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Practice Guideline
. 2025 Feb;13(1):125-172.
doi: 10.1002/ueg2.12674. Epub 2024 Dec 5.

European guidelines for the diagnosis and treatment of pancreatic exocrine insufficiency: UEG, EPC, EDS, ESPEN, ESPGHAN, ESDO, and ESPCG evidence-based recommendations

J Enrique Dominguez-Muñoz  1 , Miroslav Vujasinovic  2 , Daniel de la Iglesia  3 , Djuna Cahen  4 , Gabriele Capurso  5 , Natalya Gubergrits  6 , Peter Hegyi  7   8   9   10 , Pali Hungin  11 , Johann Ockenga  12 , Salvatore Paiella  13 , Lukas Perkhofer  14 , Vinciane Rebours  15 , Jonas Rosendahl  16 , Roberto Salvia  13 , Isabelle Scheers  17 , Andrea Szentesi  8 , Stefanos Bonovas  18   19 , Daniele Piovani  18   19 , J Matthias Löhr  20 ; European PEI Multidisciplinary Group
Collaborators, Affiliations
Practice Guideline

European guidelines for the diagnosis and treatment of pancreatic exocrine insufficiency: UEG, EPC, EDS, ESPEN, ESPGHAN, ESDO, and ESPCG evidence-based recommendations

J Enrique Dominguez-Muñoz et al. United European Gastroenterol J. 2025 Feb.

Abstract

Pancreatic exocrine insufficiency (PEI) is defined as a reduction in pancreatic exocrine secretion below the level that allows the normal digestion of nutrients. Pancreatic disease and surgery are the main causes of PEI. However, other conditions and upper gastrointestinal surgery can also affect the digestive function of the pancreas. PEI can cause symptoms of nutritional malabsorption and deficiencies, which affect the quality of life and increase morbidity and mortality. These guidelines were developed following the United European Gastroenterology framework for the development of high-quality clinical guidelines. After a systematic literature review, the evidence was evaluated according to the Oxford Center for Evidence-Based Medicine and the Grading of Recommendations Assessment, Development, and Evaluation methodology, as appropriate. Statements and comments were developed by the working groups and voted on using the Delphi method. The diagnosis of PEI should be based on a global assessment of symptoms, nutritional status, and a pancreatic secretion test. Pancreatic enzyme replacement therapy (PERT), together with dietary advice and support, are the cornerstones of PEI therapy. PERT is indicated in patients with PEI that is secondary to pancreatic disease, pancreatic surgery, or other metabolic or gastroenterological conditions. Specific recommendations concerning the management of PEI under various clinical conditions are provided based on evidence and expert opinions. This evidence-based guideline summarizes the prevalence, clinical impact, and general diagnostic and therapeutic approaches for PEI, as well as the specifics of PEI in different clinical conditions. Finally, the unmet needs for future research are discussed.

Keywords: cystic fibrosis; diabetes; diagnosis; fecal elastase; guidelines; malnutrition; pancreatectomy; pancreatic cancer; pancreatic enzyme replacement therapy; pancreatic exocrine insufficiency; pancreatitis; steatorrhea; treatment; weight loss.

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Conflict of interest statement

The authors' conflicts of interest are listed in Appendix 2.

The authors listed below report the following conflicts of interest:

Livia Archibugi—has received honoraria from Viatris

Georg Beyer—has received honoraria from the Falk Foundation

Stefanos Bonovas—spouse is an employee of Novartis

Dmitry Bordin—has received honoraria from Abbott Laboratories

Marco Bruno—has received research grants from Boston Scientific, Pentax Medical, Mylan, AMBU, ChiRoStim, and honoraria from Boston Scientific, Pentax Medical, AMBU, and Cook Medical

Gabriele Capurso—has received honoraria from Viatris, Amgen, Boston Scientific, Pangenix

Ferdinando D´Amico—has received research grants from Pfizer, AbbVie, Ferring, Galapagos, Janssen, and Nestlé, and honoraria from Sandoz, Janssen, Galapagos, Omega Pharma, Tillotts, and Takeda

Enrique de‐Madaria—has received research grants from Abbott and Viatris

Daniel de la Iglesia Garcia—has received honoraria from Abbott and Viatris

Enrique Dominguez‐Muñoz—has received honoraria from Abbott and Viatris, and research grants from Viatris.

