Low Exocrine Pancreatic Enzymes and Mycotoxin Exposure

by Dr. Susan Tanner, MD

In recent years, we practitioners are learning more about a condition called EPI, exocrine pancreatic insufficiency.  I was made aware of the prevalence of this condition by a brilliant gastroenterologist in Atlanta, Dr. Cynthia Rudert.  Dr. Rudert has researched and taught much about this, and its relevance to many other conditions, both gastrointestinal and beyond.

The exocrine portion of the pancreas is responsible for the production of digestive enzymes which enable the breakdown of foods such that nutrients may be absorbed in the small intestine. Primary enzymes are amylase ( also secreted in the saliva) for carbohydrates, proteases for proteins, and lipases for fat. Whenever any of these (and it is usually all of them, not just one) become markedly decreased in level, then maldigestion can occur which can manifest in many ways.

Symptoms of Pancreatic Insufficiency

We can begin by discussing the symptoms of pancreatic insufficiency.  Physically, this can manifest as indigestion, abdominal pain, diarrhea, and bloating.  Initially, these symptoms may be attributed to heartburn or hyperacid conditions, or “irritable bowel syndrome”.  Medical textbook descriptions of this disorder depict children with massive greasy stools, dry skin, and emaciation.  However, most cases exist on a somewhat milder and less extreme continuum and are present in adult years, not just in childhood.


Labwork-wise, suspicion of this may begin by the low blood levels of protein and fat-soluble vitamins (D, E, K), sometimes in spite of supplementation with these vitamins. The low serum protein levels can lead to deficiencies in immune proteins and neurotransmitters, as the component amino acids are not being absorbed well. I often see low ferritin levels as well, and occasionally low B12, as markers of malabsorption.  Certain minerals such as calcium may also be low leaving one more at risk for osteoporosis.

What I learned from Dr. Rudert is that a surprisingly high number of patients who have this condition are genetically set up for it by carrying one or more variants to the genes responsible for cystic fibrosis. The list of related genes is expanding, and I can’t list them all here, but I would suggest reading about this topic in one of her publications, especially if there is ANY family history of cystic fibrosis in the family.  Further testing for the manifestations of EPI may involve looking at serum levels of amylase and lipase, and even more telling, a stool level of pancreatic elastase.  While levels of amylase and lipase may fall into the “normal” range it is important to note where on the range they are, and if in the lower 1/3, I would remain suspicious enough to do the stool elastase test as well.  Other lab findings which are typical, as stated previously, are low levels of Vitamin D, E, and K.  If a diagnosis of EPI is reached, then this likely indicates a lifelong regimen of prescription digestive enzymes, such as Creon or Pertzye.  Because these prescription enzymes are quite expensive, there are at times funds available from the Cystic Fibrosis and Pancreas Foundations to support the ongoing use of these agents.

Other Reasons for Pancreatic Insufficiency

Another set of patients develop EPI for different reasons, and this is where the connection to mold and mycotoxins may come in.  First of all, the production of enzymes by the pancreas requires a lot of energy from the body.  When the body comes under severe and ongoing stress for any reason, and this includes the environmental stress of mold and toxin exposure, then in an effort to conserve energy, the pancreas may reel back its production of enzymes.  Thus, in addition to all the other inflammatory effects of mold and mycotoxins, one may encounter additional problems or exacerbated symptoms due to maldigestion.  Additionally, because the lining of the gut is already inflamed by mycotoxins and often candida, the development of food sensitivities is increased too.

Another issue that can occur with mycotoxin exposure is the immense pressure on liver functionality.  Because of the intimate relationship between liver and pancreatic function as it pertains to bile, fat emulsification, and pancreatic signaling, an already stressed pancreas may demonstrate even more symptoms and problems when a mold hit occurs.  As we know, the liver is sensitive to mycotoxins in all forms, the air being the most ubiquitous but food sources are important as well.  In my research, I was able to find one study, having to do with the improper growth of baby chicks eating mycotoxin-contaminated grains.  The point was that all chickens could be impaired but it was most evident in the young.  This would hold true not just for chickens but for all species, I believe, and all the more reasons to be diligent in our assessments, not only of air, food, and water but of the functions of the body that may have been impacted, such as the pancreas, sooner than later.

Is EPI an Issue for You?

Pancreatic insufficiency may be the first symptom or warning sign that mold and mycotoxins are a problem.  I would say, if there is any gastrointestinal problem, I would begin with simple testing.

1. Test blood levels of the fat-soluble vitamins;

2. Test levels of amylase and lipase, usually two hours after a meal;

3. Stool test for pancreatic elastase;

4. Test a full set of liver enzymes including ALT, AST, bilirubin, and GGT.

If advised, at this point, look further at your genetics to see if any recessive cystic fibrosis genes are present.  Simultaneously, evaluate your indoor air and food for mold and mycotoxins and treat this thoroughly if present.

Treatment Options

Treatment involves the use of pancreatic enzymes. If genetics is the underlying cause, then enzyme supplementation for life is suggested, whereas if EPI is due to environmental exposure, the use of enzymes is suggested until enough has been done for the body to right itself.  Progress can be monitored by overall improvement in GI symptoms on a subjective level, and by improvement in the fat-soluble vitamin status in blood tests.  Repeating levels of amylase and lipase while on enzymes is not very helpful as supplementation obviously skews the results.

As far as nutritional enzymes that may be used in place of the very expensive prescriptions, depending on the severity of the issues,  I like Digest Assist and generally recommend taking two with the first few bites of food at each meal or a heavier snack. If you are consuming a meal higher in protein or fat, then taking more may be necessary. Generally, I recommend mold-free digestive enzymes and ones that offer a broad spectrum of enzymatic support to maximize nutrient absorption.

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