Diagnosis and Management of Pancreatic Insufficiency

Clinical Recognition and Risk Stratification

The American Gastroenterological Association recommends suspecting exocrine pancreatic insufficiency (EPI) in patients presenting with steatorrhea, chronic diarrhea, bloating, abdominal pain, increased flatulence, or unexplained weight loss 3
The American Gastroenterological Association suggests that malnutrition with reduced food intake and impaired digestion is a risk factor for EPI 3
Patients with chronic pancreatitis, cystic fibrosis, pancreatic cancer, total pancreatectomy, or recurrent acute pancreatitis are at high risk for EPI and should be tested strongly 2, 3, 4
The American Gastroenterological Association recommends that patients with total pancreatectomy require no further testing and should initiate pancreatic enzyme replacement therapy (PERT) immediately 3, 4

The American Gastroenterological Association recommends using fecal elastase-1 (FE-1) testing as the initial diagnostic test for EPI, interpreting values <200 μg/g as abnormal and <100 μg/g as consistent with EPI 1, 2
FE-1 testing must be performed on semi-solid or solid stool samples for accuracy 1, 5
The American Gastroenterological Association suggests that FE-1 values between 100-200 μg/g have lower specificity, and repeat testing should be considered if initial result is in this range 1, 2
PERT use does not alter FE-1 results, so testing can be done while on therapy 1, 2
Repeat FE-1 measurements are not useful for assessing treatment response 1, 2, 5

The American Gastroenterological Association recommends cross-sectional imaging (CT or MRI) to diagnose underlying pancreatic disease 2, 3
Pancreatic protocol CT is preferred for initial evaluation 6
Endoscopic ultrasonography (EUS) can be used as an accurate alternative to screen for structural abnormalities 7

The American Gastroenterological Association recommends obtaining serum amylase or lipase level, triglyceride level, calcium level, liver chemistries, and baseline micronutrient status and fat-soluble vitamins at admission or initial evaluation 7, 5
Glucose and HbA1c should be measured for endocrine function assessment 2, 3, 5

The American Gastroenterological Association recommends not relying on a therapeutic trial with pancreatic enzymes as a diagnostic test, as response to PERT is not reliable for diagnosing EPI 5
FE-1 testing should not be performed on liquid or watery stool samples, as results will be unreliable 1, 5
Repeat FE-1 should not be used to monitor treatment response, as it does not change with therapy 1, 2, 5