Recent international guidelines on pancreatic exocrine insufficiency (PEI) recommend repeating faecal elastase-1 (FE1) in cases of diagnostic doubt; carrying out pancreatic imaging and nutrition blood testing; starting pancreatic enzyme replacement therapy (PERT); referring to a dietitian; and following up to monitor response.

How does current clinical practice at a large UK centre compare to what is considered best practice?

Which factors predict repeating an FE1 <200 μg/g, the repeat FE1 being ≥200 μg/g, initiation of PERT and clinical response to treatment?

A quarter of our patients with low (positive) FE1 underwent repeat testing, half of whom had a normal repeat result.

Patients with very low initial FE1 results (<15 μg/g) were unlikely to benefit from repeat testing.

Patients with a confirmatory low FE1 on repeat testing were more likely to be started on PERT, as were patients with abnormal imaging or nutrition blood tests.

Patients with abnormal pancreatic imaging were 10 times more likely to respond to PERT than those with normal imaging.

Overall, treated patients were managed appropriately in terms of dosing regimen and referral to dietitians.

However, treatment with PERT was documented in only half of patients with low FE1.

The initial management of PEI should adhere to the clinical standard described in Table 1, including pancreatic imaging in all patients with FE1 <200 μg/g.

We also recommend repeat FE1 testing in patients with FE1 15–199 μg/g, particularly where there is diagnostic doubt.