic Fibrosis in the Era of Personalized Medicine |journal=Pharmaceutics |date=3 January 2023 |volume=15 |issue=1 |page=162 |doi=10.3390/pharmaceutics15010162 |pmc=9862205 |pmid=36678791 |doi-access=free }}&lt;/ref&gt; [[Shwachman–Diamond syndrome]],&lt;ref&gt;{{Citation |last1=Nelson |first1=Adam |title=Shwachman-Diamond Syndrome |date=1993 |url=https://www.ncbi.nlm.nih.gov/books/NBK1756/ |work=GeneReviews® |editor-last=Adam |editor-first=Margaret P. |place=Seattle (WA) |publisher=University of Washington, Seattle |pmid=20301722 |access-date=2023-02-02 |last2=Myers |first2=Kasiani |editor2-last=Everman |editor2-first=David B. |editor3-last=Mirzaa |editor3-first=Ghayda M. |editor4-last=Pagon |editor4-first=Roberta A.}}&lt;/ref&gt; different types of pancreatitis,&lt;ref&gt;{{Cite journal |last1=Ashraf |first1=Hamza |last2=Colombo |first2=John Paul |last3=Marcucci |first3=Vincent |last4=Rhoton |first4=Jonathan |last5=Olowoyo |first5=Oluwatofunmi |date=2021-11-20 |title=A Clinical Overview of Acute and Chronic Pancreatitis: The Medical and Surgical Management |journal=Cureus |volume=13 |issue=11 |article-number=e19764 |language=en |doi=10.7759/cureus.19764 |doi-access=free |pmc=8684888 |pmid=34938639}}&lt;/ref&gt; multiple types of [[diabetes mellitus]] (Type 1 and Type 2 diabetes),&lt;ref&gt;{{Cite journal |last1=Piciucchi |first1=Matteo |last2=Capurso |first2=Gabriele |last3=Archibugi |first3=Livia |last4=Delle Fave |first4=Martina Maria |last5=Capasso |first5=Marina |last6=Delle Fave |first6=Gianfranco |date=2015 |title=Exocrine Pancreatic Insufficiency in Diabetic Patients: Prevalence, Mechanisms, and Treatment |journal=International Journal of Endocrinology |language=en |volume=2015 |article-number=595649 |doi=10.1155/2015/595649 |pmc=4393909 |pmid=25892991 |doi-access=free }}&lt;/ref&gt; advanced [[renal disease]],&lt;ref&gt;{{cite journal |last1=Griesche-Philippi |first1=J. |last2=Otto |first2=J. |last3=Schwörer |first3=H. |last4=Maisonneuve |first4=P. |last5=Lankisch |first5=P.G. |title=Exocrine pancreatic function in patients with end-stage renal disease |journal=Clinical Nephrology |date=December 2010 |volume=74 |issue=12 |pages=457–464 |doi=10.5414/CNP74457 |pmid=21084049 }}&lt;/ref&gt; older adults,&lt;ref name=&quot;Rothenbacher 697–704&quot;&gt;{{cite journal |last1=Rothenbacher |first1=Dietrich |last2=Löw |first2=Michael |last3=Hardt |first3=Philip D. |last4=Klör |first4=Hans-Ulrich |last5=Ziegler |first5=Hartwig |last6=Brenner |first6=Hermann |title=Prevalence and determinants of exocrine pancreatic insufficiency among older adults: Results of a population-based study |journal=Scandinavian Journal of Gastroenterology |date=June 2005 |volume=40 |issue=6 |pages=697–704 |doi=10.1080/00365520510023116 |pmid=16036530 }}&lt;/ref&gt; celiac disease,&lt;ref&gt;{{cite journal |last1=Balaban |first1=Daniel Vasile |last2=Enache |first2=Iulia |last3=Ciochina |first3=Marina |last4=Popp |first4=Alina |last5=Jinga |first5=Mariana |title=Pancreatic involvement in celiac disease |journal=World Journal of Gastroenterology |date=28 June 2022 |volume=28 |issue=24 |pages=2680–2688 |doi=10.3748/wjg.v28.i24.2680 |pmc=9260863 |pmid=35979168 |doi-access=free }}&lt;/ref&gt; diarrhea-predominant [[irritable bowel syndrome]] (IBS-D),&lt;ref name=&quot;Olmos 5666–5675&quot;&gt;{{cite journal |last1=Olmos |first1=Juan I. |last2=Piskorz |first2=María M. |last3=Litwin |first3=Nestor |last4=Schaab |first4=Sara |last5=Tevez |first5=Adriana |last6=Bravo-Velez |first6=Gladys |last7=Uehara |first7=Tatiana |last8=Hashimoto |first8=Harumi |last9=Rey |first9=Enzo |last10=Sorda |first10=Juan A. |last11=Olmos |first11=Jorge A. |title=Exocrine Pancreatic Insufficiency is Undiagnosed in Some Patients with Diarrhea-Predominant Irritable Bowel Syndrome Using the Rome IV Criteria |journal=Digestive Diseases and Sciences |date=December 2022 |volume=67 |issue=12 |pages=5666–5675 |doi=10.1007/s10620-022-07568-8 |pmid=35704255 }}&lt;/ref&gt; inflammatory bowel disease (IBD),&lt;ref&gt;{{Cite journal |last1=Singh |first1=Vikesh K. |last2=Haupt |first2=Mark E. |last3=Geller |first3=David E. |last4=Hall |first4=Jerry A. |last5=Diez |first5=Pedro M. Quintana |date=2017-10-21 |title=Less common etiologies of exocrine pancreatic insufficiency |journal=World Journal of Gastroenterology |language=en |volume=23 |issue=39 |pages=7059–7076 |doi=10.3748/wjg.v23.i39.7059 |pmc=5656454 |pmid=29093615 |doi-access=free }}&lt;/ref&gt; [[HIV]],&lt;ref&gt;{{cite journal |last1=Yilmaz |first1=Aylin |last2=Hagberg |first2=Lars |title=Exocrine pancreatic insufficiency is common in people living with HIV on effective antiretroviral therapy |journal=Infectious Diseases |date=4 March 2018 |volume=50 |issue=3 |pages=193–199 |doi=10.1080/23744235.2017.1370126 |pmid=28838283 }}&lt;/ref&gt; [[alcohol-related liver disease]],&lt;ref&gt;{{Cite journal |last1=Leeds |first1=John S. |last2=Oppong |first2=Kofi |last3=Sanders |first3=David S. |date=July 2011 |title=The role of fecal elastase-1 in detecting exocrine pancreatic disease |journal=Nature Reviews Gastroenterology &amp; Hepatology |language=en |volume=8 |issue=7 |pages=405–415 |doi=10.1038/nrgastro.2011.91 |pmid=21629239 }}&lt;/ref&gt; Sjogren syndrome,&lt;ref&gt;{{Cite journal |last=Ebert |first=Ellen Catherine |date=January 2012 |title=Gastrointestinal and Hepatic Manifestations of Sjogren Syndrome |journal=Journal of Clinical Gastroenterology |volume=46 |issue=1 |pages=25–30 |doi=10.1097/MCG.0b013e3182329d9c |pmid=22157220 }}&lt;/ref&gt; tobacco use,&lt;ref&gt;{{Cite journal |last1=Raphael |first1=Kara L. |last2=Chawla |first2=Saurabh |last3=Kim |first3=Sungjin |last4=Keith |first4=Christopher G. |last5=Propp |first5=David R. |last6=Chen |first6=Zhengjia N. |last7=Woods |first7=Kevin E. |last8=Keilin |first8=Steven A. |last9=Cai |first9=Qiang |last10=Willingham |first10=Field F. |date=February 2017 |title=Pancreatic Insufficiency Secondary to Tobacco Exposure: A Controlled Cross-Sectional Evaluation |journal=Pancreas |language=en |volume=46 |issue=2 |pages=237–243 |doi=10.1097/MPA.0000000000000721 |pmc=6355146 |pmid=27846134 }}&lt;/ref&gt; and use of [[somatostatin]] analogues.&lt;ref&gt;{{Cite journal |last1=Lamarca |first1=Angela |last2=McCallum |first2=Lynne |last3=Nuttall |first3=Christina |last4=Barriuso |first4=Jorge |last5=Backen |first5=Alison |last6=Frizziero |first6=Melissa |last7=Leon |first7=Rebecca |last8=Mansoor |first8=Was |last9=McNamara |first9=Mairéad G |last10=Hubner |first10=Richard A. |last11=Valle |first11=Juan W |date=2018-07-03 |title=Somatostatin analogue-induced pancreatic exocrine insufficiency in patients with neuroendocrine tumors: results of a prospective observational study |journal=Expert Review of Gastroenterology &amp; Hepatology |volume=12 |issue=7 |pages=723–731 |doi=10.1080/17474124.2018.1489232 |pmid=29923433 |url=https://pure.manchester.ac.uk/ws/files/75897623/2018_06_08_Final_SSA_manuscript.docx }}&lt;/ref&gt;

