Diagnosis and treatment of pancreatic exocrine insufficiency

Abstract

Pancreatic exocrine insufficiency is an important cause of maldigestion and a major complication in chronic pancreatitis. Normal digestion requires adequate stimulation of pancreatic secretion, sufficient production of digestive enzymes by pancreatic acinar cells, a pancreatic duct system without significant outflow obstruction and adequate mixing of the pancreatic juice with ingested food. Failure in any of these steps may result in pancreatic exocrine insufficiency, which leads to steatorrhea, weight loss and malnutrition-related complications, such as osteoporosis. Methods evaluating digestion, such as fecal fat quantification and the (13)C-mixed triglycerides test, are the most accurate tests for pancreatic exocrine insufficiency, but the probability of the diagnosis can also be estimated based on symptoms, signs of malnutrition in blood tests, fecal elastase 1 levels and signs of morphologically severe chronic pancreatitis on imaging. Treatment for pancreatic exocrine insufficiency includes support to stop smoking and alcohol consumption, dietary consultation, enzyme replacement therapy and a structured follow-up of nutritional status and the effect of treatment. Pancreatic enzyme replacement therapy is administered in the form of enteric-coated minimicrospheres during meals. The dose should be in proportion to the fat content of the meal, usually 40-50000 lipase units per main meal, and half the dose is required for a snack. In cases that do not respond to initial treatment, the doses can be doubled, and proton inhibitors can be added to the treatment. This review focuses on current concepts of the diagnosis and treatment of pancreatic exocrine insufficiency.

Keywords: Chronic pancreatitis; Pancreatic enzyme replacement therapy; Pancreatic exocrine insufficiency.

Figure 1

Different causes of pancreatic exocrine insufficiency.

Figure 2

Evaluation of the probability of pancreatic exocrine insufficiency in the absence of advanced tests for maldigestion, such as fecal fat quantification and the ¹³C-mixed triglycerides breath test. PEI: Pancreatic exocrine insufficiency; MPD: Main pancreatic duct.

Figure 3

Fundamental aspects in the care of patients with pancreatic exocrine insufficiency. PERT: Pancreatic enzyme replacement therapy; PPI: Proton pump inhibitors.