Introduction and practical approach to exocrine pancreatic insufficiency for the practicing clinician

Abstract

SummaryAimsIn exocrine pancreatic insufficiency (EPI), the quantity and/or activity of pancreatic digestive enzymes are below the levels required for normal digestion, leading to maldigestion and malabsorption. Diagnosis of EPI is often challenging because the characteristic signs and symptoms overlap with those of other gastrointestinal conditions. Additionally, there is no single convenient, or specific diagnostic test for EPI. The aim of this review is to provide a framework for differential diagnosis of EPI vs other malabsorptive conditions.MethodsThis is a non‐systematic narrative review summarising information pertaining to the aetiology, diagnosis and management of EPI.ResultsExocrine pancreatic insufficiency may be caused by pancreatic disorders, including chronic pancreatitis, cystic fibrosis, pancreatic resection and pancreatic cancer. EPI may also result from extra‐pancreatic conditions, including coeliac disease, Zollinger‐Ellison syndrome and gastric surgery. Timely and accurate diagnosis of EPI is important, as delays in treatment prolong maldigestion and malabsorption, with potentially serious consequences for malnutrition, overall health and quality of life. Symptoms of EPI are non‐specific; therefore, a high index of clinical suspicion is required to make a correct diagnosis.

Management of Exocrine Pancreatic Insufficiency in Children

“…Pancreatic amylase insufficiency usually does not cause significant clinical ramifications, as nonpancreatic sources (eg, salivary and small‐bowel glands) are able to partially compensate for the pancreatic deficiencies in most instances . Pancreatic lipase is susceptible to irreversible inactivation by acidic gastric secretion (pH < 4) and also further destroyed by intraluminal proteases . Some conditions (such as Zollinger‐Ellison syndrome) that are associated with excessive gastric acidity are known to lead to a secondary EPI due to acid‐induced inactivation of pancreatic enzymes and denaturation of bile acids, with subsequent impaired absorption exacerbating the maldigestion and malabsorption of fats …”

“…Secondary EPI is due to nonpancreatic reasons such as small‐bowel inflammation and asynchrony in the digestive process (Table ). Inflammatory bowel disease, celiac disease, and other conditions with proximal small‐bowel mucosal inflammation can result in EPI due to decreased enteropancreatic stimulation by CCK . Postcibal asynchrony is the dissociation between delivery of chyme to the proximal small bowel and discharge of pancreatic secretions mostly due to altered anatomy of the upper GI tract .…”

Chinese guidelines for the diagnosis and treatment of pancreatic exocrine insufficiency (2018 edition)

“…This leads to permanent damage to the pancreatic exocrine function. The prevalence of PEI in newborns with CF is nearly 85% …”

Perspectives, Commentaries, Consensus Reports, Grand Rounds, Meta-Analyses, Systematic Reviews, Narrative Reviews: Collecting useful information in one place

“…8 The remainder of this month's issue of the journal contains additional reviews covering a variety of conditions and/or procedures, including the management of hyperkalaemia, 9 the treatment of hypothyroidism, 10 integrated left trial evaluation, 11 the use of endobronchial ultrasound trans-bronchial needle aspiration, 12 and a discussion on exocrine pancreatic insufficiency. 13 Next month we will resume our usual publication pattern to include single study reports. In the meantime, if you are interested in submitting a perspective paper, consensus report, meta-analytic review, or other review, please do not hesitate to send a presubmission inquiry to ijcp_editorial@wiley.com.…”

“…The remainder of this month's issue of the journal contains additional reviews covering a variety of conditions and/or procedures, including the management of hyperkalaemia, the treatment of hypothyroidism, integrated left trial evaluation, the use of endobronchial ultrasound trans‐bronchial needle aspiration, and a discussion on exocrine pancreatic insufficiency . Next month we will resume our usual publication pattern to include single study reports.…”