“People with diabetes should talk to their physician about screening for EPI if they have ongoing digestive symptoms,” advises Mathioudakis. If you have diabetes, these are the signs and symptoms of EPI to be aware of:
- Abdominal pain that can be either mild or severe
- Steatorrhea, or fatty, oily stools (a sign that pancreatic enzymes aren’t getting to your digestive tract to break down fats in the food you eat)
- Unintentional weight loss or signs of poor nutrition
- Fat-soluble vitamin deficiencies, including vitamins A, D, E, or K
“Some people with type 1 diabetes also experience large, unpredictable swings in blood glucose,” says Mathioudakis. This is known colloquially as “brittle diabetes,” although he explains it’s not a formal diagnosis.
Steatorrhea is usually a sign of severe EPI. Diabetes-linked EPI is often mild to moderate, meaning you’re not likely to see the fatty stools of people with more severe EPI.
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Mathioudakis suggests that poor carbohydrate absorption can worsen this mismatch. “When glucose from a meal appears in the bloodstream later than expected, the insulin taken before the meal may peak too early, causing a low initially, followed by a rebound high when a person’s gut finally absorbs the carbs,” he says.
Mathioudakis suggests that, along with EPI, other conditions that may affect carb absorption include:
- Gastroparesis, or delayed stomach emptying
- Celiac disease
- Crohn’s disease
- Small intestinal bacterial overgrowth (SIBO)
- Having had gastric or small‑bowel surgery
“Doctors most commonly see this in forms of diabetes with complete insufficiency, such as type 1 diabetes or diabetes following complete removal of the pancreas,” says Mathioudakis. “It often reflects a mismatch between the timing and amount of insulin and the timing and amount of glucose entering the bloodstream. Some individuals are very insulin‑sensitive, so small dosing errors or delays can have exaggerated effects.” He advises that taking extra insulin for highs or eating carbs for impending lows, known as reactive dosing, can also create a yo‑yo pattern.
Although these are among the most common signs of EPI, they can also have other causes. In fact, many people with diabetes complain of general stomach problems that don’t necessarily indicate an emergency health situation.
“New or worsening diabetes plus digestive symptoms or unexplained weight loss should prompt a conversation about evaluating the pancreas for EPI and other pancreatic conditions,” advises Mathioudakis.
Fortunately, Mathioudakis says that technologies are available to help patients with brittle diabetes. “Today, continuous glucose monitors (CGMs) and automated insulin delivery systems (insulin pumps integrated with CGM) can reduce variability by adjusting insulin delivery as glucose rises or by pulling back insulin when glucose is falling,” he says.
Plus, diagnosing EPI is often possible with a simple test for an enzyme called fecal elastase. Treatment is also simple and involves taking pancreatic enzyme replacement therapy (PERT) with meals to replace the lost function of the enzymes.
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