Diagnosis and management of pancreatic exocrine insufficiency

Mehrdad Nikfarjam, Jeremy S Wilson and Ross C Smith, Australasian Pancreatic Club Pancreatic Enzyme Replacement Therapy Guidelines Working Group
Med J Aust 2017; 207 (4): . || doi: 10.5694/mja16.00851
Published online: 21 August 2017


Introduction: In 2015, the Australasian Pancreatic Club (APC) published the Australasian guidelines for the management of pancreatic exocrine insufficiency ( Pancreatic exocrine insufficiency (PEI) occurs when normal digestion cannot be sustained due to insufficient pancreatic digestive enzyme activity. This may be related to a breakdown, at any point, in the pancreatic digestive chain: pancreatic stimulation; synthesis, release or transportation of pancreatic enzymes; or synchronisation of secretions to mix with ingested food.

Main recommendations: The guidelines provide advice on diagnosis and management of PEI, noting the following:

  • A high prevalence of PEI is seen in certain diseases and conditions, such as cystic fibrosis, acute and chronic pancreatitis, pancreatic cancer and pancreatic surgery.
  • The main symptoms of PEI are steatorrhoea or diarrhoea, abdominal pain, bloating and weight loss. These symptoms are non-specific and often go undetected and untreated.
  • PEI diagnosis is predominantly based on clinical findings and the presence of underlying disease. The likelihood of PEI in suspected patients has been categorised into three groups: definite, possible and unlikely.
  • If left untreated, PEI may lead to complications related to fat malabsorption and malnutrition, and have an impact on quality of life.
  • Pancreatic enzyme replacement therapy (PERT) remains the mainstay of PEI treatment with the recommended adult initial enzyme dose being 25 000–40 000 units of lipase per meal, titrating up to a maximum of 75 000–80 000 units of lipase per meal.
  • Adjunct acid-suppressing therapy may be useful when patients still experience symptoms of PEI on high dose PERT.
  • Nutritional management by an experienced dietitian is essential.


Changes in management as a result of these guidelines: These are the first guidelines to classify PEI as being definite, possible or unlikely, and provide a diagnostic algorithm to facilitate the early diagnosis of PEI and appropriate use of PERT.

  • 1 Austin Health, Melbourne, VIC
  • 2 University of Melbourne, Melbourne, VIC
  • 3 South Western Sydney Clinical School, Liverpool Hospital, UNSW, Sydney, NSW
  • 4 Kolling Institute, Royal North Shore Hospital, University of Sydney, Sydney, NSW



Members of the APC PERT Guidelines Working Group are listed in the full guidelines available at We thank Ergo Advertising for their assistance in creating the flowcharts in this article and editing earlier versions of the manuscript.

Competing interests:

The APC has received unrestricted educational funding from Mylan Pharmaceuticals. There has been no funding directed to any of the authors in relation to this article or the production of the APC guidelines for the management of PEI.

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