EPI is a condition where you are deficient in exocrine pancreatic enzymes, which play a critical role in digesting and absorbing nutrients from food, according to The National Pancreas Foundation. Patients with cystic fibrosis, chronic pancreatitis, or pancreatic cancer are especially likely to have EPI. Without sufficient enzymes, people with EPI can have trouble getting enough nutrients, says Lucy Gettle, RDN, CNSC, a clinical dietitian specialist with the University of Virginia Health System who works with people who have EPI. Malnutrition comes in different forms. One is energy malnutrition, or a severe calorie deficit that occurs with malabsorption of all three macronutrients: carbohydrates, protein, and fat. While the body has other ways of digesting protein and carbs, you’re particularly dependent on the fat-digesting enzyme lipase, which makes you susceptible to fat malabsorption, she says. Not only is fat the most calorically dense nutrient, but it’s also needed to absorb the fat-soluble nutrients A, E, D, and K. The mainstay treatment for EPI is supplementing with prescription pancreatic enzymes. These are taken whenever you eat or drink anything that contains fat, explains Gettle. You will also likely need to take high-dose vitamin supplements to bridge the gap. If you still aren’t absorbing enough nutrients, you may also need supplemental nutrition through a procedure called enteral tube feeding. Here’s what you should know about it. While tube feeding isn’t generally recommended as a treatment for EPI, some people with EPI may need it, says Sajan Nagpal, MBBS, director of the Pancreas Clinic at the University of Chicago (UChicago) Medicine. For instance, says Dr. Nagpal, if someone is diagnosed with acute pancreatitis (a painful inflammation of the pancreas) and experiences swelling that compresses the small bowel, that person would have difficulty eating. “When this patient would try to eat,” he says, “everything sits in their stomach, and only a little liquid can get through.” This can cause a lot of discomfort and pain. In that instance, a tube may be inserted through the nose, bypass the obstruction (swollen pancreas) and open into the small bowel, where the liquid can be better absorbed. “The reason we start tube feeding for anyone is that they are unable to meet their full nutritional needs by mouth,” says Gettle. If you have cystic fibrosis, for example, you require a large number of calories, which is often more than someone can comfortably eat. In that case, an overnight tube feeding might be a helpful source of supplemental nutrition. But it wouldn’t be the only source of nutrition, because you would still eat throughout the day. Nor is it a perfect therapy, she says, since tube feeds can cause digestive discomfort or contribute to decreased appetite during the day. This is a complex situation if you have EPI, which is why tube feeding is not recommended as a treatment for the condition. For one, the liquid food given in a tube is designed to be easily digestible. Pancreatic enzyme supplements, on the other hand, are formulated for a regular diet. “We don’t have enzymes that work on these tube contents. It’s an area of evolving research to optimize nutrition on tube feeds if someone also has EPI,” says Nagpal. What it comes down to, says Gettle, is finding a formula that people can absorb the liquid nutrition from. “This is tricky but has gotten easier with newer products available,” she says. To quell digestive problems with tube feeding, she points to an FDA-approved digestive enzyme cartridge that attaches to the tube-feeding line and breaks down fats. Her patients report more digestive comfort when using it. If you have EPI and need tube feeding, know that blood sugar regulation can also be a challenge and stand in the way of success. In addition to your primary care doctor, you’ll also want to work with a registered dietitian and endocrinologist. Malnutrition with EPI can occur for many reasons, says Nagpal. The two most common are not taking enough enzymes or not taking them at the right time, which is at the first bite of every meal or snack and first sip of any liquid that contains fat. You may also be coping with more than one medical condition, including undiagnosed celiac disease, small intestinal bacterial overgrowth (SIBO), or an intestinal infection such as giardia. It’s important for your doctor to understand the reason you’re not getting enough nutrition despite enzyme supplementation.