EPI is caused by a progressive loss of the pancreatic cells that make digestive enzymes. Loss of digestive enzymes leads to [[digestion|maldigestion]] and [[malabsorption]] of nutrients from normal digestive processes. EPI can cause symptoms even before reaching the stages of malnutrition: 'mild' or 'moderate' EPI is when fecal elastase levels are &lt;200&amp;nbsp;ug/g, whereas 'severe' EPI is considered to be when fecal elastase levels is &lt;100&amp;nbsp;ug/g.&lt;ref&gt;{{Cite journal |last1=Shandro |first1=Benjamin M |last2=Ritehnia |first2=Jennifer |last3=Chen |first3=Joshua |last4=Nagarajah |first4=Rani |last5=Poullis |first5=Andrew |date=November 2020 |title=The investigation and management of pancreatic exocrine insufficiency: A retrospective cohort study |journal=Clinical Medicine |language=en |volume=20 |issue=6 |pages=535–540 |doi=10.7861/clinmed.2020-0506 |pmc=7687321 |pmid=33199316 }}&lt;/ref&gt;

The [[exocrine pancreas]] is a portion of this organ that contains clusters of ducts (acini) producing [[bicarbonate]] anion, a mild alkali, as well as an array of digestive enzymes that together empty by way of the interlobular and main pancreatic ducts into the [[duodenum]] (upper small intestine).&lt;ref&gt;{{cite book |last1=Pandol |first1=Stephen J. |title=The Exocrine Pancreas |date=2010 |publisher=Morgan &amp; Claypool Life Sciences |chapter-url=https://www.ncbi.nlm.nih.gov/books/NBK54134/ |chapter=Anatomy }}&lt;/ref&gt; The hormones [[cholecystokinin]] and [[secretin]] secreted by the stomach and duodenum in response to distension and the presence of food in turn stimulate the production of digestive enzymes by the exocrine pancreas.&lt;ref name=&quot;:0&quot;&gt;{{cite book |last1=Pandol |first1=Stephen J. |title=The Exocrine Pancreas |date=2010 |publisher=Morgan &amp; Claypool Life Sciences |chapter-url=https://www.ncbi.nlm.nih.gov/books/NBK54132/ |chapter=Regulation of Whole-Organ Pancreatic Secretion }}&lt;/ref&gt; The alkalization of the duodenum neutralizes the acidic [[chyme]] produced by the stomach that is passing into it; the digestive enzymes serve to catalyze the breakdown of complex foodstuffs into smaller molecules for absorption and integration into metabolic pathways.&lt;ref name=&quot;:0&quot; /&gt; The enzymes include [[protease]]s ([[trypsinogen]] and [[chymotrypsinogen]]), hydrolytic enzymes that cleave [[lipids]] (the [[lipase]]s [[phospholipase A2]] and [[lysophospholipase]], and [[cholesterol ester]]ase), and [[amylase]] to digest starches. EPI results from progressive failure in the exocrine function of the pancreas to provide its [[digestive enzyme]]s, often in response to a genetic condition or other disease state, resulting in the inability of the animal involved to properly digest food.{{citation needed|date=July 2014}}

