How to tell the difference between IBS and EPI

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According to the National Institutes of Diabetes and Digestive and Kidney Diseases (NIDDK), IBS is a group of digestive symptoms that occur in the absence of any visible signs of damage or disease within the digestive system.

IBS is a functional digestive disorder, meaning it occurs because of issues with how the brain and gut work together. These issues can increase gut sensitivity and may change the way bowel muscles contract.

There are three main types of IBS:

• IBS with constipation (IBS-C)
• IBS with diarrhea (IBS-D)
• IBS with mixed bowel habits (IBS-M)

While IBS can be painful and uncomfortable, it does not damage the digestive tract or lead to other health problems.

Symptoms

Some generalized symptoms of IBS include:

• abdominal pain and bloating
• white mucus in the stools
• a feeling of having an incomplete bowel movement

People with IBS may also have diarrhea, constipation, or both, depending on the type of IBS they have. In all cases, people may have normal bowel movements on some days, and abnormal bowel movements on other days.

The table below shows the different IBS types and their characteristic stool symptoms on days when bowel movements are abnormal:

According to the NIDDK, EPI is a condition in which the small intestine cannot properly digest food due to problems with enzymes produced in the pancreas.

The pancreas is a large gland that sits behind the stomach. It makes hormones, and digestive juice containing enzymes. The pancreas secretes the digestive juice into the small intestine via a single duct. Once inside the small intestine, the enzymes help to break down carbohydrates, fats, and proteins.

EPI can occur as a result of one or more of the following issues:

• a severe reduction in the amount of pancreatic enzymes
• an insufficient number of pancreatic enzymes reaching the small intestine
• other problems that prevent the pancreatic enzymes from mixing with food, or otherwise working effectively

EPI can cause complications, such as:

• malabsorption and malnutrition
• low levels of fat-soluble vitamins in the body
• low bone mass
• delayed or inhibited growth, in children
• a weakened immune system
• an increased risk of cardiovascular events, such as heart attack, and stroke

Symptoms

Symptoms of EPI may include:

• abdominal issues, such as:
  • bloating
  • cramps
  • pain or discomfort
• excessive belching or flatulence
• stools that are loose, greasy, or foul-smelling
• diarrhea
• weight loss

Rarely, EPI may cause problems with night vision or bone-related issues, such as low bone mass and osteoporosis.

IBS and EPI have different causes. These are outlined below.

IBS

Medical experts have not identified the exact cause of IBS, though most believe the condition occurs because of problems with how the brain and gut interact.

This may cause food to move too slowly or too quickly through the digestive system, or cause an increased sensitivity to normal levels of stool or gas in the gut.

Factors that may play a role in the development of IBS include:

• stressful or traumatic early life events
• certain mental health conditions, such as:
  • depression
  • anxiety
  • somatic symptom disorder
• digestive issues, such as:
  • bacterial infections in the GI tract
  • small intestinal bacterial overgrowth
  • food intolerances or sensitivities

EPI

There are many potential causes of EPI. Some common causes include:

• pancreatitis
• surgery of the pancreas or upper gastrointestinal (GI) tract
• pancreatic cancer
• cystic fibrosis

Less common causes include:

• diabetes
• untreated celiac disease
• inflammatory bowel diseases (IBDs), including ulcerative colitis (UC), and Crohn’s disease (CD)
• HIV
• Zollinger-Ellison syndrome
• rare genetic disorders, such as Shwachman-Diamond syndrome, and Johanson-Blizzard syndrome

IBS and EPI are different conditions requiring different treatment approaches. These are outlined below.

