Clinical Practice Update on the Evaluation, Diagnosis, and Management of Pancreatic Exocrine Insufficiency: Expert Review
Turkish gastroenterologists · 2026 · Türkiye
Source and licence
- Authors
- Orhan Sezgin, Dilek Oğuz, Müjde Soytürk et al.
- Title
- Clinical Practice Update on the Evaluation, Diagnosis, and Management of Pancreatic Exocrine Insufficiency: Expert Review
- Journal
- The Turkish Journal of Gastroenterology, 2026
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC13182929
Licence statement of the original publication
Content of this journal is licensed under a Creative Commons Attribution 4.0 International License.
This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Definition
- Statement 1PEI is the condition in which exocrine pancreatic secretions (pancreatic enzymes and bicarbonate) are not synthesized, secreted, and/or activated at adequate levels.
- Statement 2• PEI can occur due to both pancreatic and extrapancreatic causes. • The main pancreatic causes are CP, acute pancreatitis (AP), pancreatic cancer, CF, and pancreatic surgery. • Extrapancreatic causes include diabetes mellitus (DM), inflammatory bowel disease (IBD), celiac disease, human immunodeficiency virus (HIV) infection, GI surgery, aging, and use of somatostatin and its analogs. • The most common cause in adults is CP and in children it is CF.
- Statement 3The manifestations of PEI may include diarrhea, steatorrhea, abdominal distention, gas, bloating, abdominal pain, and/or weight loss.
Diagnosis
- Statement 4• In patients with symptoms suggestive of PEI and/or underlying pancreatic disease, the diagnosis is based on a combination of nutritional assessment, standardized patient-reported questionnaires, pancreatic imaging methods, and pancreatic function tests. However, no definitive diagnostic criteria for PEI have been established. • In clinical practice, the use of direct invasive tests for the diagnosis of PEI is not recommended. • Fecal elastase-1 or 13C-mixed triglyceride (13C-MTG) breath tests can be used as noninvasive diagnostic tests. The FE-1 test is recommended because of its accessibility and ease of application. • Imaging methods have no role in the diagnosis of PEI but are valuable in investigating its etiology.
Treatment
- Statement 5Every patient diagnosed with PEI should be treated.
- Statement 6Preparations containing a combination of amylase, lipase, and proteases should be used.
Dosing Principles
- Statement 7For adult patients, the starting PERT dose should be 40 000-50 000 lipase units with main meals and 20 000-25 000 units with snacks. Although there is no established upper dose limit for treatment, it is recommended not to exceed 10 000 lipase units/kg/day.
- Statement 8There are no major side effects associated with PERT.
- Statement 9• PERT should be integrated with optimal nutritional strategies. • If the patient’s symptoms do not improve, fiber restriction may be required. • Fat restriction is not recommended; the use of medium-chain triglycerides (MCT) may be beneficial. • Levels of fat-soluble vitamins and micronutrients should be monitored at regular intervals, and deficiencies should be replaced.
- Statement 10.1In the treatment of CF patients with PEI, a general approach should be applied, and dosing should be done according to age and weight.
- Statement 10.2In the treatment of PEI secondary to pancreatic cancer, the general approach and standard-dose PERT should be applied.
- Statement 10.3In the treatment of PEI secondary to pancreatic surgery, the general approach and standard-dose PERT should be applied.
- Statement 10.4In the treatment of PEI secondary to DM, the general approach and standard-dose PERT should be applied.
- Statement 10.5In the treatment of PEI secondary to celiac disease, the general approach and standard-dose PERT should be applied.
- Statement 10.6In the treatment of PEI secondary to IBD, the general approach and standard-dose PERT should be applied.
- Statement 10.7In the treatment of PEI in geriatric population, the general approach and standard-dose PERT should be applied.
- Statement 10.8In the treatment of PEI in pregnancy, the general approach and standard-dose PERT should be applied.
- Statement 11Both clinical and laboratory criteria should be concurrently assessed when monitoring treatment response and determining appropriate dose adjustments.
- Statement 12Dose adjustment should be made in clinical situations where treatment is insufficient.
Abstract
Pancreatic exocrine insufficiency (PEI) is characterized by inadequate synthesis, secretion, and/or activation of exocrine pancreatic secretions. This guideline has been developed to assist clinicians and researchers in understanding the definition, etiopathogenesis, epidemiology, diagnosis, treatment, and follow-up of PEI based on the current literature. All statements within this review were developed through consensus among the authors based on a comprehensive literature review.
Contents of the original publication
The section headings of the original.
- Introduction
- Methodology
- Results
- Definition
- Diagnosis
- Treatment
- Dosing Principles
- Summary
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