Pancreatic Enzyme Replacement Therapy in Chronic Pancreatitis

Diagnosis of Pancreatic Exocrine Insufficiency

Approximately 90% of pancreatic acinar tissue must be destroyed before symptoms of malabsorption become evident, as stated by the European Society of Gastrointestinal Endoscopy 1
Fecal elastase testing is the preferred non-invasive test for confirming pancreatic exocrine insufficiency, with normal values ranging from 200-500 μg/g, according to the American Gastroenterological Association 2
Values <100 μg/g indicate severe insufficiency, as recommended by the European Society of Gastrointestinal Endoscopy 2
Serum enzyme quantification is not valuable for diagnosis, as stated by the American College of Gastroenterology 1
Clinical signs of PEI include steatorrhea, weight loss, and abdominal discomfort, while laboratory tests such as fecal elastase <200 μg/g suggest PEI, as stated in Clinical Nutrition guidelines 3

Colonoscopy with biopsies should be performed to exclude microscopic colitis, as recommended by the American Gastroenterological Association 2
Testing for bile acid diarrhea with SeHCAT or serum 7α-hydroxy-4-cholesten-3-one should be considered, according to the European Society of Gastrointestinal Endoscopy 2
Empirical antibiotic therapy should be considered if small intestinal bacterial overgrowth (SIBO) is suspected, as recommended by the American College of Gastroenterology 2
Antibiotics may be considered if SIBO is suspected, as stated in Proceedings of the Nutrition Society guidelines 4

Pancreatic enzyme replacement therapy (PERT) is the first-line treatment for diarrhea in patients with chronic pancreatitis, addressing the underlying pancreatic exocrine insufficiency (PEI) causing malabsorption and steatorrhea, as recommended by Clinical Nutrition guidelines 3
The preferred formulation of PERT is pH-sensitive, enteric-coated microspheres (1.0-1.2mm diameter), as recommended by Clinical Nutrition guidelines 3
Acid suppression therapy, such as proton pump inhibitors or H2 blockers, may be added to PERT to prevent enzyme denaturation in an acidic environment, according to Proceedings of the Nutrition Society guidelines 4
A normal fat diet (30% of total energy intake) with PERT is preferable to low-fat diets, with frequent small meals to improve digestion, and protein intake of 1.0-1.5 g/kg body weight, as recommended by Clinical Nutrition guidelines 5
Medium-chain triglycerides (MCT) may be considered if steatorrhea persists despite optimal PERT, according to Clinical Nutrition guidelines 5
Clinical response to PERT should be assessed by reduction in steatorrhea, weight gain, and improved symptoms, with titration of PERT dose based on clinical response, as stated in Clinical Nutrition guidelines 3

Empirical antibiotic therapy, such as rifaximin, may be effective in normalizing hydrogen breath tests and reducing symptoms in patients with chronic pancreatitis and SIBO, although the specific recommendation is ignored 2
Secondary factors such as small intestinal bacterial overgrowth (SIBO) complicate PEI in up to 92% of patients, according to Proceedings of the Nutrition Society guidelines 4

Undertreatment of PEI is common, with up to 70% of chronic pancreatitis patients with PEI being undertreated, according to Proceedings of the Nutrition Society guidelines 4
Improper timing, inadequate dosing, failure to recognize SIBO, and inappropriate use of PERT are common pitfalls, as stated in Praxis Medical Insights guidelines 6
For patients with severe malabsorption not responding to oral PERT, enteral nutrition via nasojejunal route may be required, with long-term jejunostomy access (PEG-J or DPEJ) considered for those requiring enteral nutrition for more than 30 days, as recommended by Clinical Nutrition guidelines 3, 5