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Introduction and Practical Approach to Exocrine Pancreatic Insufficiency for the Practicing Clinician


Introduction and Practical Approach to Exocrine Pancreatic Insufficiency for the Practicing Clinician

Mohamed O Othman et al. Int J Clin Pract.


Aims: In exocrine pancreatic insufficiency (EPI), the quantity and/or activity of pancreatic digestive enzymes are below the levels required for normal digestion, leading to maldigestion and malabsorption. Diagnosis of EPI is often challenging because the characteristic signs and symptoms overlap with those of other gastrointestinal conditions. Additionally, there is no single convenient, or specific diagnostic test for EPI. The aim of this review is to provide a framework for differential diagnosis of EPI vs other malabsorptive conditions.

Methods: This is a non-systematic narrative review summarising information pertaining to the aetiology, diagnosis and management of EPI.

Results: Exocrine pancreatic insufficiency may be caused by pancreatic disorders, including chronic pancreatitis, cystic fibrosis, pancreatic resection and pancreatic cancer. EPI may also result from extra-pancreatic conditions, including coeliac disease, Zollinger-Ellison syndrome and gastric surgery. Timely and accurate diagnosis of EPI is important, as delays in treatment prolong maldigestion and malabsorption, with potentially serious consequences for malnutrition, overall health and quality of life. Symptoms of EPI are non-specific; therefore, a high index of clinical suspicion is required to make a correct diagnosis.


Figure 1
Figure 1
The pathology of exocrine pancreatic insufficiency. Reproduced with permission under the Creative Commons Attribution license from Lindkvist B. World J Gastroenterol 2013; 19: 7258‐7266
Figure 2
Figure 2
A general strategy for differential diagnosis of EPI. The patient history and physical examination inform the most efficient sequence of subsequent investigations, not all of which may be necessary. CT, computed tomography; EPI, exocrine pancreatic insufficiency; FE‐1, faecal elastase‐1; IBD, inflammatory bowel disease (Crohn's disease and ulcerative colitis); IBS, irritable bowel syndrome; MRI, magnetic resonance imaging; NSAID, non‐steroidal anti‐inflammatory drug; PERT, pancreatic enzyme replacement therapy; PPI, proton pump inhibitor; SIBO, small intestinal bacterial overgrowth; ZES, Zollinger‐Ellison syndrome

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