APP Perspective: Diagnostic Test for EPI

Hello. I’m Carol Antequera, I’m a physician assistant with a clinical focus in gastroenterology and pancreatic diseases. The objective of this video is to enhance your diagnostic confidence in identifying Exocrine Pancreatic Insufficiency, or EPI.EPI results from impaired pancreatic enzyme production, delivery, or activity, often due to pancreatic damage, duct obstruction, or low duodenal pH. EPI is more common in clinical practice than often realized, with high prevalence in conditions like cystic fibrosis, acute or chronic pancreatitis, pancreatectomy, and pancreatic cancer. While not as common, EPI is also reported in conditions such as certain enteropathies, like Crohn's or celiac disease, and it is increasingly recognized following GI surgeries like gastric bypass. We often encounter patients describing non-specific symptoms such as diarrhea, abdominal pain, bloating and flatulence. These complaints can be attributed to various gastrointestinal disorders, such as EPI, irritable bowel syndrome with diarrhea, small intestinal bacterial overgrowth, inflammatory bowel disease, and celiac disease.2The presence of these symptoms alone may be insufficient for accurate diagnosis, as such, symptom overlap can lead to delayed or misdiagnosis. A more targeted diagnostic conversation is beneficial to identify the subtle distinctions. By moving beyond the apparent symptom overlap into a frank discussion with our patients about specific clinical features, we can provide more precise and effective care. When assessing patients with non-specific gastrointestinal symptoms, it's imperative to look for distinct characteristics that highlight less common diagnoses like EPI. Despite symptom overlap in various disorders, EPI's specific clinical features can distinguish it in differential diagnosis. For example, the presence of fatty stool, unexplained weight loss, and symptoms related to meals can further distinguish EPI from other GI conditions. Keeping EPI high in the differential diagnosis when these clinical features are present may refine and expedite diagnosis. When diagnosing EPI, it's essential to weigh the pros and cons of different tests because there is no single convenient and specific test for EPI. Let’s review these tests. The Endoscopic Pancreatic Function Test is the reference standard with high sensitivity and specificity for mild to moderate EPI, but its invasiveness and limited availability can be a drawback. Next we have the Quantitative Fecal Fat Test, known as the gold standard for measuring fat malabsorption, offers reliable results but requires a cumbersome 72-hour stool collection and diet adherence. Lastly, we have the Fecal Elastase-1 Test. This is a non-invasive and convenient test for detecting severe EPI but struggles with accuracy in mild to moderate cases. Notably, the test must be performed on formed stool to avoid false positive results. This test is the most commonly used test in clinical practice, despite its limitations For patients with common conditions linked to EPI, additional tests are often unnecessary. However, there may be instances that despite your emphasis on detailed diagnostic discussions, some patients may To wrap up, remember these key points about EPI: It is often under-recognized, though prevalent in various conditions, leading to bothersome symptoms, malnutrition, weight loss, and reduced quality of life. Diagnosis is difficult due to overlapping symptoms, varying guidance, and test limitation, often leaving healthcare providers to primarily rely on a clinical diagnostic approach. Recognizing unique clinical features may help you confidently make a timelier clinical diagnosis. Thank you for your dedication to the care of patients with EPI.benefit from additional testing to confirm your clinical diagnosis, particularly in patients with less common etiologies of EPI.