Overview
Exocrine pancreatic insufficiency (EPI) results from inadequate pancreatic enzyme secretion, leading to maldigestion and malabsorption of nutrients, often manifesting as steatorrhea, weight loss, and deficiencies in fat-soluble vitamins 1.Diagnosis
Key Diagnostic Criteria: Presence of steatorrhea, weight loss, and nutrient deficiencies 1.
Recommended Tests:
- Fecal elastase 1 (FE1) level: <200 mcg/g indicates EPI 2.
- Coefficient of fat absorption (CFA) <93% confirms EPI 2.
- Serum levels of fat-soluble vitamins (A, D, E, K) for assessing deficiencies 45.
Grading:
- Stage I (Mild): FE1 100-200 mcg/g; consider non-pancreatic causes if steatorrhea is present 2.
- Stage II (Moderate): FE1 <100 mcg/g; assess CFA and vitamin levels 2.Management
First-Line Treatment:
- Pancreatic enzyme replacement therapy (PERT) to improve digestion and absorption 125.
Adjunctive Treatments:
- Supplementation with fat-soluble vitamins (A, D, E, K) to correct deficiencies 45.
- Nutritional counseling to optimize dietary intake 1.Special Populations
Pediatrics: Endoscopic pancreatic function testing (ePFT) can be used for diagnosis, though its utility and interpretation require careful consideration 3.
Comorbidities: EPI management should consider coexisting conditions like chronic pancreatitis or malignancies, tailoring PERT and nutritional support accordingly 5.Key Recommendations
Increase awareness and promote appropriate diagnosis and treatment of EPI to address underdiagnosis and undertreatment 1 (Evidence: Expert opinion).
Use fecal elastase 1 levels as a primary non-invasive test for EPI, with CFA and vitamin levels for confirmation in moderate cases 2 (Evidence: Moderate).
Implement pancreatic enzyme replacement therapy as first-line treatment, complemented by vitamin supplementation to manage deficiencies 145 (Evidence: Moderate).References
1 Whitcomb DC, Buchner AM, Forsmark CE. AGA Clinical Practice Update on the Epidemiology, Evaluation, and Management of Exocrine Pancreatic Insufficiency: Expert Review. Gastroenterology 2023. link
2 Khan A, Vege SS, Dudeja V, Chari ST. Staging exocrine pancreatic dysfunction. Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.] 2022. link
3 Patel N, Sellers ZM, Grover A, Liu QY, Maqbool A, Morinville VD et al.. Endoscopic Pancreatic Function Testing (ePFT) in Children: A Position Paper From the NASPGHAN Pancreas Committee. Journal of pediatric gastroenterology and nutrition 2021. link
4 Barko PC, Williams DA. Serum concentrations of lipid-soluble vitamins in dogs with exocrine pancreatic insufficiency treated with pancreatic enzymes. Journal of veterinary internal medicine 2018. link
5 Pezzilli R, Andriulli A, Bassi C, Balzano G, Cantore M, Delle Fave G et al.. Exocrine pancreatic insufficiency in adults: a shared position statement of the Italian Association for the Study of the Pancreas. World journal of gastroenterology 2013. link