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The AGA's updated best practice advice offers essential guidance on exocrine pancreatic insufficiency, focusing on fecal elastase testing and the vital role of pancreatic enzyme replacement therapy in improving patient health outcomes.
The American Gastroenterological Association (AGA) has issued a new Clinical Practice Update offering vital guidance on the diagnosis and management of exocrine pancreatic insufficiency (EPI)—a condition often missed in routine care, despite its substantial impact on nutrition and quality of life.
EPI occurs when the pancreas fails to release sufficient digestive enzymes, resulting in poor absorption of nutrients. Left untreated, it can arouse substantial malnutrition, fat-soluble vitamin deficiencies, and loss of weight loss. The latest AGA expert review calls attention to the underdiagnosis of this ailment and underscores the importance of early intervention.
Best Practice Advice
1. Be alert to EPI in high-risk individuals, including those with chronic or recurring acute pancreatitis, pancreatic cancer, cystic fibrosis, or a history of pancreatic surgery.
2. Evaluate for EPI in moderate-risk ailments such as celiac disease, Crohn’s disease, prior intestinal surgery, long-term diabetes, or hypersecretory disorders such as Zollinger-Ellison syndrome.
3. Common clinical indicators of EPI encompass greasy stools (with or without diarrhea), weight loss, bloating, frequent gas, deficiencies in fat-soluble vitamins, and signs of protein or calorie malnutrition.
4. The preferred initial diagnostic test is fecal elastase, which must be done on a semi-solid or formed stool sample:
5. Fecal elastase testing remains valid even while patients are on pancreatic enzyme therapy.
6. Fecal fat analysis is not routinely required and must only be done after the patient follows a high-fat diet. Quantitative methods are impractical for regular clinical use.
7. A trial of pancreatic enzymes is not a dependable way to diagnose EPI.
8. Imaging techniques such as magnetic resonance imaging, computed tomography, or endoscopic ultrasound are indeed valuable for identifying pancreatic diseases. But, they cannot confirm EPI presence.
9. Breath tests and direct function tests show potential for EPI diagnosis but are not commonly accessible in the United States.
10. Once EPI is confirmed, pancreatic enzyme replacement therapy (PERT) should commence. Without treatment, EPI can trigger significant fat and nutrient malabsorption, which may impair overall health and well-being.
11. All currently available PERT products come from porcine sources and offer similar effectiveness when matched for enzyme dosage. Acid-suppressing medications may be warranted if using non-enteric–coated forms.
12. PERT must be taken with meals. A starting dose for adults is 40,000 United States Pharmacopeia (USP) units of lipase per main meal and half of that with snacks. Dosage adjustments depend on the meal’s fat content and portion size.
13. Monitor fat-soluble vitamin levels regularly and advocate supplementation as needed.
Dietary guidance includes consuming moderate-fat meals, eating smaller portions more frequently, and evading diets extremely low in fat.
14. Ascertain therapeutic success by looking for:
15. Continue monitoring nutritional health over time by:
By providing this update, the AGA aims to bridge the gap in clinical recognition and ascertain that EPI sufferers receive timely, evidence-informed care that addresses both digestive symptoms and long-term nutritional risks.
Gastroenterology
AGA Clinical Practice Update on the Epidemiology, Evaluation, and Management of Exocrine Pancreatic Insufficiency: Expert Review
David C Whitcomb et al.
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