==Signs and symptoms==
Loss of pancreatic enzymes leads to maldigestion and [[malabsorption]]. Other symptoms may include:&lt;ref&gt;{{Cite journal |last1=Othman |first1=Mohamed O. |last2=Harb |first2=Diala |last3=Barkin |first3=Jodie A. |date=February 2018 |title=Introduction and practical approach to exocrine pancreatic insufficiency for the practicing clinician |journal=International Journal of Clinical Practice |language=en |volume=72 |issue=2 |article-number=e13066 |doi=10.1111/ijcp.13066 |pmc=5873407 |pmid=29405509}}&lt;/ref&gt;
* Abdominal discomfort or pain
* Bloating
* Diarrhea
* [[Anemia]] ([[Vitamin B12 deficiency|vitamin B12]], [[Iron deficiency|iron]], [[folate deficiency|folate]] deficiency)
* [[Bleeding disorder]]s ([[Vitamin K deficiency|vitamin K]] malabsorption)
* [[Edema]] ([[hypoalbuminemia]])
* Fatigue
* Flatulence and [[abdominal distention]] (bacterial fermentation of unabsorbed food)
* [[Hypocalcaemia|Hypocalcemia]]
* [[Metabolic bone disease]] ([[vitamin D deficiency]])
* Neurologic manifestation
* [[Steatorrhea]]
* Weight loss

==Causes==
In humans, the most common causes of EPI are likely related to diabetes (10.5% global prevalence of diabetes,&lt;ref&gt;{{Cite journal |last1=Sun |first1=Hong |last2=Saeedi |first2=Pouya |last3=Karuranga |first3=Suvi |last4=Pinkepank |first4=Moritz |last5=Ogurtsova |first5=Katherine |last6=Duncan |first6=Bruce B. |last7=Stein |first7=Caroline |last8=Basit |first8=Abdul |last9=Chan |first9=Juliana C. N. |last10=Mbanya |first10=Jean Claude |last11=Pavkov |first11=Meda E. |last12=Ramachandaran |first12=Ambady |last13=Wild |first13=Sarah H. |last14=James |first14=Steven |last15=Herman |first15=William H. |date=2022-01-01 |title=IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045 |journal=Diabetes Research and Clinical Practice |volume=183 |article-number=109119 |doi=10.1016/j.diabres.2021.109119 |pmid=34879977 |pmc=11057359 |hdl=20.500.11820/85919e8b-f73d-433d-a236-058a9561e24d |hdl-access=free }}&lt;/ref&gt; with EPI rates of ranging from 30–50% in Type 1 and 20–30% of Type 2&lt;ref name=&quot;Capurso et al&quot;/&gt;) and IBS-D (7.6–10.8% global prevalence of IBS-D,&lt;ref&gt;{{cite journal |last1=Oka |first1=Priya |last2=Parr |first2=Heather |last3=Barberio |first3=Brigida |last4=Black |first4=Christopher J |last5=Savarino |first5=Edoardo V |last6=Ford |first6=Alexander C |title=Global prevalence of irritable bowel syndrome according to Rome III or IV criteria: a systematic review and meta-analysis |journal=The Lancet Gastroenterology &amp; Hepatology |date=October 2020 |volume=5 |issue=10 |pages=908–917 |doi=10.1016/S2468-1253(20)30217-X |pmid=32702295 |hdl=11577/3363482 |url=https://eprints.whiterose.ac.uk/165295/3/thelancetgastrohep-D-20-00505R1%20CLEAN.pdf }}&lt;/ref&gt; with EPI rates around 5–6%&lt;ref name=&quot;Olmos 5666–5675&quot;/&gt;). Other causes of EPI include [[Acute pancreatitis|acute]] or [[chronic pancreatitis]] and [[cystic fibrosis]], Crohn's disease, ulcerative colitis, celiac, advanced renal disease, older age, IBD, HIV, alcohol-related liver disease, Sjogren's syndrome, tobacco use, and use of somatostatin analogues.

EPI can also occur in 10–20% of the general population.&lt;ref&gt;{{cite journal |last1=Campbell |first1=Jennifer A. |last2=Sanders |first2=David S. |last3=Francis |first3=Katherine A. |last4=Kurien |first4=Matthew |last5=Lee |first5=Sai |last6=Taha |first6=Hatim |last7=Ramadas |first7=Arvind |last8=Joy |first8=Diamond |last9=Hopper |first9=Andrew D. |title=Should we Investigate Gastroenterology Patients for Pancreatic Exocrine Insufficiency? A Dual Centre UK Study |journal=Journal of Gastrointestinal and Liver Diseases |date=September 2016 |volume=25 |issue=3 |pages=303–309 |doi=10.15403/jgld.2014.1121.253.uks |pmid=27689193 |doi-access=free }}&lt;/ref&gt;&lt;ref name=&quot;Rothenbacher 697–704&quot;/&gt;&lt;ref&gt;{{Cite journal |last1=Herzig |first1=Karl-Heinz |last2=Purhonen |first2=Anna-Kaisa |last3=Räsänen |first3=Kati M |last4=Idziak |first4=Joanna |last5=Juvonen |first5=Petri |last6=Phillps |first6=Ryszard |last7=Walkowiak |first7=Jaroslaw |date=December 2011 |title=Fecal pancreatic elastase-1 levels in older individuals without known gastrointestinal diseases or diabetes mellitus |journal=BMC Geriatrics |volume=11 |issue=1 |page=4 |doi=10.1186/1471-2318-11-4 |pmc=3039595 |pmid=21266058 |doi-access=free }}&lt;/ref&gt;

