From the Guidelines
Pancreatic insufficiency symptoms should be suspected in patients with high-risk clinical conditions, such as chronic pancreatitis, relapsing acute pancreatitis, pancreatic ductal adenocarcinoma, cystic fibrosis, and previous pancreatic surgery, and treated with pancreatic enzyme replacement therapy (PERT) to improve morbidity, mortality, and quality of life. The symptoms of pancreatic insufficiency include steatorrhea with or without diarrhea, weight loss, bloating, excessive flatulence, fat-soluble vitamin deficiencies, and protein-calorie malnutrition 1. These symptoms occur because the pancreas fails to produce enough digestive enzymes to properly break down food, especially fats, proteins, and carbohydrates. Without these enzymes, nutrients cannot be properly absorbed in the intestines, leading to maldigestion and malabsorption. The severity of symptoms typically correlates with the degree of enzyme deficiency, with symptoms usually appearing when enzyme production falls below 10% of normal levels. Common causes include chronic pancreatitis, cystic fibrosis, pancreatic cancer, and previous pancreatic surgery. Treatment typically involves pancreatic enzyme replacement therapy (PERT) with meals and snacks, along with dietary modifications and fat-soluble vitamin supplementation to address nutritional deficiencies. Some key points to consider in the treatment of pancreatic insufficiency include:
- PERT formulations are all derived from porcine sources and are equally effective at equivalent doses 1.
- PERT should be taken during the meal, with the initial treatment of at least 40,000 USP units of lipase during each meal in adults and one-half of that with snacks 1.
- Routine supplementation and monitoring of fat-soluble vitamin levels are appropriate, and dietary modifications include a low-moderate fat diet with frequent smaller meals and avoiding very-low-fat diets 1.
- Measures of successful treatment with PERT include reduction in steatorrhea and associated gastrointestinal symptoms; a gain of weight, muscle mass, and muscle function; and improvement in fat-soluble vitamin levels 1. It is also important to monitor and baseline measurements of nutritional status should be obtained (body mass index, quality-of-life measure, and fat-soluble vitamin levels), and a baseline dual-energy x-ray absorptiometry scan should be obtained and repeated every 1–2 years 1. In contrast to older studies, such as the 2006 ESPEN guidelines on enteral nutrition 1, the most recent and highest quality study, the 2023 AGA clinical practice update on the epidemiology, evaluation, and management of exocrine pancreatic insufficiency, provides the best guidance for the treatment of pancreatic insufficiency 1.
From the Research
Pancreatic Insufficiency Symptoms
The symptoms of pancreatic insufficiency can be severe and impact a patient's quality of life. Some of the key symptoms include:
- Steatorrhea (excess fat in the stool) 2, 3, 4
- Malabsorption of nutrients, including fat, proteins, and carbohydrates 2, 5, 4
- Weight loss 2, 3, 4
- Abdominal discomfort 4
- Nutritional deficiencies 2, 5, 4
Causes of Pancreatic Insufficiency
Pancreatic insufficiency can be caused by a variety of factors, including:
- Chronic pancreatitis 6, 2, 4
- Cystic fibrosis 6, 5, 4
- Pancreatic cancer 6, 5, 4
- Pancreatic surgery 5, 4
- Acute pancreatitis 5
Diagnosis of Pancreatic Insufficiency
Diagnosing pancreatic insufficiency can be done through a variety of methods, including:
- Testing fecal elastase-1 level 6
- Evaluating patient symptoms and medical history 5
- Conducting randomized controlled trials to verify efficacy of pancreatic enzymes 5
Treatment of Pancreatic Insufficiency
Treatment for pancreatic insufficiency typically involves pancreatic enzyme replacement therapy (PERT) 6, 2, 5, 3, 4. The goal of PERT is to replace the missing pancreatic enzymes and improve nutrient absorption. Dosage guidelines for PERT vary, but typical starting doses include: