In this article we dive into a common stool test marker, pancreatic elastase. Firstly, we explore what pancreatic elastase is, typically reference ranges for pancreatic elastase on a stool test and how our team of Nutritionists and Functional Medicine Practitioners might interpret pancreatic elastase results.
Next, we look at the symptoms and conditions associated to low pancreatic elastase as well as exploring the nutrition and lifestyle interventions to help increase faecal pancreatic elastase
What is faecal pancreatic elastase?
Pancreatic elastase is an enzyme produced by the pancreas that plays a role in the digestion of proteins in the small intestine. Specifically, it helps break down elastin, a protein found in animal tissue. Pancreatic elastase is released into the digestive tract along with other pancreatic enzymes as part of the digestive process (1).
Conventionally, pancreatic elastase has been of interest primarily in the context of pancreatic disease, particularly chronic pancreatitis. Chronic pancreatitis is a long-term inflammation of the pancreas, which can lead to impaired pancreatic function (1).
It’s now understood that if pancreatic elastase is suboptimal, there may be several different reasons for that, and it may not indicate pancreatitis in every case (2).
What are the reference ranges for faecal pancreatic elastase?
Normal Range: Typically, a stool elastase level greater than 200 micrograms per gram (µg/g) of stool is considered within the normal range (3).
Borderline Range: Levels between 100 and 200 µg/g may be considered borderline or equivocal and could suggest a mild impairment in pancreatic function. Further evaluation may be needed in these cases (3).
Abnormal Range: Levels below 100 µg/g are generally considered abnormal and may indicate pancreatic insufficiency, such as that seen in chronic pancreatitis or other pancreatic disorders (3).
However, a more up to date perspective has suggested that individuals with a faecal pancreatic elastase between 200 – 500ug/g may benefit from pancreatic enzyme replacement therapy (PERT). This research suggested that 71 % of participants offered PERT saw either abolished or reduced diarrhoea, reduced steatorrhea (fatty stools) and reduced flatulence (4). This advice closely mirrors the Nutritional Therapy and Functional Medicine perspective that an optimal pancreatic elastase level should be 500ug/g and above.
How we interpret faecal pancreatic elastase in clinic
Nutritional Therapy and Functional Medicine practitioners look at faecal pancreatic elastase as an overall health marker of our client’s digestion and absorption and like to see optimal function of 500ug/g and above. If a client’s result is lower than this, it should be taken into context with the overall symptoms.
The pancreas is part of the initial stages of digestion involving multiple chemical reactions which begins with the cephalic response. The cephalic response occurs when we see, smell, or begin to handle food. Our brains trigger the production of saliva in our mouths which begins the breakdown of our food in preparation for swallowing. At the same time our stomachs and pancreas are stimulated to begin to create and release gastric juices (hydrochloric acid (HCL), lipase, pepsin etc) and digestive enzymes, respectively (5).
The gastric fluids are very acidic, ideally between a 1.5-3.5 on the pH scale (6), this assists with protein breakdown, in particular. As this acidic soup passes into the first part of the small intestine – the duodenum – it stimulates another chain reaction which directly involves the pancreas. In response to the acidity level of the stomach contents entering the duodenum, the hormone secretin is released which in turn stimulates the pancreas to produce neutralising fluids (bicarbonates) as well as digestive enzymes to help break down our food further in preparation for absorption (7).
Understanding these chain reactions helps our Nutritionists and Functional Medicine Practitioners to interpret faecal pancreatic elastase in relation to the health of the stomach, HCL production and the cephalic response so our clients can be guided on how to improve their pancreatic output.
What symptoms are associated with low pancreatic elastase?
Severe cases
In more acute cases of pancreatitis, there can be a stabbing pain in the centre of your stomach, beneath your ribs. A feeling of nausea or being sick and a high temperature (38c or above). If this is the case, seek immediate medical attention (8).
