A close look at recent guidelines for the consensus management of pancreatic exocrine insufficiency

In August’s blog we have decided to take a detailed look at one of the most impactful papers published in BMJOG within the last 12 months. Phillips and colleagues detail practical guidelines on the consensus management of pancreatic exocrine insufficiency. This widely shared article provides concise, evidence-based, recommendations for managing patients with pancreatic exocrine insufficiency (PEI), directly translating to clinical practice.

Additionally, the last 12 months has seen an increase in submissions, views and publications for BMJOG, we are grateful to authors and reviewers for continuing to raise the profile and quality of the journal. Remember to visit the journal website for continued free access to all articles and keep an eye out for high- profile commissioned articles over the next 12 months.

Back to the article- PEI is a failure of the enzymatic-production of the pancreas and results in malabsorption leading to malnutrition. It often presents with non-specific GI symptoms including steatorrhoea, weight loss, diarrhoea, abdominal pain and bloating, and is associated with increased mortality. The most common causes are cystic fibrosis, post-acute pancreatitis (especially in those with necrosis) and pancreatic cancer (and subsequent to resection). Treatment with enzyme replacement promotes increased quality of life and long-term survival.

The authors reviewed the literature and undertook a standardised consensus process involving 48 experts in pancreatology from the UK. A series of recommendations on diagnosis, initial management, patient education and long-term follow-up were agreed on with over 85% consensus for each point. Here I discuss some of the key recommendation but please read the full article for a comprehensive overview on the topic.

The authors provide a standardised definition of PEI, ‘reduction of pancreatic exocrine activity in the intestine at a level that prevents normal digestion’. When considering the diagnosis of PEI, the authors recommend a (standardised to water content) faecal pancreatic elastase as a first-line test, despite the gold standard being the direct coefficient of fat absorption. Routine nutritional work-up, including anthropometry and micronutrient levels should be considered as adjuncts to making the diagnosis of PEI. Considering imaging, an CT scan should be performed to rule out a neoplastic cause at the point of diagnosis.

Pancreatic enzyme replacement therapy is the cornerstone of treatment and is associated with improved nutritional status and survival in those patients with PEI related to cystic fibrosis. The dose of pancreatic enzyme replacement therapy should be at least 50,000 units lipase with meals and 25,000 units lipase with snacks, and should be spread out throughout the meal. Doses can be escalated to response, and a fat-restrictive diet is not recommended. Overall, consensus was pancreatic enzyme replacement therapy is extremely safe but further studies in pregnancy and breastfeeding would be useful.

In the follow-up of PEI patients it is vital to ensure signs and symptoms of malnutrition are normalising, and lack of improvement should prompt further investigation and ensuring medication is being taken as prescribed. Despite a lack of direct evidence, monitoring of bone mineral density was deemed important and should be a routine part of ongoing management.

The full guidelines and recommendations are free to access at BMJOG and we highly recommend taking a look.

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