Exocrine pancreatic insufficiency (EPI) is more common than most people realize. General population estimates put the prevalence at roughly 10% to 20%, though many cases go undiagnosed because the symptoms overlap with other digestive conditions. The rates climb significantly higher in people with certain underlying health problems, particularly chronic pancreatitis, cystic fibrosis, and diabetes.
EPI in the General Population
EPI happens when your pancreas doesn’t produce enough digestive enzymes to properly break down fats, proteins, and carbohydrates from food. Without those enzymes, nutrients pass through your system unabsorbed, leading to oily stools, bloating, gas, weight loss, and nutritional deficiencies over time.
Population-level estimates suggest that somewhere between 10% and 20% of people have some degree of reduced pancreatic enzyme output. That’s a wide range, partly because the condition exists on a spectrum. Some people have mildly reduced enzyme levels with few noticeable symptoms, while others have severe deficiency that causes obvious digestive problems. The prevalence also increases with age, and it appears to be slightly more common in men than in women.
Who Is at Highest Risk
Certain conditions dramatically increase the likelihood of developing EPI. The numbers vary by study, but the patterns are consistent.
Chronic pancreatitis carries the strongest association. Between 30% and 90% of people with chronic pancreatitis develop EPI, with the risk climbing the longer the disease progresses. Years of inflammation gradually destroy the enzyme-producing cells of the pancreas, and by the time someone has had chronic pancreatitis for a decade or more, some degree of EPI is almost expected.
Cystic fibrosis affects the pancreas from early in life. About 85% of people with cystic fibrosis have pancreatic insufficiency. Thick, sticky mucus blocks the ducts that carry enzymes from the pancreas to the small intestine, so even though the pancreas may still produce some enzymes, they can’t reach where they’re needed. Most people with cystic fibrosis begin enzyme replacement therapy in infancy.
Diabetes is a less obvious but surprisingly common risk factor. A systematic review found that EPI prevalence in type 1 diabetes ranges from 14% to 77.5%, with a median of about 33%. In type 2 diabetes, the range is 16.8% to 49.2%, with a median around 29%. The wide ranges reflect differences in how studies defined and tested for EPI, but the takeaway is clear: roughly one in three people with diabetes may have some level of pancreatic enzyme deficiency.
EPI After Surgery
Bariatric surgery can also trigger EPI. In one study of 150 patients who underwent weight-loss surgery, 9.3% were diagnosed with EPI afterward. Gastric bypass carried a higher risk (10.3%) compared to sleeve gastrectomy (4.2%). The rerouting of the digestive tract changes how food interacts with pancreatic enzymes, and in some cases, enzyme output itself declines. Symptoms like fatty stools and unintentional weight loss after bariatric surgery are sometimes chalked up to the surgery itself when EPI is actually the culprit.
The Connection to Celiac Disease
About one in eight people with celiac disease also has EPI. A meta-analysis found the overall prevalence at 13.5%, with similar rates in children and adults. Interestingly, people with untreated celiac disease had significantly higher rates (18.2%) compared to those already following a gluten-free diet (6.9%). This suggests that the intestinal inflammation from active celiac disease may impair pancreatic function, and that treating the celiac disease itself can partially restore enzyme output.
Why EPI Is Often Missed
The symptoms of EPI, particularly bloating, diarrhea, and abdominal discomfort, overlap heavily with irritable bowel syndrome and other common gut disorders. Research suggests that EPI accounts for about 1% to 2% of cases initially diagnosed as IBS. That sounds like a small percentage, but given how many people carry an IBS diagnosis, it represents a meaningful number of individuals whose real problem is treatable enzyme deficiency.
Part of the diagnostic challenge is that EPI doesn’t have a clean on-or-off threshold. The most common test measures a protein called fecal elastase in a stool sample. Levels below 200 micrograms per gram generally indicate EPI, while levels above 500 are considered normal. But there’s a large gray zone between 200 and 500 where pancreatic function is reduced but not clearly deficient. Recent evidence suggests the decline is gradual rather than a sharp cutoff, which means some people with borderline results may still benefit from treatment even if they don’t meet the traditional diagnostic threshold.
EPI and Aging
Pancreatic function naturally declines as you get older. Population studies show a clear increase in EPI prevalence with age, which makes sense given that the pancreas, like most organs, gradually loses some of its capacity over decades. For older adults experiencing unexplained digestive symptoms, weight loss, or nutritional deficiencies, EPI is worth considering, especially if they also have diabetes or a history of heavy alcohol use, both of which accelerate pancreatic damage.
The combination of age-related decline and overlapping conditions means that EPI in older adults is likely underrecognized. When digestive problems in a 75-year-old are attributed to “just getting older,” a simple stool test could reveal a treatable cause.