==Diagnosis==
The three main tests used in considering a diagnosis of EPI are: fecal [[elastase]] test, fecal fat test, and a direct pancreatic function test.&lt;ref&gt;{{cite journal |author=Domínguez-Muñoz, JE |date=2011 |title=Pancreatic insufficiency: diagnosis and treatment |journal=J Gastroenterol Hepatol |volume=26 |issue=Supplement s2 |pages=12–16 |doi=10.1111/j.1440-1746.2010.06600.x |pmid=21323992 |hdl=20.500.11940/5522 |hdl-access=free }}&lt;/ref&gt; The latter is a less used test that assesses exocrine function in the pancreas by inserting a tube into the small intestine to collect pancreatic secretions.

The fecal elastase test is a less cumbersome test that has replaced the 72-hour fecal fat test; in the fecal elastase test, pancreatic enzyme replacement therapy (enzyme supplementation, the treatment for EPI) does not have to be stopped for or during fecal elastase testing.&lt;ref&gt;{{Cite journal |last1=Struyvenberg |first1=Maarten R. |last2=Martin |first2=Camilia R. |last3=Freedman |first3=Steven D. |date=December 2017 |title=Practical guide to exocrine pancreatic insufficiency – Breaking the myths |journal=BMC Medicine |volume=15 |issue=1 |pages=29, s12916–017–0783-y |doi=10.1186/s12916-017-0783-y |pmc=5301368 |pmid=28183317 |doi-access=free }}&lt;/ref&gt;

==Treatment==
EPI is treated with pancreatic enzyme replacement therapy (PERT) called [[pancrelipase]], which is used to break down fats (via a [[lipase]]), proteins (via a [[protease]]), and carbohydrates (via [[amylase]]) into units that can be digested.&lt;ref&gt;{{cite web|url=https://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/Over-the-CounterOTCDrugs/StatusofOTCRulemakings/ucm063031.htm |archive-url=https://web.archive.org/web/20090622235833/http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/Over-the-CounterOTCDrugs/StatusofOTCRulemakings/ucm063031.htm |archive-date=June 22, 2009 |title=FDA rulemaking history of OTC EPI drug products |website=Fda.gov |access-date=2011-11-08}}&lt;/ref&gt; Pancrelipase is typically porcine derived in the prescription products although over-the-counter options also exist, including those made with plants and other non-porcine materials. In the US, there are 6 FDA-approved PERT products available on the market as of 2012.

Dosing can vary based on the need of the individual.&lt;ref&gt;{{Cite journal |last1=Trang |first1=Tony |last2=Chan |first2=Johanna |last3=Graham |first3=David Y |date=2014-09-07 |title=Pancreatic enzyme replacement therapy for pancreatic exocrine insufficiency in the 21st century |journal=World Journal of Gastroenterology |volume=20 |issue=33 |pages=11467–11485 |doi=10.3748/wjg.v20.i33.11467 |pmc=4155341 |pmid=25206255 |doi-access=free }}&lt;/ref&gt; PERT is considered to be safe, effective, and tolerable for people with EPI regardless of the cause of EPI.&lt;ref&gt;{{Cite journal |last1=Gan |first1=Can |last2=Chen |first2=Yan-Hua |last3=Liu |first3=Ling |last4=Gao |first4=Jin-Hang |last5=Tong |first5=Huan |last6=Tang |first6=Cheng-Wei |last7=Liu |first7=Rui |date=2017-10-07 |title=Efficacy and safety of pancreatic enzyme replacement therapy on exocrine pancreatic insufficiency: a meta-analysis |journal=Oncotarget |volume=8 |issue=55 |pages=94920–94931 |doi=10.18632/oncotarget.21659 |pmc=5706924 |pmid=29212278}}&lt;/ref&gt;

