Exocrine Pancreatic Insufficiency

The pancreas can be damaged (chronic pancreatitis from alcohol, genes or other causes, repeated acute pancreatitis, cystic fibrosis, tumours), removed or bypassed by surgery, or the enzymes may not mix well with food (after some stomach operations) or may be blocked from reaching the gut (a blocked pancreatic duct). In coeliac disease and some other bowel diseases, enzyme release can drop temporarily because of changes in gut hormones. Smoking and alcohol increase the risk of pancreatic damage.

EPI is common in people with long-standing pancreatitis, cystic fibrosis, after pancreatic or stomach surgery, and in some with pancreatic cancer. It can also occur in people with diabetes or coeliac disease and in older age, and is often under-recognised because the symptoms resemble other digestive problems. Anyone with chronic loose or greasy stools and weight loss should be considered for assessment.

If you wish to fast in Ramadan, talk to your doctor first. Enzymes should be taken with the iftar and suhoor meals and with any snacks that contain fat, and your weight and blood sugar need monitoring.

Diagnosis combines symptoms, risk factors and tests. A stool test for pancreatic elastase is the commonly used screening test; low levels suggest EPI, although watery stools can give a false low result. Other tests include blood tests for vitamins and nutrition, imaging of the pancreas (ultrasound, CT, MRI or endoscopic ultrasound) to look for the cause, and in some centres breath tests. In people with a clear cause such as chronic pancreatitis or pancreatic surgery, doctors often start treatment based on symptoms.

Habits that protect the pancreas and support treatment.

• Take the enzyme capsules with every meal and snack that contains fat, exactly as your doctor instructed.

• Do not drink alcohol and do not smoke; both damage the pancreas.

• Keep a record of your weight and stools to help your team adjust treatment.

• Stay physically active as tolerated to support bone and muscle health.

• Check blood sugar regularly if you have or are at risk of diabetes.

Contrary to old advice, a very low-fat diet is not recommended, because fat provides much-needed calories. Instead, eat normally and let the enzymes do their work.

• Eat small, frequent meals (about 5 or 6 a day) with enough calories and protein.

• Include moderate amounts of healthy fats such as olive oil, nuts and fish, with enzymes.

• Avoid very large, very fatty meals, which are hardest to digest.

• Ask your dietitian about vitamins A, D, E and K, calcium and other nutrients.

• Oral nutrition supplements can add calories if you cannot maintain weight.

Pancreatic enzyme replacement therapy (PERT) is the main treatment. The dose is individual: your doctor decides and adjusts it, so never change it without advice.

• Swallow the capsules whole with a cool drink at the start of the meal, or spread them through the meal; do not crush or chew them, and do not hold them in the mouth.

• If you cannot swallow capsules, the contents can usually be mixed with a small amount of acidic soft food such as apple puree; ask your pharmacist.

• Take a smaller dose with snacks and drinks containing fat or milk.

• Your doctor may add acid-lowering medicine if symptoms persist despite enzymes.

• Fat-soluble vitamin supplements are given if blood tests show low levels.

Most enzyme capsules are made from pig (porcine) pancreas. Some patients ask about this for religious reasons; discuss it with your doctor, as alternatives may be limited.

Procedures treat the underlying cause or complications rather than EPI itself.

• Endoscopic or surgical treatment of a blocked or narrowed pancreatic duct may help some patients.

• Bone density scanning (DEXA) is advised to check for thinning of bones.

• Feeding tubes are only needed rarely, if nutrition cannot be maintained by mouth.

Modern enzyme capsules are designed to release their contents in the small intestine. Research shows that many patients are under-dosed or take the capsules at the wrong time, so adjusting how and when they are taken often improves results. Experts also stress checking and replacing fat-soluble vitamins, assessing bone health, and treating EPI early to prevent malnutrition.

EPI is usually a long-term condition, but with correct enzyme treatment and nutrition most people have fewer symptoms, regain or keep their weight, and live normally. The outlook mainly depends on the underlying disease. Regular review is needed to adjust the enzyme dose and check vitamins and bone health.

• What is causing my pancreatic insufficiency?

• What enzyme dose do I need and how should I adjust it?

• Which vitamins should be checked or replaced?

• Do I need a bone density scan?

• Are there options if I have religious concerns about the source of the enzymes?

This guide comes from the Saudi Gastroenterology Association (SGA) patient library, prepared by the Approved for publication by SGA; individual clinician review is ongoing. Last reviewed: 2026-04-24. It is for education and does not replace your doctor's advice.