State of the Art in Exocrine Pancreatic Insufficiency

Abstract

Exocrine pancreatic insufficiency (EPI) is defined as the maldigestion of foods due to inadequate pancreatic secretion, which can be caused by alterations in its stimulation, production, transport, or interaction with nutrients at duodenal level. The most frequent causes are chronic pancreatitis in adults and cystic fibrosis in children. The prevalence of EPI is high, varying according to its etiology, but it is considered to be underdiagnosed and undertreated. Its importance lies in the quality of life impairment that results from the malabsorption and malnutrition and in the increased morbidity and mortality, being associated with osteoporosis and cardiovascular events. The diagnosis is based on a set of symptoms, indicators of malnutrition, and an indirect non-invasive test in at-risk patients. The treatment of choice combines non-restrictive dietary measures with pancreatic enzyme replacement therapy to correct the associated symptoms and improve the nutritional status of patients. Non-responders require the adjustment of pancreatic enzyme therapy, the association of proton pump inhibitors, and/or the evaluation of alternative diagnoses such as bacterial overgrowth. This review offers an in-depth overview of EPI in order to support the proper management of this entity based on updated and integrated knowledge of its etiopathogenesis, prevalence, diagnosis, and treatment.

Actualización en el manejo nutricional de la insuficiencia pancreática exocrina: revisión de la literatura

“…Por el contrario, los indirectos carecen de sensibilidad en las etapas iniciales, pero son menos costosos y más fáciles de aplicar. La ausencia de prueba de diagnóstico precisa, disponible y fácilmente reproducible ha contribuido al infradiagnóstico de IPE (31,32) .…”

“…Existe una alta probabilidad de que se pueda establecer un diagnóstico de IPE antes de realizar una prueba de diagnóstico en pacientes con causas definidas de IPE, por ejemplo, PC, PA con necrosis extensa, cáncer de cabeza de páncreas o cirugía gastrointestinal (32) .…”

“…Es fácil de realizar y se encuentra ampliamente disponible, pero su precisión para la IPE es limitada (15) . Los valores de EF-1 menores de 200 µg/g se asocian con IPE, mientras que valores mayores de 500 µg/g permiten excluirla (3,32) .…”

“…La elección del método dependerá del escenario en el que deba diagnosticar la IPE y de la disponibilidad de las pruebas (2) . En la actualidad se sugiere que el correcto diagnóstico de IPE debe basarse en la evaluación combinada de síntomas relacionados con mala digestión, malabsorción de nutrientes, parámetros nutricionales y la prueba de EF-1 en el contexto clínico apropiado (3,32) . La combinación de dos de estos tres criterios debe considerarse suficiente para el diagnóstico y para iniciar el tratamiento de la mala digestión pancreática (Figura 2).…”

Responses of Ileal and Fecal Microbiota to Withdrawal of Pancreatic Enzyme Replacement Therapy in a Porcine Model of Exocrine Pancreatic Insufficiency

“…However, not all patients respond to PERT, and the reported symptoms under SIBO are often refractory to PERT [ 8 ]. SIBO might play a pivotal role in the persistence of steatorrhea in individuals adequately supplemented with enzymes, accompanied by a malabsorption of bile acids and an alteration of intestinal permeability during EPI [ 12 ]. Therefore, a better understanding of gut microbiota under EPI can potentially reveal biomarkers for monitoring treatment efficacy and assist in the development of new therapeutic strategies [ 12 ].…”