Table 1.

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.