Diagnosis and management of pancreatic exocrine insufficiency (PEI) in primary care: consensus guidance of a Canadian expert panel

Abstract

Background: Pancreatic exocrine insufficiency (PEI) results in maldigestion due to inadequate activity of pancreatic enzymes in the small bowel. PEI can arise from a variety of medical conditions that reduce enzyme synthesis within the pancreatic parenchyma or from secondary factors that may occur despite optimal parenchymal function, such as pancreatic duct obstruction or impaired or poorly synchronized enzyme release.

Purpose: To provide practical guidance for primary care physicians managing patients who are at risk of PEI or who present with symptoms of PEI.

Methods: For each of six key clinical questions identified by the authors, PubMed searches were conducted to identify key English-language papers up to April 2017. Forward and backward searches on key articles were conducted using Web of Science. Clinical recommendations proposed by the co-chairs (P.D. and C.T.) were vetted and approved based on the authors? consensus.

Findings: The most characteristic symptom of PEI is steatorrhea ? voluminous, lipid-rich stools; other common signs and symptoms include unexplained weight loss and deficiencies of fat-soluble vitamins and other micronutrients. Pancreatic enzyme replacement therapy (PERT) can relieve symptoms and long-term sequelae of PEI. Diagnosis of PEI and initiation of PERT are usually the responsibility of gastroenterology specialists. However, primary care physicians (PCPs) are well positioned to identify potential cases of PEI and to participate in the collaborative, long-term management of patients already seen by a specialist.

Conclusions: In this document, a panel of Canadian gastroenterologists has conducted a critical review of the literature on PEI and PERT and has developed practical diagnostic and treatment recommendations for PCPs. These recommendations provide guidance on identifying patients at risk of PEI, the triggers for PEI testing and referral, and best practices for co-managing patients with confirmed PEI.

Keywords:

• Pancreatic enzymes
• pancreatitis
• cystic fibrosis
• steatorrhea
• maldigestion
• vitamin deficiency

Transparency

Declaration of funding

This manuscript was funded by BGP Pharma ULC.

Declaration of financial/other relationships

C.T. has disclosed that he has received grant/research funding from Medtronic, consultant/advisor fees from Boston Scientific, speakers’ bureau from Cook Endoscopy and other fees from Olympus. P.D., J.-D.B., S.B., F.D. and S.Z.-G. have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article.

CMRO peer reviewers on this manuscript have received an honorarium from CMRO for their review work, and one reviewer declares having acted as an advisor and speaker for Mylan and Abbott Pharmaceuticals.

Acknowledgements

The authors gratefully acknowledge writing and editorial support from Sarah von Riedemann MSc and John Ashkenas PhD (SCRIPT, Toronto, Canada). Their participation in this project was made possible by support from BGP Pharma ULC.