From the Guidelines
Low fecal pancreatic elastase (FPE) levels are a significant indicator of pancreatic exocrine insufficiency (PEI), a condition where the pancreas doesn't produce enough digestive enzymes, leading to malabsorption and malnutrition. This condition can result in symptoms such as steatorrhea, weight loss, abdominal pain, and malnutrition due to poor nutrient absorption, as stated in the 2023 study by the American Gastroenterological Association 1.
Key Points to Consider
- A fecal elastase level <100 mg/g of stool provides good evidence of EPI, and levels of 100–200 mg/g are indeterminate for EPI, as recommended by the American Gastroenterological Association 1.
- Common causes of PEI include chronic pancreatitis, cystic fibrosis, pancreatic cancer, diabetes, and previous pancreatic surgery.
- Treatment usually involves pancreatic enzyme replacement therapy (PERT) such as pancrelipase taken with meals, typically starting at a dose adjusted based on symptom response, as well as a low-fat diet and fat-soluble vitamin supplements (A, D, E, K) 1.
- Further diagnostic testing like CT scans or MRI may be needed to determine the specific cause of pancreatic insufficiency.
Importance of Early Detection and Treatment
Early detection and treatment of PEI are crucial to prevent malnutrition and improve quality of life, as untreated PEI can have a deleterious impact on the quality of life of patients 1.
Recommendations for Management
The management of PEI involves replacing the inadequate pancreatic enzymes, which should be used to maintain weight and improve the symptoms of maldigestion 1. Some key recommendations for management include:
- Starting enzyme replacement when clinical signs of malabsorption, or anthropometric and/or biochemical signs of malnutrition are present 1.
- Monitoring symptoms, anthropometric and biochemical signs of malnutrition, and adjusting treatment accordingly 1.
- Providing patient education on diet, digestion, and management of gastrointestinal symptoms to improve quality of life 1.
From the Research
Significance of Low Fecal Pancreatic Elastase (FPE) Levels
- Low levels of fecal pancreatic elastase (FPE) are associated with exocrine pancreatic insufficiency (EPI) 2, 3, 4, 5
- FPE levels can be used to diagnose EPI, but the sensitivity and specificity of the test vary depending on the population and the cutoff value used 2, 3
- A low FPE level (< 100 μg/g) is more commonly associated with marked chronic pancreatitis than with mild chronic pancreatitis 2
- However, low FPE levels do not always indicate EPI, and other factors such as non-pancreatogenic steatorrhea may contribute to low FPE levels 6
- FPE levels can be used to rule out EPI in patients with a low pre-test probability of the disorder, but an abnormal FPE level has a high false-positive rate in this population 3
- Endoscopic ultrasound (EUS) findings in patients with low FPE levels often include chronic pancreatitis, fatty pancreas, and pancreatic solid masses or cysts 4
- FPE levels can be used as a measure of pancreatic exocrine function in children with pancreatitis, and low FPE levels are associated with malnutrition in severe pancreatic insufficiency cases 5
Diagnostic Performance of FPE
- The sensitivity and specificity of FPE in detecting EPI vary depending on the population and the cutoff value used, but a pooled sensitivity value of 0.77 and specificity value of 0.88 have been reported 3
- FPE has a high false-negative rate in patients with a high pre-test probability of EPI, and approximately 10% of patients with EPI may be missed 3
- FPE has a high false-positive rate in patients with a low pre-test probability of EPI, and an abnormal FPE level should be interpreted with caution in this population 3
Clinical Implications
- Low FPE levels should be interpreted in the context of the patient's clinical presentation and other diagnostic tests, such as EUS and secretin stimulation tests 2, 6, 4
- FPE levels can be used to monitor pancreatic exocrine function in patients with pancreatitis and to adjust treatment accordingly 5
- Further studies are needed to fully understand the significance of low FPE levels and to establish clear guidelines for the use of FPE in clinical practice 2, 6, 3, 4, 5