Evaluation and management of exocrine pancreatic insufficiency: pearls and pitfalls

Abstract

Purpose of reviewThe 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 findingsAn 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.SummaryAmong 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.

Pancreas and pancreatitis: Exocrine pancreatic insufficiency

“…66 In addition to these causes, a number of gastrointestinal comorbidities that may contribute. 66,73 These include small intestinal bacterial overgrowth (SIBO), cholestasis, celiac disease, and short bowel syndrome-conditions that are more prevalent in CF and should be considered before escalating PERT dose above 10,000 LU/kg/ day. Once these factors have been considered and addressed, such as prescribing antibiotics for SIBO, other adjunctive treatments may be considered such as the addition of anti-acids (e.g., proton pump inhibitors or histamine type-2 receptor antagonists) to optimize duodenal pH for enzymatic activity.…”