Concise current gold standard for the initial management of pancreatic exocrine insufficiency
| FE1 should be repeated in cases of diagnostic doubt. | FE1 has a false positive rate of approximately 10%.4 A low FE1 should be repeated in patients with a low pre-test probability of PEI, such as those lacking established risk factors.7,13 |
| Patients with PEI should undergo pancreatic imaging at diagnosis. | This provides structural information about the pancreas and excludes pancreatic cancer as a potential aetiology.11–14 |
| Patients with PEI should undergo biochemical screening for malnutrition. | Malnutrition is common in patients with PEI, and responsible for significant morbidity if left untreated eg osteoporosis.11–13 |
| Patients with PEI should be prescribed PERT, at an initial dose of ≥40,000 IU/meal. | PERT is the cornerstone of PEI treatment. There is evidence that previous recommendations to start PERT at a dose of 20,000 IU/meal undertreats two-thirds of patients, therefore 40,000–50,000 IU/meal is now preferred.12–15 |
| Alcohol and smoking cessation should be advised. | Both alcohol and smoking are considered risk factors for the progression of PEI, particularly in patients with chronic pancreatitis.11–13 |
| Patients with PEI should be referred to a dietitian. | Dietary management is an important aspect of treatment. Dietitians are expert in assessing malnutrition, obtaining diet histories, and tailoring meal content and PERT regimens to individual circumstances.11–13 |
| Response to PERT should be monitored at follow-up. | Clinical response is a satisfactory outcome in most settings.12 Where available, the CFA or 13C-mixed triglyceride breath test can be used to identify patients with symptomatic improvement who remain at risk of malnutrition.15 |
CFA = coefficient of faecal fat absorption; FE1 = faecal elastase-1; PEI = pancreatic exocrine insufficiency; PERT = pancreatic enzyme replacement therapy.