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Focusing on Fecal Elastase-1 with GI-MAP to Diagnose Exocrine Pancreatic Insufficiency

Wednesday, April 7, 2021

By Ilana Gurevich, ND, L.Ac.

Uprooting Underlying Causes of a Common Patient Complaint

Diarrhea is one of the most common patient complaints in clinical practice. The underlying causes of diarrhea are complex and multifactorial. The goal of this post is to explain how testing fecal elastase-1 can assist providers with diagnosis and treatment of pancreatic insufficiency.

Exocrine pancreatic insufficiency (EPI) is a common underlying cause of chronic diarrhea that presents in clinical practice. It is defined as inadequate activity or deficiency of the pancreatic enzymes within the intestinal lumen, resulting in maldigestion and malabsorption.1 Symptoms of EPI often include steatorrhea, abdominal bloating, weight loss, vitamin deficiencies as well as metabolic bone loss. Moderate to severe cases of EPI generally present with conditions such as diabetes, cystic fibrosis, chronic pancreatitis, IBD, celiac disease and pancreatic cancer. However, many patients without these underlying conditions report having an improvement in diarrhea symptoms as well as improvement of overall digestive function when giving digestive enzymes to support pancreatic activities. Elastase was found to be highly sensitive (93%) and specific (93%) for the detection of exocrine pancreatic insufficiency. The advantages of fecal elastase measurement include lack of requirement of timed stool collection or a prerequisite for specific diet prior to testing.2

Long-Term Risks of Untreated EPI

One of the most significant long-term risks of untreated EPI include bone demineralization. Because patients have a decreased ability to absorb vitamin D, patients with EPI are at high risk of developing osteopenia or osteoporosis. They can generally end up with decreased bone mineral density. While these patient struggle to digest fat, protein, and carbohydrates efficiently, malabsorption of fat appears to be the most clinically impactful and could produce the most significant harm to patients.2

Diagnosing Exocrine Pancreatic Insufficiency

Severe EPI is diagnosed by a fecal elasase-1 of under 100 ug/g. Intermediate pancreatic function is diagnosed at 200–400 ug/g and normal pancreatic function is anywhere above 400 ug/g.4 Any value that presents at lower than the 400 ug/g warrants treatment with digestive enzyme supplementation. Treatment includes supplementing with key digestive enzymes such as lipase, protease, and amylase to assist in the breakdown of lipids, proteins, and carbohydrates. There are many pharmaceutical and nutraceutical options for treatment available on the market. The key is to make sure enzymes are dosed appropriately for patients’ size and food intake.5


Ilana Gurevich, ND, L.Ac.

Ilana Gurevich, ND, L.Ac.

Dr. Gurevich is a board-certified naturopathic physician and acupuncturist. Her special interests and specializations include gastrointestinal disorders, women’s health and menopause, thyroid disorders, and endocrine imbalances. She uses individualized natural therapies to address the underlying cause of disease and encourages her patients to take an active role in their own health care.


  1. JOP 2019;20 Pancreatic Enzyme Replacement Therapy: A Concise Review Gregory T Brennan [PMID 31736680] VIEW
  2. F1000Res. 2019; F1000 Faculty Rev-1991. Update on the diagnosis and management of exocrine pancreatic insufficiency. Yaseen Perbtani [PMID 31824646] VIEW
  3. F1000Res. 2019; F1000 Faculty Rev-1991. Update on the diagnosis and management of exocrine pancreatic insufficiency. Yaseen Perbtani PMID 31824646] VIEW
  4. 2017. Functional Gastroenterology – Assessing and addressing the causes of functional gastrointestinal disorders Sandberg-Lewis, Steven p183.
  5. Clin Exp Gastroenterol. 2019; 12: Exocrine pancreatic insufficiency: prevalence, diagnosis, and management Gabriele Capurs [PMID 30962702] VIEW


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