Exocrine pancreatic insufficiency in adults: A shared position statement of the Italian association for the study of the pancreas

Table 3 Indirect diagnostic tests for evaluating pancreatic exocrine insufficiency

Test	In favour	Against
CFA	Gold standard	72 h stool collection; 100 g standard diet; no simultaneous PERT; not pancreas specific
Acid steatocrit	Linear correlation with CFA also in a single sample; Good as screening	High fat diet needed; 24-72 h stool collection is ideal
Fecal elastase 1	Single stool sample; PERT can be continued	Poor sensitivity in mild EPI, watery stools and small bowel disease
13C-mixed triglyceride breath test	Simple; Also for mild forms of EPI and therapy assessment	Requires further validation
Fecal chymotrypsin	Good for compliance control; Single small stool sample	Sensitivity low for clinical practice (chymotrypsin is variably inactivated during intestinal transit); not for mild EPI; watery stools decrease enzyme activity; PERT must be discontinued
Secretin-enhanced magnetic resonance cholangiopancreatograpgy	Morphological and semi-quantitative functional changes	Requires further validation
Nutritional status (magnesium < 2.05 mg/dL, ↓prealbumin, ↓albumin, ↓retinol binding protein, ↓ferritin, ↓hemoglobin)	Simple	Requires further validation

CFA: Coefficient of fat absorption; PERT: Pancreatic enzyme supplementation therapy; EPI: Pancreatic exocrine insufficiency.