Asbjørn Drewes—has received grants from Digestive Care Inc and Shionogi, and honoraria from Coloplast, Pangenics, and Shionogi

Sinead Duggan—has received research grants from the Meath Foundation, Department of Public Expenditure & Reform Innovation (Government of Ireland), and honoraria from Mylan

Nils Ewald—has received honoraria from Lilly, Novo Nordisk, and Novartis

Pierluigi Fracasso—has received honoraria from Schwabe and Reckitt

Luca Frulloni—has received honoraria from Viatris

Andrew Hopper—has received honoraria from Viatris

Pali Hungin—has received research grants from Ricketts and is a member of the ROME Foundation for Functional GI Disorders

Julio Iglesias‐Garcia—has received research grants and honoraria from Viatris and Abbott

Jutta Keller—has received a research grant from Canon Medical, and honoraria from Enterra, Falk, GE Healthcare, Medtronic, Mylan, Repha GmbH, Standard Instruments, Takeda

Alexander Kleger—has received honoraria from Sanofi, Sobi, and Falk Foundation

Andrea Laghi—has received honoraria from Lument, Bracco, GE Healthcare, Geurbet Bayer

José Larino‐Noia—has received honoraria from Viatris and Abbott

John Leeds—has received honoraria from Viatris

Björn Lindkvist—has received honoraria from Viatris, Takeda,

J. Matthias‐Löhr—has received honoraria from Abbott, Viatris, and Nordmark

Emma Martinez‐Moneo—has received honoraria from Viatris

Julia Mayerle—has received research grants from DFG, BMBF, DKH, and honoraria from the Falk Foundation

Johanna Ockenga—has received a research grant from the Innovationsfond, GBA (German government)

Alexey Okhlobystin—has received honoraria from Abbott Laboratories

Salvatore Paiella—has received honoraria from AlphaTau Medical

Lukas Perkhofer—has received research grants from Deutsche Forschungsgesellschaft, German Cancer Aid, and honoraria from AstraZeneca, Servier, and Roche

Mary Phillips—has recieved honoraria from Viatris and Nutricia Clinical Care

Goran Poropat—has received honoraria from Abbott Nutrition, Fresenius, Sandoz, and Krka Farma

Vinciane Rebours—has received research grants and honoraria from Mayoly Spindler and Viatris

Jonas Rosendahl—has received honoraria from the Falk Foundation, Nordmark, Viatris, Alexxion, MicroTech

Oleg Shvets—has received honoraria from Abbott, Takeda, Berlin‐Chemie, Nutricia, B.Braun

Hester Timmerhuis—has received honoraria from Viatris and Tramedico

Miroslav Vujasinovic—has received honoraria from Viatris and Abbott

Michael Wilschanski—has received a research grant from Vertex Pharmaceuticals, and honoraria from Synspira

Figures

FIGURE 1
FIGURE 1
Overview of the various guidelines and consensus recommendations for CP (above) and PEI (below) referring to the following: American College of Gastroenterology (ACG); American Gastroenterological Association (AGA); American Pancreatic Association (APA); Australia, , ; Belgium; Canada; Cochrane; German Society for Digestive and Metabolic Diseases (DGVS); Hungary; Italy, ; Japan Pancreas Society (JPS); Poland; Russia, ; Spain, ; South Africa; Turkey; United European Gastroenterology (UEG); Romania; Sweden ; United Kingdom. CP, chronic pancreatitis; PEI, pancreatic exocrine insufficiency.
FIGURE 2
FIGURE 2
Unmet needs, lacking scientific evidence, and future directions.
FIGURE 3
FIGURE 3
Key general concepts and recommendations. PEI, pancreatic exocrine insufficiency; PERT, pancreatic enzyme replacement therapy. PRO, Patient reported outcome.
See this image and copyright information in PMC

References

    1. DiMagno EP, Go VL, Summerskill WH. Relations between pancreatic enzyme ouputs and malabsorption in severe pancreatic insufficiency. N Eng J Med. 1973;288(16):813–815. 10.1056/nejm197304192881603 - DOI - PubMed
    1. Hoffmeister A, Mayerle J, Beglinger C, Büchler M, Bufler P, Dathe K, et al. S3‐leitlinie chronische pankreatitis: Definition, Ätiologie, Diagnostik, konservative, interventionell endoskopische und operative Therapie der chronischen Pankreatitis. Leitlinie der Deutschen Gesellschaft für Verdauungs‐und Stoffwechselkrankheiten (DGVS). Z Gastroenterol. 2012;50(11):1176–1224. 10.1055/s-0032-1325479 - DOI - PubMed
    1. Gardner TB, Adler DG, Forsmark CE, Sauer BG, Taylor JR, Whitcomb DC. ACG clinical guideline: chronic pancreatitis. Am J Gastroenterol. 2020;115(3):322–339. 10.14309/ajg.0000000000000535 - DOI - PubMed
    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;165(5):1292–1301. 10.1053/j.gastro.2023.07.007 - DOI - PubMed
    1. Conwell DL, Lee LS, Yadav D, Longnecker DS, Miller FH, Mortele KJ, et al. American pancreatic association practice guidelines in chronic pancreatitis: evidence‐based report on diagnostic guidelines. Pancreas. 2014;43(8):1143–1162. 10.1097/mpa.0000000000000237 - DOI - PMC - PubMed

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