In addition, various nutrient deficiencies that can be caused by EPI need to be evaluated, tested, and treated. The impact of nutrient deficiencies on the body's metabolic pathways, muscle tissue, bone density, organs, and overall health can cause a wide range of often misdiagnosed symptoms for those impacted by exocrine pancreatic insufficiency.&lt;ref&gt;{{Cite book |last=Toxopeus |first=A. |title=Primal Pancreas - Pancreas Damage Survival Guide |year=2019 |isbn=978-0-9600679-1-6 |pages=180–200|publisher=Delft Consulting LLC }}&lt;/ref&gt;

==Other animals==
EPI also occurs in [[dog]]s and other animals. [[Chronic pancreatitis]] is the most common cause of EPI in [[cat]]s. In dogs, the most common cause is ''pancreatic acinar atrophy'', arising as a result of [[genetics|genetic conditions]], a blocked [[pancreatic duct]], or prior infection.

=== Causes and pathogenesis ===
Pancreatic acinar atrophy and chronic pancreatitis are the most common causes of exocrine pancreatic insufficiency in dogs and cats.&lt;ref&gt;{{cite journal |last1=Cridge |first1=Harry |last2=Williams |first2=David A. |last3=Barko |first3=Patrick C. |title=Exocrine pancreatic insufficiency in dogs and cats |journal=Journal of the American Veterinary Medical Association |date=February 2024 |volume=262 |issue=2 |pages=246–255 |doi=10.2460/javma.23.09.0505 |pmid=37944252 |doi-access=free }}&lt;/ref&gt;

In dogs, EPI is most common in young German Shepherds, and in Finland [[Rough Collie]]s,&lt;ref name=Westermarck_2003&gt;{{cite journal |author1=Westermarck, E. |author2=Wiberg, M. |title=Exocrine pancreatic insufficiency in dogs |journal=Vet Clin N Am Small Animal Pract |volume=33 |issue=5 |pages=1165–79, viii–ix |year=2003 |pmid=14552166 |doi=10.1016/S0195-5616(03)00057-3}}&lt;/ref&gt; and is inherited.&lt;ref name=Hall&gt;{{cite web | last = Hall | first = Edward J. | title = Exocrine Pancreatic Insufficiency | work = Proceedings of the 28th World Congress of the World Small Animal Veterinary Association | year = 2003 | url = http://www.vin.com/proceedings/Proceedings.plx?CID=WSAVA2003&amp;PID=6553&amp;O=Generic | access-date = 2007-02-24 }}&lt;/ref&gt;  In German Shepherds, the method of inheritance is through an [[recessive gene|autosomal recessive gene]].&lt;ref&gt;{{cite journal |last1=Clark |first1=Leigh Anne |last2=Wahl |first2=Jacquelyn M. |last3=Steiner |first3=Jörg M. |last4=Zhou |first4=Wenli |last5=Ji |first5=Wan |last6=Famula |first6=Thomas R. |last7=Williams |first7=David A. |last8=Murphy |first8=Keith E. |title=Linkage analysis and gene expression profile of pancreatic acinar atrophy in the German Shepherd Dog |journal=Mammalian Genome |date=December 2005 |volume=16 |issue=12 |pages=955–962 |doi=10.1007/s00335-005-0076-1 |pmid=16341675 }}&lt;/ref&gt;  In these two breeds, at least, the cause appears to be [[immune-mediated disease|immune-mediated]] as a sequela to [[lymphocyte|lymphocytic]] pancreatitis.&lt;ref&gt;{{cite journal |last1=Wiberg |first1=M. E. |last2=Saari |first2=S. A. M. |last3=Westermarck |first3=E. |title=Exocrine Pancreatic Atrophy in German Shepherd Dogs and Rough-coated Collies: An End Result of Lymphocytic Pancreatitis |journal=Veterinary Pathology |date=November 1999 |volume=36 |issue=6 |pages=530–541 |doi=10.1354/vp.36-6-530 |pmid=10568434 }}&lt;/ref&gt; The German Shepherd makes up about two-thirds of cases seen with EPI.&lt;ref&gt;{{cite journal |last1=Kim |first1=Ju Won |last2=Jung |first2=Dong In |last3=Kang |first3=Byeong Teck |last4=Kim |first4=Ha Jung |last5=Park |first5=Chul |last6=Park |first6=Eun Hee |last7=Lim |first7=Chae Young |last8=Park |first8=Hee Myung |title=Canine exocrine pancreatic insufficiency treated with porcine pancreatic extract |journal=Journal of Veterinary Science |date=2005 |volume=6 |issue=3 |pages=263–266 |doi=10.4142/jvs.2005.6.3.263 |pmid=16131834 |doi-access=free }}&lt;/ref&gt;  Other breeds reported to be predisposed to EPI include [[terrier]] breeds, [[Cavalier King Charles Spaniel]]s, [[Chow Chow]]s,&lt;ref name=Hall/&gt; and [[Berger Picard|Picardy Shepherd]]s.

