Exocrine pancreatic insufficiency (EPI)

Question 1

Exocrine pancreatic insufficiency (EPI)

Answer 1

Exocrine pancreatic insufficiency (EPI) = a deficiency of exocrine pancreatic enzymes needed to maintain normal digestion resulting in nutrient (especially fat) malabsorption

Question 2

EPI: Causes

Answer 2

• Chronic stress — ↓ Vagus nerve activity.
• Hypochlorhydria — ↓ CCK stimulation. most comprehensive stool tests.
• Chronic diseases: cystic fibrosis, chronic pancreatitis, obstructive pancreatic tumours, GI surgery (resection), diabetes mellitus.
• Damaged small intestinal wall (e.g., coeliac, IBD) — ↓ CCK production and ↓ pancreatic stimulation.
• Xenobiotics (pesticides, herbicides, phthalates, BPA) can inactivate pancreatic enzymes.
• Microbial interactions: SIBO (although it could be a cause or effect) can deconjugate pancreatic enzymes; dysbiosis.

Low pancreatic function is indicated by low pancreatic elastase-1, a marker found in most comprehensive stool tests

Question 3

EPI: Common symptoms

Answer 3

• Bloating / belching / flatulence 1–2 hours after eating.
• Steatorrhoea (excessive fat in faeces; i.e., greasy or floating stools).
• Drowsiness after meals.
• Food intolerances.
• Low zinc, B12 and folate absorption.
• Symptoms of IBS, candidiasis or SIBO

Question 4

Naturopathic approach to pancreatic insufficiency

Answer 4

• Don’t overeat, chew adequately, avoid snacking between meals.
• Correct stomach acid levels.
• Stimulate the Vagus nerve to activate the parasympathetic nervous system:

‒ Deep (diaphragmatic) breathing before meals.

‒ Gargle, hum or sing.

‒ Laughter and social enrichment. Gentian

‒ Using bitters such as gentian, artichoke and dandelion.

• Pancreatic enzyme replacement

Question 5

Pancreatic Enzyme Replacement Therapy (PERT):

Answer 5

• Animal-derived (pork pancreatin) has been the standard of care in conventional medicine providing amylase, lipase and protease.
• Plant-based and microbe-derived enzymes appear to offer advantages, e.g., better acid stability, broader range of enzymes, more variants and wider pH range.
• Take enzymes with the first bite of a meal and consider adding extra enzymes during, or at the end of a meal depending on the meal size and duration, e.g., if the meal is:

‒ <15 minutes — take all at the start of the meal.

‒ 15–30 minutes — take half the enzymes at the start and half in the middle of the meal.

‒ >30 minutes — take a third at the beginning, middle and end of the meal.

• The rationale is to mimic endogenous secretion whereby enzyme secretion increases as more food is ingested.

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