What are the characteristic stool changes in patients with exocrine pancreatic insufficiency?

From the Guidelines

Patients with exocrine pancreatic insufficiency typically present with steatorrhea, characterized by bulky, greasy, foul-smelling stools that are difficult to flush and may float due to their high fat content. These stools often appear pale or clay-colored because of inadequate fat digestion and may contain visible oil droplets. Patients frequently experience increased stool frequency, with loose or watery consistency. The undigested fat in the stool leads to the characteristic oily appearance that may leave an oily residue in the toilet bowl. These stool changes occur because the pancreas fails to produce sufficient digestive enzymes (particularly lipase, amylase, and proteases) needed to break down fats, proteins, and carbohydrates in the diet. Without these enzymes, fats pass through the digestive tract unabsorbed, resulting in steatorrhea. Patients may also experience weight loss despite normal or increased food intake, abdominal discomfort, bloating, and malnutrition due to poor nutrient absorption. Treatment typically involves pancreatic enzyme replacement therapy taken with meals to aid in proper digestion and absorption of nutrients, as recommended by the American Gastroenterological Association (AGA) Clinical Practice Update Expert Review 1. The use of PERT in patients with chronic pancreatitis and EPI improves outcomes, and it is also an essential part of managing EPI and nutrition in the setting of cystic fibrosis 1. Best Practice Advice 11 suggests that once EPI is diagnosed, treatment with PERT is required to prevent complications related to fat malabsorption and malnutrition, which can have a negative impact on quality of life 1. The initial treatment should include at least 40,000 USP units of lipase during each meal in adults, and the dosage can be adjusted based on the meal size and fat content 1. It is essential to note that over-the-counter commercially available pancreas enzyme replacements should not be used, as they are classified as dietary supplements only and lack standardization and regulation 1.

Some key points to consider in the diagnosis and management of exocrine pancreatic insufficiency include:

• The presence of steatorrhea, characterized by bulky, greasy, foul-smelling stools
• Increased stool frequency, with loose or watery consistency
• Weight loss despite normal or increased food intake
• Abdominal discomfort, bloating, and malnutrition due to poor nutrient absorption
• The use of PERT to aid in proper digestion and absorption of nutrients
• The importance of adjusting the dosage of PERT based on the meal size and fat content
• The need to avoid using over-the-counter commercially available pancreas enzyme replacements due to lack of standardization and regulation. The AGA Clinical Practice Update Expert Review provides guidance on the epidemiology, evaluation, and management of EPI, emphasizing the importance of proper diagnosis and treatment to improve patient outcomes 1.

From the Research

Characteristic Stool Changes in Exocrine Pancreatic Insufficiency

• Patients with exocrine pancreatic insufficiency (EPI) often experience steatorrhea, which is characterized by fatty stools 2
• The stools may be bulky, greasy, and have a foul odor due to the malabsorption of fat 2
• Fecal fat quantification is one of the most accurate tests for diagnosing EPI, and it can help identify the presence of excess fat in the stool 2
• The (13)C-mixed triglycerides test is another method used to evaluate digestion and diagnose EPI, which can also indicate malabsorption of fat 2

Diagnosis and Treatment of Exocrine Pancreatic Insufficiency

• Fecal elastase 1 levels can be used to estimate the probability of EPI diagnosis, and low levels may indicate pancreatic exocrine insufficiency 2, 3
• Treatment for EPI includes pancreatic enzyme replacement therapy (PERT), which is administered in the form of enteric-coated minimicrospheres during meals 2
• The dose of PERT should be individualized based on the fat content of the meal, with typical starting doses ranging from 40,000 to 50,000 units of lipase per main meal 2, 4
• In cases where patients do not respond to initial treatment, the doses can be doubled, and proton inhibitors can be added to the treatment 2

Clinical Manifestations and Management of Exocrine Pancreatic Insufficiency

• Clinical manifestations of EPI are often nonspecific and can lead to lack of timely recognition and diagnosis 5
• Identification of high-risk patients is key in the diagnosis of EPI, including those with pancreatic parenchyma disorders, cystic fibrosis, and those undergoing pancreatic resection 5
• Goals of treatment have been aimed at repleting exocrine enzyme deficiency by oral PERT, which can improve signs and symptoms associated with EPI, decrease prevalence of osteopathy, and improve survival outcomes in subsets of patients 5