===Symptoms===
In animals, signs of EPI are not present until 85 to 90 percent of the pancreas is unable to secrete its enzymes.&lt;ref name=Ettinger_1995&gt;{{cite book|author1=Ettinger, Stephen J. |author2=Feldman, Edward C. |title=Textbook of Veterinary Internal Medicine|edition=4th|publisher=W.B. Saunders Company|year=1995|isbn=0-7216-6795-3}}{{page needed|date=October 2024}}&lt;/ref&gt;  In dogs, symptoms include weight loss, poor hair coat, [[flatulence]], increased appetite, [[coprophagia]], and diarrhea.  Feces are often yellow-gray in color with an oily texture. There are many concurrent diseases that mimic EPI, and severe pancreatitis is one that if allowed to continue unabated can lead to EPI.{{citation needed|date=July 2018}}

===Diagnosis and treatment===
The most reliable test for EPI in dogs and cats is serum trypsin-like immunoreactivity (TLI);&lt;ref&gt;{{cite journal |author1=Steiner, J. |author2=Rutz, G. |author3=Williams, D. |title=Serum lipase activities and pancreatic lipase immunoreactivity concentrations in dogs with exocrine pancreatic insufficiency |journal=Am J Vet Res |volume=67 |issue=1 |pages=84–7 |year=2006 |pmid=16426216 |doi=10.2460/ajvr.67.1.84|doi-access=free }}&lt;/ref&gt;  a low value indicates EPI.  Fecal [[elastase]] levels may also be used for diagnosis in dogs.&lt;ref name=Rallis&gt;{{cite web | last = Rallis | first = Timoleon S. |author2=Adamama-Moraitou, K. | title = Exocrine Pancreatic Insufficiency in Dogs and Cats: An Update | work = Proceedings of the 29th World Congress of the World Small Animal Veterinary Association | year = 2004 | url = http://www.vin.com/proceedings/Proceedings.plx?CID=WSAVA2004&amp;PID=8673&amp;O=Generic | access-date = 2007-02-24 }}&lt;/ref&gt;

In dogs and cats, the best treatment is to supplement the animals' food with dried pancreatic extracts. Fresh pancreas can be substituted, but there is slight risk of disease transmission.&lt;ref&gt;{{cite conference |first1=Jörg M. |last1=Steiner |title=How I Treat--Exocrine Pancreatic Insufficiency |conference=World Small Animal Veterinary Association World Congress Proceedings |date=2008 |url=https://www.vin.com/apputil/content/defaultadv1.aspx?id=3866688&amp;pid=11268 |quote=However, there is a slight risk of transmission of Aujeszky's disease from raw pork pancreas, BSE from raw bovine pancreas, and Echinococcus from raw game pancreas. }}&lt;/ref&gt;&lt;ref&gt;{{cite journal |last1=Szkopek |first1=Dominika |last2=Pierzynowski |first2=Stefan G. |last3=Pierzynowska |first3=Kateryna |last4=Zaworski |first4=Kamil |last5=Kondej |first5=Agata |last6=Wychowański |first6=Piotr |last7=Konieczka |first7=Paweł |last8=Seklecka |first8=Blanka |last9=Donaldson |first9=Janine |last10=Jank |first10=Michał |last11=Woliński |first11=Jarosław |title=A review: Pancreatic enzymes in the treatment of chronic pancreatic insufficiency in companion animals |journal=Journal of Veterinary Internal Medicine |date=2024 |volume=38 |issue=4 |pages=2026–2033 |doi=10.1111/jvim.17096 |pmid=38721836 |pmc=11256127 |quote=raw animal tissues can be contaminated with pathogens, for example Salmonella spp. or Campylobacter spp. }}&lt;/ref&gt;&lt;ref&gt;{{cite journal |last1=Davies |first1=R. H. |last2=Lawes |first2=J. R. |last3=Wales |first3=A. D. |title=Raw diets for dogs and cats: a review, with particular reference to microbiological hazards |journal=Journal of Small Animal Practice |date=June 2019 |volume=60 |issue=6 |pages=329–339 |doi=10.1111/jsap.13000 |pmid=31025713 |pmc=6849757 }}&lt;/ref&gt; Symptoms usually improve within a few days, but lifelong treatment is required to manage the condition.  A rare side-effect of use of dried pancreatic extracts is [[oral ulcer]]ation and bleeding.&lt;ref&gt;{{cite journal |author=Snead E |title=Oral ulceration and bleeding associated with pancreatic enzyme supplementation in a German shepherd with pancreatic acinar atrophy |journal=Can Vet J |volume=47 |issue=6 |pages=579–82 |year=2006 |pmid=16808232 |pmc=1461413}}&lt;/ref&gt;

