When Digestive Symptoms Might Be Pointing at Your Pancreas
- Joyce Knieff, ND, LAc
- 5 minutes ago
- 6 min read
A patient comes in with a familiar story. Years of bloating, intermittent diarrhea, vague abdominal discomfort after meals, weight that won't quite stay on. She has been told it's IBS. She has been told it's stress. She has been told to try a low-FODMAP diet, which helped a little but not as much as she expected. The piece that hasn't been checked, in some of these patients, is whether the pancreas is keeping up with the work of digestion. A practitioner-focused review by Christine Krall, ND, published in April 2026 in Today's Practitioner, makes the case that exocrine pancreatic insufficiency is more common, and more often missed, than the textbook framing suggests.
TL;DR: Many people labeled with IBS may actually have early exocrine pancreatic insufficiency. A simple fecal elastase-1 stool test can flag it, and several common conditions raise the risk.
Key takeaways:
EPI shows up in diabetes, celiac, IBD, and after pancreatic surgery, not just classic pancreatitis.
Standard IBS workups don't rule out EPI. The fecal elastase-1 test does.
A result between 200–500 µg/g deserves a real conversation, not a brush-off.
Untreated EPI can steadily drain fat-soluble vitamins A, D, E, and K over time.
What the research found
Exocrine pancreatic insufficiency, or EPI, describes a state where the pancreas isn't producing enough digestive enzymes to break down food properly. The classic teaching has linked EPI to chronic or acute pancreatitis, cystic fibrosis, and pancreatic cancer. Krall's review catalogs more than 20 additional contributors that show up in real-world practice: type 1 and type 2 diabetes, obesity, celiac disease, inflammatory bowel disease, small intestinal bacterial overgrowth (SIBO), bariatric surgery, age over 80, heavy alcohol use, smoking, autoimmune pancreatitis, certain cancer therapies, and proton pump inhibitor (PPI) use, among others. Reported prevalences for those conditions are higher than most clinicians realize, including up to 77.5 percent in type 1 diabetes, 17 to 61 percent in celiac disease, and 18 to 80 percent in inflammatory bowel disease depending on the population studied.
A 2026 review in Current Opinion in Gastroenterology by Cotton and colleagues reached a similar conclusion from a different angle. In unselected gastroenterology clinic populations, the prevalence of pancreatic exocrine insufficiency runs about 11 to 21 percent. The authors specifically called out that a subset of patients carrying an IBS diagnosis may actually have early pancreatic dysfunction, which the standard IBS workup doesn't capture. They referenced new 2025 European guidelines and a 2025 meta-analysis showing fecal elastase-1 (FE-1) testing has good sensitivity for moderate to severe EPI, while acknowledging it under-detects mild disease.
There's also a downstream signal worth knowing about. A 2026 study in Pancreas by Ogbu and colleagues used a large clinical cohort to show that the combination of low fecal elastase and diabetes was associated with a roughly 3.7-fold increased risk of pancreatic ductal adenocarcinoma compared with patients who had normal fecal elastase and no diabetes. That doesn't mean low elastase causes pancreatic cancer. It means low elastase plus diabetes may flag a higher-risk group worth watching more closely.
Where this fits in the broader practice picture
For decades, the assumption has been that digestive enzyme deficits show up loudly: severe diarrhea, fatty stools, dramatic weight loss. That's the late presentation. The earlier picture is often subtler and less specific. Bloating after meals. Irregular bowel habits. Fatigue. Subtle nutrient deficiencies, particularly the fat-soluble vitamins A, D, E, and K. The Krall review's emphasis on causes beyond pancreatitis matters because most of those conditions share that subtler pattern. A person with well-managed type 2 diabetes who has been working on weight loss and notices ongoing digestive discomfort may not get a fecal elastase test ordered, since the clinical picture doesn't match the classic EPI script.
The Cotton review also lands on a specific clinical move that matters: when symptoms persist despite standard workups, fecal elastase testing is reasonable to add, and a borderline result deserves repeat testing rather than dismissal. Krall makes a related point in her piece about cutoffs. The conventional threshold for diagnosing EPI is below 200 µg/g, but several research groups have noted that healthy adults typically test well over 500 µg/g, and a result in the 200 to 500 range may still represent partial insufficiency worth addressing.
The naturopathic perspective
Digestion is the workhorse of clinical naturopathic medicine. When patients say they aren't absorbing nutrients, gaining strength, or feeling well after meals, the conversation often starts somewhere upstream of "what supplement should I take?" Stomach acid, bile flow, pancreatic enzymes, and the integrity of the small intestinal lining are the four pillars of upper-GI function. When one of them is compromised, the whole cascade downstream takes a hit, including the microbial environment, the brain-gut signaling loop, and the systemic inflammatory tone.
