Published online Nov 6, 2021. doi: 10.12998/wjcc.v9.i31.9469
Peer-review started: April 1, 2021
First decision: June 23, 2021
Revised: July 3, 2021
Accepted: September 19, 2021
Article in press: September 19, 2021
Published online: November 6, 2021
Pancreatic exocrine insufficiency (PEI) is said to be associated with numerous conditions both within and outside the gastrointestinal (GI) system. The majority of research has been concerned with conditions that reduce the volume of functioning pancreatic tissue or prevent adequate drainage to the small bowel, such as chronic pancreatitis, cystic fibrosis, pancreatic cancer and pancreatic resection. However, the evidence base supporting an association with extra-pancreatic conditions, such as coeliac disease, diabetes mellitus and congestive cardiac failure, is heterogeneous.
To strengthen the evidence base by studying all previously reported associations with PEI in a large cohort of outpatients.
A single-centre retrospective study was performed. General gastroenterology outpatients tested for PEI with faecal elastase-1 (FE1) were identified and information retrieved from the electronic patient record. PEI was defined as FE1 < 200 μg/g. Patients already taking pancreatic enzyme replacement therapy were excluded. Multiple imputation was used to handle missing data. Univariable logistic regression was used to study which presenting symptoms predicted PEI. Multivariable logistic regression was used to explore the relationship between all previously reported associations and PEI.
Of 1027 patients were included. 182 patients (17.7%) were diagnosed with PEI. Steatorrhoea [odds ratios (OR): 2.51, 95% confidence intervals (CI): 1.58-3.98] and weight loss (OR: 1.49, 95%CI: 1.08-2.06) were the only presenting symptoms that predicted PEI. Chronic pancreatitis (OR: 7.98, 95%CI: 3.95-16.15), pancreatic cancer (OR: 6.58, 95%CI: 1.67-25.98), upper GI surgery (OR: 2.62, 95%CI: 1.32-5.19), type 2 diabetes (OR: 1.84, 95%CI: 1.18-2.87), proton pump inhibitor therapy (OR: 1.87, 95%CI: 1.25-2.80) and Asian ethnicity (OR: 2.11, 95%CI: 1.30-3.42) were significantly associated with PEI in the multivariable analysis. None of the other historically reported associations with PEI were significant after adjustment for the other variables included in our multivariable analysis.
PEI is common in patients with chronic pancreatitis, pancreatic cancer, upper GI surgery and type 2 diabetes. Proton pump inhibitor therapy may also be associated with PEI or a false positive FE1.
Core Tip: Pancreatic exocrine insufficiency (PEI) is associated with chronic pancreatitis, pancreatic cancer, previous upper gastrointestinal surgery and type 2 diabetes. There should be a low threshold for testing for PEI in these patients. Proton pump inhibitor therapy may also be associated with PEI, or a false positive faecal elastase-1 (FE1). Until further evidence becomes available, we recommend repeat testing after a washout period. Steatorrhoea and weight loss were the only symptoms that predicted PEI in our cohort. Therefore, the diagnostic yield of FE1 testing in patients with non-specific presentations, such as bloating, is likely to be low.