Elevating EPI in the differential diagnosis

MELISSA: When it comes to EPI, it's important to diagnose as soon as possible.

DR. RANNEY: I agree. Rapid and accurate diagnosis is absolutely key. Diagnosis of EPI is often delayed up to two to three years, and I think that shows that EPI is not kept at the forefront of the differential diagnosis, and it's taking too long to make the proper diagnosis for patients.

MELISSA: Within a differential diagnosis, there can be so many other conditions to consider, like IBS, IBS-D, SIBO, or even celiac disease, based on overlapping GI symptoms and clinical features across these conditions. This may delay proper diagnosis and management of EPI.

DR. RANNEY: I think it's important to elevate EPI in the differential diagnosis so we can diagnose it in a timelier fashion. One of the reasons an earlier diagnosis is so important is because sometimes the symptoms of EPI may be the patient's first sign of having an underlying condition like chronic pancreatitis or pancreatic cancer. I can think of several examples of patients that I've personally seen who presented with symptoms of bloating and diarrhea due to EPI who were ultimately diagnosed with pancreatic cancer, and you know, their symptoms were relatively mild, but had we not discovered EPI early in the diagnosis, it may have led to a delay in the diagnosis of their cancer.

MELISSA: That's a really good point, and we know that patients typically only see their PCPs once a year, if that. Sometimes these symptoms are not at the top of the list when they're coming to see us as providers. But these frequent and recurring symptoms are not typical, and they need to know that. And they need to feel comfortable talking about diarrhea, gas, bloating, abdominal pain, or even loose and oily stools. Those are key symptoms that should alert us as health care providers that something is not right and should probably be investigated.

DR. RANNEY: Yeah, absolutely. I think a key symptom that can be confused with so many other conditions, but is an indicator of EPI, is chronic diarrhea. I've had seemingly healthy patients come in who are experiencing that and ultimately were diagnosed with EPI.

MELISSA: Yeah, that's so interesting because that's, I think, one of the reasons why I usually start asking patients about their previous diagnosis or what previous treatments they've had. And I like to understand what diets they might have tried to treat their chronic diarrhea. I also look for some alarm features associated with chronic diarrhea, like weight loss or a family or personal history of celiac disease or Crohn's disease. And, you know, chronic diarrhea can happen for a myriad of reasons. But once you ask these really pointed questions, you can start to figure out whether you need to order, you know, a fecal elastase test, for example, or if you can just do a clinical diagnosis of EPI and you can start the patient on a PERT like CREON.

DR. RANNEY: I kind of break up my patients into two categories when I'm thinking they may have EPI: patients who have EPI risk factors and patients who don't. For patients who do not have risk factors of EPI but are presenting with the symptoms of EPI, I think that ordering stool studies including a fecal elastase is a great place to start. And that should help rule out many conditions and really help determine if what they're experiencing is in fact related to EPI. If a patient has an underlying condition of EPI and they tell me that, I don't necessarily need to do any kind of testing for that patient. A clinical suspicion may be sufficient to diagnose them with EPI. In my practice, we've actually seen an increase in our diagnostic yield for EPI with this categorical approach.

MELISSA: Yeah, I think this is why keeping EPI in the differential diagnosis is essential, so we can identify EPI in a timelier manner and help treat this manageable condition.



CREON® (pancrelipase) delayed-release capsules are indicated for the treatment of exocrine pancreatic insufficiency in adult and pediatric patients.

Important Safety Information

  • Fibrosing colonopathy has been reported following treatment with pancreatic enzyme products. Do not exceed the recommended dosage of 2,500 lipase units/kg/meal (or 10,000 lipase units/kg/day) or 4,000 lipase units/g fat ingested/day in adult and pediatric patients greater than 12 months of age without further investigation.
  • To avoid irritation of oral mucosa, care should be taken to ensure that CREON is not crushed, chewed, or retained in the mouth. CREON should always be taken with food.
  • Pancreatic enzyme products contain purines that may increase blood uric acid levels. High dosages have been associated with hyperuricosuria and hyperuricemia. Consider monitoring blood uric acid levels in patients with gout, renal impairment, or hyperuricemia during treatment with CREON.
  • There is theoretical risk of viral transmission with all pancreatic enzyme products, including CREON.
  • Severe hypersensitivity reactions including anaphylaxis, asthma, hives, and pruritus have been reported with pancreatic enzyme products. Monitor patients with a known hypersensitivity reaction to proteins of porcine origin for hypersensitivity reactions during treatment with CREON.
  • Adverse reactions that occurred in at least 2 cystic fibrosis patients (greater than or equal to 4%) receiving CREON were vomiting, dizziness, and cough.
  • Adverse reactions that occurred in at least 1 chronic pancreatitis or pancreatectomy patient (greater than or equal to 4%) receiving CREON were hyperglycemia, hypoglycemia, abdominal pain, abnormal feces, flatulence, frequent bowel movements, and nasopharyngitis.

Please see the accompanying full Prescribing Information, including Medication Guide or visit https://www.rxabbvie.com/pdf/creon_pi.pdf

Additional videos are available for your patients to help educate them about EPI and CREON.