Romanian Guidelines on the Diagnosis and Treatment of Exocrine Pancreatic Insufficiency

Abstract

In assessing exocrine pancreatic insufficiency (EPI), its diverse etiologies and the heterogeneous population affected should be considered. Diagnosing this condition remains a challenge in clinical practice especially for mild-to-moderate EPI, with the support of the time-consuming breath test or the coefficient of fat absorption. The fecal elastase-1 test, less precise for the diagnosis, cannot be useful for assessing treatment efficacy. Pancreatic enzyme replacement therapy (PERT) is the mainstay of treatment, whereby enteric-coated mini-microspheres are taken with every meal, in progressive doses based on an individual's weight and clinical symptoms. The main indication for PERT is chronic pancreatitis, in patients who have clinically relevant steatorrhea, abnormal pancreatic function test or abnormal function tests associated with symptoms of malabsorption such as weight loss or meteorism. While enzyme replacement therapy is not recommended in the initial stages of acute pancreatitis, pancreatic exocrine function should be monitored for at least 6-18 months. In the case of unresectable pancreatic cancer, replacement enzyme therapy helps to maintain weight and improve overall quality of life. It is also indicated in patients with celiac disease, who have chronic diarrhea (in spite of gluten-free diet), and in patients with cystic fibrosis with proven EPI.

Clinical outcomes after total pancreatectomy for malignant neoplasms; a single center retrospective study of 26 cases

“…In accordance with standard practice in our institution, all TP patients in this study were controlled by intensive insulin therapy in an attempt to mimic the normal pattern of insulin secretion, and to deliver replacement insulin using the concepts of basal and bolus insulin coverage. In addition to intensive insulin therapy, pancreatic enzyme formula in pancreatic enzyme replacement therapy (PERT) was indispensable, preventing fat maldigestion and malabsorption as well as deficiencies of fat-soluble vitamins as a consequence of exocrine pancreatic insufficiency [14,15]. Moreover, PERT reduces glycemic variability through the prevention of fatty stool [16].…”

Less common etiologies of exocrine pancreatic insufficiency

“…Often patients make dietary modifications to reduce symptoms. Patients may have low serum levels of fat-soluble vitamins, micronutrients, and lipoproteins[ 21 ]. Severe symptomatic EPI can be diagnosed by the presence of steatorrhea, diarrhea, flatulence, or weight loss[ 22 ], which often manifest when fecal fat excretion is > 7 g/d (Table 4 ).…”

“…The aims of PERT are to compensate for deficiencies in endogenous enzyme secretion, correct maldigestion and malabsorption, and ameliorate symptoms resulting from a loss of exocrine function. To achieve this, the enzymatic activity delivered into the duodenum in conjunction with gastric emptying must be sufficient to optimize digestion and nutrient absorption[ 21 ]. A main goal of PERT is to restore sufficient intestinal lipase levels[ 11 ].…”

Pancreatic enzyme replacement therapy after gastric resection: An update

“…There are no strict regimens of PERT for gastrectomized patients and the dosage of pancreatic enzymes must be tailored according to patient's clinical symptoms [44]. The starting recommended trial dose in adults is 25,000-50,000 IU of lipase per main meal, and 10,000-25,000 IU of lipase for small meals or snacks [3,45,46]. Dosage should be increased adjusting to patient's symptoms response, keeping in mind that the maximum daily dose should not exceed 75,000 IU with a meal [46].…”

“…Patients in which accelerated gastric emptying is suspected should be treated by granules preparations or by opening the capsules and mixing the contents with soft food [46]. If symptoms do not improve after a trial of PERT, adjunct therapy with acid-suppressing agents should be considered in patients who have undergone partial gastrectomy [3,45,46].…”