What are the diagnostic criteria for pancreatic exocrine insufficiency (PEI)?

From the Guidelines

Pancreatic insufficiency evaluation should begin with a fecal elastase test, as it is the most appropriate initial test, and a level <100 mg/g of stool provides good evidence of exocrine pancreatic insufficiency (EPI) 1. When evaluating pancreatic insufficiency, it is essential to consider the clinical features, such as steatorrhea with or without diarrhea, weight loss, bloating, excessive flatulence, fat-soluble vitamin deficiencies, and protein-calorie malnutrition, as outlined in the best practice advice statements 1.

Key Considerations

• The fecal elastase test can be performed while the patient is on pancreatic enzyme replacement therapy (PERT) 1.
• Fecal fat testing is rarely needed and should only be performed when the patient is on a high-fat diet, with quantitative testing generally not practical for routine clinical use 1.
• Response to a therapeutic trial of pancreatic enzymes is unreliable for EPI diagnosis, and cross-sectional imaging methods cannot identify EPI, although they play a crucial role in diagnosing benign and malignant pancreatic disease 1.

Diagnostic Approach

• The initial evaluation should focus on identifying high-risk clinical conditions, such as chronic pancreatitis, relapsing acute pancreatitis, pancreatic ductal adenocarcinoma, cystic fibrosis, and previous pancreatic surgery, which should raise suspicion for EPI 1.
• Moderate-risk clinical conditions, including duodenal diseases, previous intestinal surgery, longstanding diabetes mellitus, and hyper-secretory states, should also be considered when evaluating for EPI 1.

Treatment and Management

• Once EPI is diagnosed, treatment with PERT is required, with the initial dosage of at least 40,000 USP units of lipase during each meal in adults, and subsequent adjustments based on meal size and fat content 1.
• Routine supplementation and monitoring of fat-soluble vitamin levels are essential, along with dietary modifications, such as a low-moderate fat diet with frequent smaller meals, and avoiding very-low-fat diets 1.

From the Research

Pancreatic Insufficiency Evaluation

• Pancreatic insufficiency is a condition where the pancreas does not produce enough enzymes to digest food properly, leading to malabsorption of nutrients 2, 3, 4, 5, 6.
• The evaluation of pancreatic insufficiency involves determining the underlying cause of the condition, such as chronic pancreatitis, cystic fibrosis, pancreatic cancer, or pancreatic surgery 3, 4, 6.
• Testing for pancreatic insufficiency can be done through various methods, including fecal elastase-1 level testing, which is useful for diagnosing pancreatic exocrine insufficiency 4.

Diagnosis and Treatment

• The diagnosis of pancreatic insufficiency is often based on clinical symptoms, such as steatorrhea, weight loss, and malabsorption of nutrients 2, 3, 5.
• Pancreatic enzyme replacement therapy (PERT) is the mainstay of treatment for pancreatic insufficiency, and involves taking enzymes to replace those not produced by the pancreas 2, 3, 4, 5, 6.
• The dosage of PERT should be individualized, with starting doses of at least 30-40,000 IU with each meal and 15-20,000 IU with snacks 4.
• PERT should be taken in divided doses throughout meals to ensure adequate mixing with food and optimal enzyme activity 4.

Challenges and Future Directions

• Despite the effectiveness of PERT, challenges remain, including enzyme destruction in the stomach, lack of adequate mixing with food in the duodenum, and difficulty in delivering enzymes to the appropriate site at the appropriate time 5.
• Current research is aimed at developing new enzymes and delivery systems to improve the efficiency of PERT, as well as better means to monitor therapy 5.
• Future developments are needed to optimize treatment and improve patient outcomes, particularly in patients with pancreatic cancer, where malnutrition and weight loss are common complications 6.