Moderate cases
In most cases, symptoms will be noticeable, however not serious, unless unchecked. Individuals experiencing pancreatic exocrine insufficiency (PEI), which is effectively a reduced ability to produce pancreatic enzymes may experience general digestive symptoms such as fat-rich/floating stools (steatorrhea), unintentional weight reduction, frequent bowel movements (diarrhoea), discomfort in the abdominal region, and a sensation of fullness or bloating (3).
Clinical experience
Typically, in clinic, PEI is often coupled with IBS symptoms which usually consist of irregular bowel movements, bloating, excessive gas, burping, acid reflux and general abdominal discomfort. Understanding the causes of these symptoms is key to addressing PEI as it may well be multifactorial.
What conditions can cause suboptimal pancreatic elastase?
There are several conditions that can cause PEI through various mechanisms, this is known as secondary PEI.
Coeliac disease
Coeliac causes damage to the intestinal wall which may reduce the production of the hormones responsible for stimulating the pancreas (2).
Inflammatory bowel disease (IBD)
People with IBD have a higher risk of PEI due to various factors such as gallstone formation, prescribed medication such as steroids, autoimmune disease development and whether they smoke (2).
Diabetes mellitus
The pancreas looks after both insulin and digestive enzymes production. In a case of diabetes type 3c, where the pancreas has become damaged due to chronic pancreatitis or surgery, its output is affected.
Bile acid diarrhoea
This condition causes chronic diarrhoea which can often be confused for PEI. Co-ordination between the pancreas and the gall bladder is essential for adequate fat breakdown (2).
HIV infection
It’s not clear why people with HIV tend to have symptoms such as diarrhoea and weight loss, however, their symptoms seem to improve with pancreatic enzyme replacement therapy (PERT) (2).
What diet and lifestyle interventions support pancreatic elastase?
Stress and pancreatic elastase
When we experience stress, it causes a sympathetic response from the central nervous system (CNS), this triggers biological changes to help manage the stressor such as increasing heart rate, breathing ability, dilating pupils, and slowing down digestion. The opposite of this is the parasympathetic system, which is commonly describes as our ‘rest and digest’ response. A vital nerve called the vagus nerve represents a major component of the parasympathetic nervous system. During stress, its activity is reduced, which leads to a reduced stimulation of the digestive system, including decreased secretion of digestive enzymes and hormones from the pancreas, as well as less regulation of the sphincter of oddi (valve in digestive system), which enables the flow of bile and pancreatic enzymes into the intestines. Chronic exposure to stress and subsequent sympathetic response likely impacts pancreatic function as a whole, including elastase production (13).
Supplementation
- Pancreatic enzyme replacement therapy (PERT) – the most common recommendation for low pancreatic elastase is PERT. This is a safe and effective way of ensuring your food is being broken down adequately which can improve absorption, reduce IBS symptoms and increase energy production (2,3,9)
- Support HCL production – As discussed above, adequate HCL production is vital to begin the digestive cascade, therefore supporting this can help the pancreas as well. This can be done by taking Betaine HCL supplements, using Swedish bitters and potentially incorporating foods that help to stimulate digestion, in particular bitter foods and potentially bone broth as well.
Lifestyle modifications
- Smoking or excessive alcohol consumption are primary risk factors for pancreatic disorders (10).
- Adherence to a strict gluten-free diet is essential for individuals with celiac disease to avoid pancreatic complications (11).
- Effectively managing blood sugar levels can help reduce stress on pancreatic tissues for those experiencing issues in this area (2).
- Thoroughly chewing food improves the chances of pancreatic enzymes effectively breaking down proteins, carbs, and fats in each meal. Those with pancreatic exocrine insufficiency (PEI) should focus on mindful chewing before swallowing (9).
- Take time to perform diaphragmatic breathing practices prior to eating to increase Heart Rate Variability, stimulating the parasympathetic nervous system, and thus supporting vagus nerve function.
Further investigations
Patients dealing with small intestinal bacterial overgrowth (SIBO) should aim to identify and address the underlying causes of their condition. SIBO can impact the pH of the small intestine which can impair the potency of pancreatic enzymes. (12) Equally, an impaired pH of the small intestine can contribute to SIBO development, thus it can be a bit of a chicken or the egg situation.
Conclusion
We hope you found the content in this article useful. Our team of practitioners are on hand to assist you with your goal of improving your digestive health and reversing pancreatic enzyme insufficiency. Our team use a combination of nutrition, lifestyle, and functional medicine approaches to help our clients meet their health goals.
Assuming there is no underlying pancreatic disorder, addressing functional low levels of pancreatic elastase requires a holistic approach. How you eat, overall stress levels, nutritional status, underlying overgrowths, or infections can all play a role in the underlying causes of this imbalance.
References
- Naruse, S. et al. (2006) ‘Fecal pancreatic elastase: A reproducible marker for severe exocrine pancreatic insufficiency’, Journal of Gastroenterology, 41(9), pp. 901–908. doi:10.1007/s00535-006-1884-0.
- Lam, K.W. and Leeds, J. (2019) ‘How to manage: Patient with a low faecal elastase’, Frontline Gastroenterology, 12(1), pp. 67–73. doi:10.1136/flgastro-2018-101171.
- Phillips, M.E. et al. (2021) ‘Consensus for the management of pancreatic exocrine insufficiency: UK practical guidelines’, BMJ Open Gastroenterology, 8(1). doi:10.1136/bmjgast-2021-000643.
- Mathew, A., Fernandes, D. and Andreyev, H.J. (2023) ‘What is the significance of a faecal elastase-1 level between 200 and 500μg/G?’, Frontline Gastroenterology, 14(5), pp. 371–376. doi:10.1136/flgastro-2022-102271.
- Lasschuijt, M.P. et al. (2020) ‘Endocrine cephalic phase responses to food cues: A systematic review’, Advances in Nutrition, 11(5), pp. 1364–1383. doi:10.1093/advances/nmaa059.
- Martinsen, T., Fossmark, R. and Waldum, H. (2019) ‘The phylogeny and biological function of gastric juice—microbiological consequences of removing gastric acid’, International Journal of Molecular Sciences, 20(23), p. 6031. doi:10.3390/ijms20236031.
- Afroze, S. et al. (2013) ‘The physiological roles of secretin and its receptor’, Annals of Translational Medicine, 1(3), pp. 1–14. doi:10.3978/j.issn.2305-5839.2012.12.01.
- NHS (2022) Acute pancreatitis, NHS choices. Available at: https://www.nhs.uk/conditions/acute-pancreatitis/ (Accessed: 15 November 2023).
- Domínguez-Muñoz, J.E. and Phillips, M. (2018) ‘Nutritional therapy in chronic pancreatitis’, Gastroenterology Clinics of North America, 47(1), pp. 95–106. doi:10.1016/j.gtc.2017.09.004.
- Yadav, D. (2009) ‘Alcohol consumption, cigarette smoking, and the risk of recurrent acute and chronic pancreatitis’, Archives of Internal Medicine, 169(11), p. 1035. doi:10.1001/archinternmed.2009.125.
- Freeman, H.J. (2016) ‘Celiac-associated pancreatic disease’, Annals of Gastroenterology [Preprint]. doi:10.20524/aog.2016.0048.
- Ní Chonchubhair, H.M. et al. (2018) ‘The prevalence of small intestinal bacterial overgrowth in non-surgical patients with chronic pancreatitis and pancreatic exocrine insufficiency (PEI)’, Pancreatology, 18(4), pp. 379–385. doi:10.1016/j.pan.2018.02.010.
- Breit, S. et al. (2018) ‘Vagus nerve as modulator of the brain–gut axis in psychiatric and inflammatory disorders’, Frontiers in Psychiatry, 9. doi:10.3389/fpsyt.2018.00044.
