Recognizing Exocrine Pancreatic Insufficiency in Patients with Diabetes: A Case Study

BACKGROUND Exocrine pancreatic insufficiency (EPI) is characterized by inadequate delivery of pancreatic digestive enzymes to the small intestine, and can result in steatorrhea, weight loss, and fat-soluble vitamin deficiencies without treatment. We present a case of EPI attributed to longstanding type 2 diabetes mellitus. CASE REPORT A 71-year-old man with type 2 diabetes mellitus and remote history of Roux-en-Y bypass surgery 35 years ago and cholecystectomy 50 years ago presented with an 8-month history of steatorrhea and 41-kg weight loss despite increased caloric intake. Workup was notable for fecal elastase less than 40 µg/g and significant steatorrhea with total fat 277 g over 24 hours. Computed tomography (CT) enterography revealed marked pancreatic atrophy without any sign of pancreatic tumor. He was diagnosed with EPI, and with initiation of pancreatic enzyme replacement therapy (PERT), his diarrhea improved, allowing him to regain weight to his prior baseline and to reduce caloric intake. CONCLUSIONS Although exocrine pancreatic insufficiency affects close to one-third of patients with type 2 diabetes mellitus, it remains under-recognized due to the nonspecific nature of presenting symptoms and their frequent attribution to the effects of diabetes mellitus itself or diabetes medications. EPI can lead to marked malabsorption, reduced quality of life, and increased morbidity and mortality, and therefore should be included in the differential diagnosis for steatorrhea, weight loss, and vitamin deficiencies in patients with diabetes during initial assessment by internal medicine providers. A high index of suspicion and assessment with fecal elastase testing can allow for early recognition and timely initiation of PERT, helping mitigate long-term complications.