Synopsis
Recognise pancreatic maldigestion before advanced malnutrition, identify the pancreatic cause, and optimise enzyme replacement with food, dietetic support and objective nutritional follow-up.
- Pancreatic exocrine insufficiency is inadequate delivery or activity of digestive enzymes and bicarbonate, causing maldigestion, weight loss and micronutrient consequences.
- Common settings include chronic pancreatitis, pancreatic cancer, pancreatic resection, cystic fibrosis and severe or necrotising acute pancreatitis; always identify the underlying pancreatic disease.
- Steatorrhoea is a late and variably recognised sign; bloating, abdominal discomfort, diarrhoea, excess wind, difficulty maintaining weight and fat-soluble vitamin deficiency may appear earlier.
Key red flags
New painless jaundice, progressive weight loss, palpable gallbladder or new diabetes with pancreatic symptoms requires urgent pancreatic cancer assessment rather than PERT alone.
Investigation priorities
Estimate pancreatic exocrine secretion using a practical non-invasive stool test.
Management branches
Maldigestion, nutritional decline or a high-risk pancreatic condition raises suspicion of exocrine failure.
- Clarify stool character, weight, diet, alcohol, smoking, pancreatitis, surgery, cancer symptoms, diabetes and current enzyme timing, then examine nutrition and jaundice.
- Use formed-stool faecal elastase when uncertainty remains, while commencing PERT empirically in a high-probability condition where delay would harm nutrition.
Key medicines
Pancreatin pancreatic enzyme replacementUsually start at least 50,000 lipase units with meals and 25,000 with snacks, then titrate.
Proton pump inhibitor adjunctStandard licensed acid-suppression regimen trialled after adequate PERT timing and dose review.