Diagnosis and Management of Exocrine Pancreatic Insufficiency (EPI) in Primary Care

Consensus Guidance of a Canadian Expert Panel

Introduction

Exocrine pancreatic insufficiency (EPI) is a condition that occurs due to a reduction in pancreatic enzyme production, delivery, and/or activity to a level below the threshold required to maintain normal digestion. EPI results in impaired digestion and decreased absorption of nutrients.1,2

Key recommendations3*

EPI should always be considered in individuals with a newly diagnosed pancreatic disease predisposing to EPI, including chronic pancreatitis, cystic fibrosis, pancreatic cancer, pancreatectomy, and gastrointestinal surgeries.

Investigate EPI if suggestive signs and symptoms develop in a patient with a known pancreatic disease or in patients with a predisposing condition.


The following signs and symptoms should be considered suggestive of EPI:

  • Large-volume malodorous stools
  • Steatorrhea
  • Unexplained weight loss
  • Unexplained deficits in fat-soluble vitamins
  • Clinical sequelae of certain micronutrient deficiencies
  • Diabetes mellitus secondary to chronic pancreatitis

For patients with a condition predisposing to EPI, regular screening should include:

  • Weight and body mass index
  • Fat-soluble vitamins and other nutritional markers
  • HbA1c
  • Bone mineral density scan
  • Fecal tests such as FE-1

For patients with signs or symptoms suggestive of EPI, thorough investigation should include the following considerations:

  • Duration and nature of symptoms (eg, steatorrhea)
  • Documented unexplained weight loss
  • Other basic laboratory values (including complete blood counts with differential, comprehensive metabolic panel, international normalized ratio, serum albumin, and prealbumin levels)
  • Patient’s clinical history (including prior chronic or recurrent acute pancreatitis, alcohol abuse, smoking, and GI surgery)
  • Any family history of a pancreatic disease

*These are select recommendations from the consensus guidance. For a complete list of recommendations, please refer to Durie P, et al. Curr Med Res Opin. 2018;34(1):25-33.

References

  1. Lindkvist B. Diagnosis and treatment of pancreatic exocrine insufficiency. World J Gastroenterol. 2013;19(42):7258-7266.
  2. Pezzilli R, Andriulli A, Bassi C, et al. Exocrine pancreatic insufficiency in adults: a shared position statement of the Italian Association for the Study of the Pancreas. World J Gastroenterol. 2013;19(44):7930-7946.
  3. Durie P, Baillargeon JD, Bouchard S, Donnellan F, Zepeda-Gomez S, Teshima C. Diagnosis and management of pancreatic exocrine insufficiency (PEI) in primary care: consensus guidance of a Canadian expert panel. Curr Med Res Opin. 2018;34(1):25-33.