From the Guidelines
Exocrine pancreatic insufficiency (EPI) should be treated with pancreatic enzyme replacement therapy (PERT) and dietary modifications to improve digestion, absorption, and nutritional status, as recommended by the most recent guidelines 1.
Diagnosis and Treatment
The primary treatment for EPI is PERT with products like Creon, Zenpep, or Pancreaze, which should be taken with every meal and snack, starting at a dose of at least 40,000 USP units of lipase during each meal in adults, as stated in the AGA clinical practice update 1.
- The capsules should be swallowed whole with plenty of water during meals, not crushed or chewed.
- A proton pump inhibitor like omeprazole (20-40mg daily) may be added to reduce stomach acid that can deactivate the enzymes.
- Dietary modifications include consuming smaller, more frequent meals, limiting high-fat foods initially, and ensuring adequate caloric intake.
- Fat-soluble vitamin supplements (A, D, E, K) are often necessary, as recommended in the guidelines 1.
Monitoring and Follow-up
Regular monitoring of nutritional status and symptom improvement is essential for managing this chronic condition effectively, with measures including:
- Anthropomorphic assessments (height, weight, handgrip strength, muscle mass, and body mass index)
- Serum biomarkers
- Clinical assessment (eg, physical activity, diet, alcohol use, smoking, sitophobia, abdominal pain, bloating, bowel habits, and steatorrhea)
- Baseline measurements of fat-soluble vitamins and serum markers of malnutrition, with regular screening for diabetes with hemoglobin A1c levels, as recommended in the guidelines 1.
Quality of Life and Mortality
EPI can have a significant impact on quality of life, with symptoms such as steatorrhea, weight loss, abdominal pain, and malnutrition, which can be improved with effective treatment and management, as stated in the guidelines 1.
- Untreated EPI can lead to complications related to fat malabsorption and malnutrition, having a negative impact on quality of life and potentially increasing mortality risk.
- Effective treatment and management of EPI can improve quality of life, reduce morbidity, and potentially decrease mortality risk, as recommended by the guidelines 1.
From the Research
Definition and Causes of Exocrine Pancreatic Insufficiency
- Exocrine pancreatic insufficiency (EPI) is defined as the maldigestion of foods due to inadequate pancreatic secretion, which can be caused by alterations in its stimulation, production, transport, or interaction with nutrients at duodenal level 2.
- The most frequent causes of EPI are chronic pancreatitis in adults and cystic fibrosis in children 2.
- Other causes of EPI include pancreatic diseases leading to a loss of pancreatic parenchyma, obstruction of the main pancreatic duct, decreased pancreatic stimulation, or acid-mediated inactivation of pancreatic enzymes 3.
- Gastrointestinal and pancreatic surgical resections are also frequent causes of EPI 3.
Diagnosis of Exocrine Pancreatic Insufficiency
- The diagnosis of EPI is based on a set of symptoms, indicators of malnutrition, and an indirect non-invasive test in at-risk patients 2.
- Assessments of exocrine pancreatic function, such as fecal fat quantification and (13) C-triglyceride breath test, are the method of choice for diagnosis 3.
- High-risk patient populations include those with severe necrotizing pancreatitis, gastrointestinal and pancreatic surgery, cancer of pancreas head, and those with pancreatic calcifications 3.
Treatment of Exocrine Pancreatic Insufficiency
- The treatment of choice for EPI combines non-restrictive dietary measures with pancreatic enzyme replacement therapy to correct the associated symptoms and improve the nutritional status of patients 2.
- Pancreatic enzyme replacement therapy is administered in the form of enteric-coated minimicrospheres during meals, with a dose proportional to the fat content of the meal 4.
- The dose of pancreatic enzymes should be adjusted based on the individual patient's response to treatment, and proton pump inhibitors may be added to the treatment in cases of non-response 4, 5.
- Non-responders to initial treatment may require adjustment of pancreatic enzyme therapy, association of proton pump inhibitors, and/or evaluation of alternative diagnoses such as bacterial overgrowth 2.
Management and Lifestyle Changes
- Lifestyle changes, such as decrease in alcohol consumption and smoking cessation, are also important in the management of EPI 6.
- Dietary management and consultation are essential to ensure adequate nutrition and to prevent malnutrition-related complications 4, 6.
- Regular follow-up of nutritional status and the effect of treatment is necessary to ensure optimal management of EPI 4.