Gastrointestinal health
EPI in practice: a quick clinical guide to improving diagnosis
Download a cheat sheet as a rapid reference during chronic GI case workups.
- Published on May 1st, 2026
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Exocrine pancreatic insufficiency (EPI) is a treatable but frequently underdiagnosed cause of chronic gastrointestinal disease in dogs and cats. While prognosis is generally good with appropriate therapy, missed or delayed diagnosis remains a common issue in clinical practice.
This quick guide focuses on when to suspect EPI and how to confirm it efficiently.
When should you think about EPI?
EPI should be on your differential list for any patient with chronic GI signs and weight loss, even if routine diagnostics are unremarkable.
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Dogs (more classic presentation)
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Cats (often missed)
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Clinical tip: Feline EPI is easy to miss—screen proactively in chronic GI cases.
Don’t rely on routine diagnostics
- CBC/chemistry → often normal
- Ultrasound → may be normal
- Pancreatic size is not reliable for ruling out EPI
If clinical suspicion exists, move directly to specific testing.
The test that matters: TLI
Serum trypsin-like immunoreactivity (TLI) is the gold standard.
- Low TLI → diagnostic for EPI
- Gray zone → repeat test
- Not affected by enzyme supplementation
Conclusion: If you suspect EPI, run TLI early—not last.
Commonly missed piece: cobalamin
Deficiency occurs in:
- 60% of dogs
- Up to 100% of cats
Low cobalamin = worse outcomes
Conclusion: Supplement if low—or empirically if testing isn’t available.
Why some cases don’t respond
If treatment fails, don’t just increase enzymes, look deeper:
- Incorrect enzyme dosing/formulation
- Concurrent chronic enteropathy
- Persistent dysbiosis
- Dietary mismatch
Practical takeaways for busy clinics
- Include EPI in all chronic GI workups
- Test earlier with TLI, not as a last resort
- Don’t rule out EPI based on normal labs or ultrasound
- Always assess (or supplement) cobalamin
- Re-evaluate non-responders for concurrent disease
EPI is straightforward to diagnose and highly manageable, but only if you think of it. A simple shift—testing earlier in the diagnostic process—can significantly improve patient outcomes and reduce chronic case frustration.
Use this cheat sheet as a rapid reference during chronic GI case workups.
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REFERENCES
Cridge H, Williams DA, Barko PC. Exocrine pancreatic insufficiency in dogs and cats. J Am Vet Med Assoc. 2023 Nov 9