IBS

According to the American College of Gastroenterology (ACG), most IBS treatments focus on lifestyle changes, such as:

• avoiding or cutting out foods that may cause gas, such as:
  • beans
  • onions
  • cabbage
  • certain fruits
  • wheat
  • dairy
• increasing intake of soluble fiber and water
• managing stress, which may include:
  • exercising regularly
  • engaging in a hobby
  • practicing meditation

While there is no cure for IBS, medical treatment options include:

• antidiarrheal medications to help reduce stool frequency in people with IBS-D
• laxatives to increase stool frequency in people with IBS-C
• the antibiotic Rifaximin, which may reduce IBS symptoms in some people with IBS-D
• antidepressant medications, which can change nerve signalling in the gut, and reduce IBS pain
• medications to slow or increase bowel movements, reducing IBS pain

EPI

According to the NIDDK, doctors use a combination of pancreatic enzyme replacement treatment (PERT) and lifestyle changes to treat EPI.

PERT treatment involves taking oral medications containing pancreatic enzymes. Taking the medications with meals or snacks helps the small intestine digest food. This boosts nutrient absorption and helps reduce EPI symptoms.

Lifestyle changes that can help to treat EPI include:

• avoiding alcohol
• quitting smoking, if a person smokes
• eating small, frequent meals throughout the day
• taking nutritional supplements to help boost levels of fat-soluble vitamins and other nutrients

When diagnosing digestive diseases, a doctor will ask about a person’s symptoms and medical history, including any medications or supplements they may be taking. The doctor may also ask if there is a family history of digestive issues.

IBS

According to the NIDDK, a doctor may diagnose IBS if a person has abdominal pain in addition to two or more of the following symptoms:

• pain that typically improves or worsens following bowel movements
• a change in the frequency of bowel movements
• a change in the appearance of stools

Doctors may also diagnose IBS if a person has experienced IBS symptoms at least once a week in the past 6 months, and their symptoms began at least 6 months prior.

EPI

If a doctor suspects possible EPI, they may ask additional questions to determine if a person has risk factors for EPI. These include:

• having a family history of pancreatitis
• having a personal history of excessive alcohol consumption
• having a personal history of smoking

Doctors will then perform a physical examination to check for possible signs of EPI. This will typically involve:

• examining the body for signs of weight loss or malnutrition
• checking for abdominal swelling
• tapping or palpating the abdomen to check for signs of pain or discomfort
• using a stethoscope to listen to abdominal sounds

Tests that doctors may use to diagnose EPI include:

• Stool tests: The most common stool test for EPI is a fecal elastase-1 or FE-1 test. Low levels of the FE-1 enzyme in the stool may indicate EPI.
• Blood tests: This test checks for signs of malnutrition, such as low levels of fat-soluble vitamins and minerals in the blood.
• Pancreatic function tests: This test measures how the pancreas responds to a hormone called “secretin,” which is made in the small intestine. However, it may not always accurately diagnose EPI.

EPE and IBS share similar symptoms, but the latter condition is much more common. As such, doctors may initially misdiagnose EPI as IBS.

Moreover, EPI and IBS may occur together. In a 2022 study, 5% of people with IBS-D also had EPI. In this study, factors that helped in the differential diagnosis of EPI included:

• indigestion, which was an independent symptom strongly associated with EPI
• a pancreatic ultrasound showing an accumulation of fat in the pancreas, which is consistent with EPI

Anyone who has risk factors for EPI should mention these to a doctor when being tested for gastrointestinal issues. This should help to reduce the risk of misdiagnosis.

EPI and IBS are GI conditions that can share similar symptoms. However, these conditions have different causes, affect different parts of the GI tract, and require different treatments.

In EPI, the small intestine cannot properly digest food because of issues with digestive enzymes produced in the pancreas. Treatment options include dietary changes and PERT.

In IBS, issues with the gut-brain interaction speed up or slow down bowel movements, and may increase sensitivity to normal levels of gas in the gut. Treatment typically involves dietary changes or medications to ease constipation or diarrhea.

It is possible for doctors to misdiagnose EPI for IBS, especially given that IBS is more common, and the two conditions can occur together in some cases. Anyone who has risk factors for EPI should make their doctor aware of these during the diagnostic process.