Pancreatic exocrine insufficiency

Pancreatic exocrine insufficiency (PEI) can be caused by a number of conditions, including cystic fibrosis, chronic pancreatitis, acute pancreatitis, pancreatic cancer, and upper gastrointestinal surgery, including pancreatectomy and gastrectomy.1,2

When PEI is suspected, a pancreatic function test should be performed.3 The most widely used non-invasive test is faecal elastase-1 (FE-1) level. It is reliable in patients with moderate to severe PEI. A single stool sample is used for analysis with concentrations of less than 200 mcg/g of stool indicating mild PEI, and less than 100mcg/g indicating severe PEI.

Use of pancreatic enzyme replacement therapy

Pancreatic enzyme replacement therapy (PERT) is the pharmacological mainstay of treatment of PEI. Newer preparations contain pancreatic extract encapsulated in microtablets or mini-microspheres with pH-sensitive enteric coating. The enzymes mix intragastrically with the chyme yet are protected from acid degradation by the enteric coating. The higher pH found in the duodenum dissolves the coating to release the enzymes at the appropriate site.2

The Australasian Pancreatic Club updated their guidelines on the management of PEI in late 2015. Motivating this update was the knowledge that some patients are not being prescribed enzymes when their use has clear clinical benefits (eg, reduction in pain and steatorrhea) and a desire to evaluate new evidence since the previous guidelines were published.2

Key recommendations for the use of PERT2

• Commence on 25,000 to 40,000 units lipase with each meal (adults)
• Titrate dosage up to 75,000 to 80,000 units lipase with each meal according to presence of malabsorption (adults)
• Trial acid suppressing agents in patients failing to respond to high dose PERT


1. Lindkvist B. World J Gastroenterol 2013;19:7258-66.
2. Australasian Pancreatic Club. (Accessed February 29, 2016, at
3. Lohr JM, et al. United European Gastroenterol J 2013;1:79-83