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Review
. 2023 Sep 1;39(5):428-435.
doi: 10.1097/MOG.0000000000000951. Epub 2023 May 11.

Evaluation and management of exocrine pancreatic insufficiency: pearls and pitfalls

Mitchell L Ramsey  1 , Phil A Hart  1 , Christopher E Forsmark  2
Affiliations
Review

Evaluation and management of exocrine pancreatic insufficiency: pearls and pitfalls

Mitchell L Ramsey et al. Curr Opin Gastroenterol. .

Abstract

Purpose of review: The diagnosis and management of exocrine pancreatic dysfunction (EPD) can be challenging. EPD classically results from conditions that cause loss of pancreatic acinar cell function and decreased digestive enzyme production. However, several conditions may contribute to signs or symptoms of EPD with otherwise normal pancreatic exocrine function. A thoughtful approach to considering these conditions, along with their specific therapies, can guide a tailored management approach.

Recent findings: An EPD severity classification schema has been proposed, which emphasizes a shift towards a more restrictive prescription of pancreas enzyme replacement therapy (PERT) for patients with milder EPD. In contrast, PERT use has been associated with a measurable survival benefit among individuals with EPD and pancreatic cancer, so the prescription of PERT may be more liberal in this population. Recent publications in the cystic fibrosis population offer pearls guiding the titration and optimization of PERT.

Summary: Among individuals with severe EPD, PERT is an effective therapy. Among individuals with milder EPD, although PERT is effective, there may be opportunities to provide additional and potentially more effective therapies.

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Conflict of interest statement

Conflicts of Interest: The Authors declare no conflicts of interest.

Figures

Figure 1:
Figure 1:
Change in PERT dose measured in units of lipase according to grams of dietary fat before and after use of a PERT dosing application. Used with permission from Calvo Lerma, et al.
See this image and copyright information in PMC

References

    1. DiMagno EP, Go VL, Summerskill WH. Relations between pancreatic enzyme outputs and malabsorption in severe pancreatic insufficiency. N Engl J Med 1973;288:813–5. - PubMed
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    2. ** This study proposes a new EPD staging system based on clinical and laboratory features, and proposes to reserve PERT therapy to only individuals with severe EPD. If adopted, this staging system will identify distinct sub-populations with varying stages of EPD which will facilitate more nuanced and specific treatment recommendations.

    1. Kunovský L, Dítě P, Jabandžiev P, et al. Causes of Exocrine Pancreatic Insufficiency Other Than Chronic Pancreatitis. J Clin Med 2021;10. - PMC - PubMed
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