EPI is one of the specific places where naturopathic and conventional thinking line up cleanly. The mechanism is testable. The intervention, pancreatic enzyme replacement therapy when clinically warranted, is well established. What naturopathic practice often adds is the rest of the picture: identifying the upstream contributor (diabetes management, celiac diagnosis, SIBO treatment, alcohol reduction, PPI weaning when appropriate); supporting the broader digestive ecosystem with bile flow, gastric acidity, and gut barrier integrity; and addressing the nutrient deficiencies that build up over time when fat-soluble vitamins haven't been absorbing well for years.
It also means taking patient-reported symptoms seriously when the conventional workup comes back clean. A normal colonoscopy, normal CT, and an IBS diagnosis don't actually rule out EPI. Testing it directly takes a fecal elastase, which is non-invasive and inexpensive.
How to apply this now
If your digestion has been off and the standard workups haven't found an answer, a few practical pieces. Ask your provider about fecal elastase-1 testing, particularly if you carry any of the conditions associated with EPI: diabetes, celiac, inflammatory bowel disease, history of pancreatitis, long-term PPI use, gastric or pancreatic surgery, or significant alcohol exposure. Keep in mind that results in the 200 to 500 µg/g range deserve a clinical conversation, not just a "you're fine" reading. Pay attention to the bigger digestive picture: are you eating in a parasympathetic state, with time to chew thoroughly? Are stools formed and regular? Are fat-soluble vitamin levels (A, D, E, K) being checked periodically? And if you have an underlying condition that raises EPI risk, ask whether routine fecal elastase monitoring would make sense as part of your care plan.
For anyone managing diabetes, IBD, celiac, or recovering from GI surgery, this is testing worth bringing up directly with your gastroenterologist or primary care provider. Earlier identification gives you more options.
Frequently asked questions
Should I ask my provider for a fecal elastase test?
If your digestion's been off and any of these are part of your history (diabetes, celiac, IBD, long-term PPI use, heavy alcohol exposure, or pancreatic or gastric surgery), yes. The test is non-invasive (a single stool sample) and inexpensive. It won't catch every mild case, but it's the most accessible first look at whether your pancreas is producing enough enzymes.
My result was in the 200–500 µg/g range. What does that mean?
It means the picture is partial, not all-or-nothing. The standard cutoff for diagnosing EPI is below 200, and healthy adults usually run well over 500. A result in between deserves a clinical conversation. Sometimes that means repeating the test, sometimes a trial of enzymes, and always a look at what else might be contributing.
What does Yggdrasil look at when someone has stubborn digestive symptoms?
We don't stop at the symptoms. Stomach acid, bile flow, pancreatic enzymes, and gut barrier integrity all get considered together, alongside whether something upstream like diabetes, celiac, SIBO, PPI use, or alcohol is driving the picture. EPI is one piece. The point is to find which piece is yours.
If over-the-counter digestive enzymes help me, does that mean I have EPI?
Not necessarily. The enzymes sold at the pharmacy are weaker and differently formulated than the pancreatic enzyme replacement therapy used for diagnosed EPI. Feeling better on them is information (your digestion is asking for support), but it's not a substitute for actually testing what's going on.
Where does the evidence go from here?
The 2026 reviews are pushing for fecal elastase to move into broader use, particularly for people with diabetes or persistent GI symptoms that don't fit IBS cleanly. Better cutoffs and more sensitive tests for mild EPI are likely the next step. For now, the leverage point is asking the question earlier.
References
Krall C. Exocrine Pancreatic Insufficiency: Not Just Pancreatitis — 20+ Additional Factors to Consider. Today's Practitioner. April 29, 2026. https://todayspractitioner.com/pancreatic-disorders/exocrine-pancreatic-insufficiency-not-just-pancreatitis-20-additional-factors-to-consider/
Cotton CEM, Hopper AD, Sanders DS. Are we missing early pancreatic dysfunction? Expanding faecal elastase testing beyond pancreatic disease. Curr Opin Gastroenterol. 2026;42(3):154-162. PMID: 41782402. DOI.
Ogbu C, Wang Y, Babajide O, et al. The Coexistence of Diabetes Mellitus and Low Fecal Elastase Is Associated With Increased Pancreatic Cancer Risk: A Retrospective, Real-world Cohort Study. Pancreas. 2026;55(4):e352-e358. PMID: 41217437. DOI.
Ni P, Baglini C, Meurer J, et al. Disparities in the diagnosis and management of exocrine pancreatic insufficiency in resectable vs metastatic pancreatic cancer. Oncologist. 2026;31(4). PMID: 41863288. DOI.
Related reading
A note before you go
This is for educational purposes and is not a substitute for individualized medical care. If you have ongoing digestive symptoms or any of the conditions discussed here, please work with a clinician who can review your full clinical picture and order appropriate testing.
Reviewed by Joyce Knieff, ND, LAc on 2026-05-28.
If this resonates with what you're experiencing and you'd like to explore a naturopathic approach, book a consultation with our clinic.