A meta-analysis landed at the end of September with a clean headline number. About 40 percent of people with chronic pancreatitis have exocrine pancreatic insufficiency, EPI.
The number underneath it is more useful. Depending on which test the studies used, the share with EPI ran from 21 percent to 52 percent.
Same disease. Different ruler.
What the study found
The researchers, from Shanghai, pooled 14 studies covering 7,663 people with chronic pancreatitis, published between 2004 and 2024. Of those, 2,947 had EPI. Pooled prevalence: 40 percent.
By test:
- Faecal elastase (stool elastase) studies: 52 percent
- Breath test studies: 32 percent
- Faecal fat studies: 21 percent
Smoking was linked to 51 percent higher odds of EPI across four studies. Single studies also linked it to low body weight, male sex, diabetes, stents in the pancreatic or bile duct, and pancreatic surgery.
The authors want routine EPI screening in chronic pancreatitis, with the elastase test first. They also wrote that enzyme replacement is still underused and badly monitored. That last line stuck with me.
The three tests, in plain words
Faecal elastase. You hand in a small stool sample. The lab measures elastase-1, an enzyme your pancreas makes that survives the trip through your gut. A result under 200 micrograms per gram usually suggests EPI, and under 100 suggests it’s severe, though the studies in this review didn’t all use the same cut-off. It’s the easy one. Two things worth knowing: a very watery sample can read falsely low, and the test measures human elastase, so you don’t normally stop your enzyme capsules for it. Check that with whoever orders it.
Breath test. You eat a test meal with a labelled fat in it, then breathe into bags over several hours. It measures how well you actually digest fat. It’s more direct, and much less widely available.
Faecal fat. The old standard. You collect every stool for three days, usually on a diet with around 100 g of fat a day. For people like us that’s a frightening amount of fat, which is one reason it’s rarely done now. It only picks up EPI once fat is clearly coming through undigested, which is why it found the lowest numbers.
So the elastase test catches milder EPI. The fat collection catches the obvious cases. Each one answers a slightly different question.
What I’d ask at my next appointment
Have I had an elastase test? What was the actual number?
Was my stool loose when I gave the sample?
If the number is borderline, do we repeat it, or try enzymes and see if things change?
Are my vitamins A, D, E and K being checked? EPI hits those first, because they need fat to be absorbed.
And if you smoke, this is one more reason to talk about stopping. I wrote about smoking and pancreatitis earlier.
Stepan’s Rule: always ask for the actual number. “Normal” on a printout can mean 210 or 500, and those are different stories.
I’m a patient, not a doctor. Testing and enzyme doses belong with your own team.
How I take my enzymes, the timing point from the ESPEN guidance, and the full fat system I eat by are all in the book. Get PancreasZen: the patient’s manual.