Because of malabsorption, serum levels of [[cyanocobalamin]] (vitamin B12) and [[tocopherol]] (vitamin E) may be low.  These may be supplemented, although since cyanocobalamin contains the toxic chemical [[cyanide]], dogs that have serious cobalamin issues should instead be treated with [[hydroxocobalamin]] or [[methylcobalamin]].{{citation needed|date=November 2011}}

Cyanocobalamin deficiency is very common in cats with EPI because about 99 percent of [[intrinsic factor]] (which is required for cyanocobalamin absorption from the intestine) is secreted by the pancreas.  In dogs, this figure is about 90 percent, and only about 50 percent of dogs have this deficiency.{{citation needed|date=June 2025}}

Cats may suffer from [[Vitamin K]] deficiencies.  If there is [[Small bowel bacterial overgrowth syndrome|bacterial overgrowth]] in the intestine, antibiotics should be used, especially if treatment is not working.

In dogs failing to gain weight or continuing to show symptoms, modifying the diet to make it low-fiber and highly digestible may help.  Despite previous belief that low-fat diets are beneficial in dogs with EPI, more recent studies have shown that a high-fat diet may increase absorption of nutrients and better manage the disease.&lt;ref&gt;{{cite journal |vauthors=Biourge V, Fontaine J |title=Exocrine pancreatic insufficiency and adverse reaction to food in dogs: a positive response to a high-fat, soy isolate hydrolysate-based diet |journal=J Nutr |volume=134 |issue=8 Suppl |pages=2166S–2168S |year=2004 |doi=10.1093/jn/134.8.2166S |pmid=15284428 |doi-access=free }}&lt;/ref&gt;  However, it has been shown that different dogs respond to different dietary modifications, so the best diet must be determined on a case-by-case basis.&lt;ref&gt;{{cite journal |last1=Westermarck |first1=Elias |last2=Wiberg |first2=Maria E. |title=Effects of diet on clinical signs of exocrine pancreatic insufficiency in dogs |journal=Journal of the American Veterinary Medical Association |date=15 January 2006 |volume=228 |issue=2 |pages=225–229 |doi=10.2460/javma.228.2.225 |pmid=16426193 |doi-access=free }}&lt;/ref&gt;

One possible [[sequela]], [[volvulus]] (mesenteric torsion), is a rare consequence of EPI in dogs.&lt;ref name=Ettinger_1995/&gt;

==References==
{{reflist}}

== External links ==
{{Medical resources
|   DiseasesDB     =
|   ICD10CM        = {{ICD10CM|K86.81}}
|   ICD10          = {{ICD10|K86.8}}
|   ICD9           = {{ICD9|577.8}}
|   ICDO           =
|   OMIM           =
|   MedlinePlus    =
|   eMedicineSubj  =
|   eMedicineTopic =
|   MeshID         = D010188
}}
{{Gastroenterology}}

[[Category:Dog diseases]]
[[Category:Pancreas disorders]]
[[Category:Steatorrhea-related diseases]]