Should we Investigate Gastroenterology Patients for Pancreatic Exocrine Insufficiency? A Dual Centre UK Study

Abstract

Background & Aims: Pancreatic exocrine insufficiency may be under recognised in gastroenterological practice. We aimed to identify the prevalence of pancreatic insufficiency in secondary care gastroenterology clinics and determine if co-morbidity or presenting symptoms could predict diagnosis. A secondary aim was to assess response to treatment.
 Methods: A dual centre retrospective analysis was conducted in secondary care gastroenterology clinics. Patients tested for pancreatic exocrine insufficiency with faecal elastase-1 (FEL-1) between 2009 and 2013 were identified in two centres. Demographics, indication and co-morbidities were recorded in addition to dose and response to pancreatic enzyme replacement therapy. Binary logistic regression was used to assess if symptoms or co-morbidities could predict pancreatic insufficiency.
 Results: 1821 patients were tested, 13.1% had low FEL-1 (<200μg/g). This prevalence was sub-analysed with 5.4% having FEL-1 100-200μg/g (mild insufficiency) and 7.6% having faecal elastase readings <100μg/g. Low FEL-1 was most significantly associated with weight loss or steatorrhoea. Co-morbidity analysis showed that low levels were significantly associated with excess alcohol intake, diabetes mellitus or human immunodeficiency virus; 80.0% treated with enzyme supplements reported symptomatic benefit with no difference in response between high and low dose supplementation (p=0.761).
 Conclusion: Targeting the use of FEL-1 in individuals with specific symptoms and associated conditions can lead to improved recognition of pancreatic exocrine insufficiency in a significant proportion of secondary care patients. Intervening with lifestyle advice such as smoking cessation and minimising alcohol intake could improve outcomes. In addition, up to 80% of patients with low faecal elastase respond to supplementation.
 Abbreviations: CFA: coefficient of fat absorption; CP: chronic pancreatitis; ELISA: enzyme-linked immune-absorbent assay; PEI: pancreatic exocrine insufficiency; FEL-1: faecal elastase-1; HIV: human immunodeficiency virus; IBD: inflammatory bowel disease; IBS: irritable bowel syndrome; PERT: pancreatic enzyme replacement therapy.

Letter: the under‐treatment and under‐diagnosis of pancreatic exocrine insufficiency in chronic pancreatitis and pancreatic cancer is just the tip of the iceberg

“…3 Among 238 patients with abnormal FEL-1 who went on to further assessment, 34.2% showed changes consistent with CP on subsequent cross-sectional imaging reflecting undiagnosed CP as a cause. 3 This is in keeping with post mortem studies showing a higher prevalence of CP than clinically reported. 4,5 Of the 61.8% of 238 patients with low FEL-1 who were followed up and treated with PERT, 79.6% reported symptomatic improvement.…”

Diagnosis and management of pancreatic exocrine insufficiency

“…There are limited reliable data on the prevalence of PEI in the general population 5 . PEI often goes undetected and patients referred from primary care may not represent the majority of PEI sufferers within the community 3 , 4 , 17 , 18 …”

“…The symptoms of PEI are gastrointestinal‐related and non‐specific. If undiagnosed, patients may have ongoing symptoms such as diarrhoea and abdominal pain that can sometimes be mistaken as a functional bowel disorder 3 , 18 . PEI symptoms can vary from patient to patient, and are dependent on the degree of PEI experienced and its aetiology 5 …”

“…PEI is an underdiagnosed and often undertreated condition 3 , 5 , 18 , 38 . ‐ 41 The dilemma for the clinician, therefore, is to be able to determine which patients will benefit from further investigations and PEI treatment.…”

The investigation and management of pancreatic exocrine insufficiency: A retrospective cohort study

“…5,6 It is estimated that 80% of patients respond clinically, and PERT has been shown to relieve the symptoms of PEI and improve survival. [6][7][8] However, studies have shown that treatment is initiated in as few as 21% of patients who might benefit, and that dosing may be inadequate in many patients on treatment. 9,10 However, the factors predicting initiation of, and response to, PERT are unknown.…”