Detection of Exocrine Pancreatic Insufficiency in Patients With Diarrhea and Bloating

Exocrine pancreatic insufficiency (EPI) diagnosis can be challenging due to several reasons.
First, the main symptoms of EPI such as diarrhea, loose stool, bloating or weight loss have
low specificity because they could be associated with many other conditions such as IBS or
celiac disease. Second, EPI could be found concomitantly as an exacerbating factor with other
causes of diarrhea and bloating leading to incomplete treatment and increased patient
dissatisfaction due to partial resolution of symptoms. Although the prevalence of EPI in
general population is not well known, a recent population study in 914 patients from Norway
showed up to 10% prevalence of EPI using the measurement of fecal elastase-1 level in
elderly. In another study, the prevalence of EPI diagnosed by low fecal elastase-1 in 314
patients with chronic diarrhea who satisfied the Rome II criteria for irritable bowel
syndrome diarrhea (IBS-D) was 6.1%.Furthermore, an EPI prevalence of 4.4% (diagnosed by low
fecal elastase-1) was documented in 90 patients who had serological and histological evidence
of celiac disease. Interestingly, MRI was normal in all patients diagnosed with EPI in this
study.

The gold standard tests for diagnosing EPI is three-day fecal fat quantification and
determination of the coefficient of fat absorption. The patient is required to keep an intake
of 100g of fat for five days and then collect feces for a time period of three days. Direct
measurement of pancreatic function test with secreting stimulation is another sensitive test.
. However these tests are cumbersome to apply to large number of patients with common
complaints. Spot fecal elastase-1 measurement using enzyme linked immunosorbent assay (ELISA)
has been shown to be highly sensitive and specific in diagnosing moderate to severe chronic
pancreatitis in several studies. The favorable operating characteristics combined with the
ease of using of the test makes it a good initial screening test for EPI.

Our preliminary data indicate that a large proportion (10 %) of patients with undiagnosed
bloating and or diarrhea have EPI initially detected by low fecal elastase-1 and subsequently
confirmed with Endoscopic Ultrasound and or direct measurement of pancreatic function tests.
Therefore, Investigators propose to test the hypothesis that including fecal elastase-1 as
part of the initial work-up for patients presenting with diarrhea and or bloating will
identify patients who are confirmed EPI and may benefit from pancreatic enzyme replacement
therapy and limit further unnecessary work up.

Inclusion Criteria:

1. Patients aged 18 to 80 years old who presents to the gastroenterology clinic with main
complaints of diarrhea

2. Patients aged 18-80 years old who presents to the gastroenterology clinic with main
complaints of flatulence, and/or bloating

3. Patients with known IBS, microscopic colitis or celiac disease diagnosis will be
included.

4. Patients on Diphenxoylate, loperamide or cholestyramin will be included.

Exclusion Criteria:

1. Known chronic pancreatitis, recurrent acute pancreatitis or autoimmune pancreatitis.

2. Known Pancreatic cancer

3. Prior History of distal pancreatictomy or Whipple surgery.

4. Prior history of gastric bypass surgery or any Roux en Y gastrojeujunal anastomosis.

5. Pregnant Patients