This evidence-based United European Gastroenterology guideline reframes exocrine pancreatic insufficiency (EPI) as a maldigestion syndrome rather than simply an isolated pancreatic secretory defect. The authors emphasize that normal digestion depends not only on pancreatic enzyme output but also on gastrointestinal anatomy, timing of enzyme delivery, and intraluminal pH. It recommends considering EPI in the right clinical context by combining symptoms, nutritional status, and pancreatic function rather than relying on any single measure. High-risk settings include chronic pancreatitis, cystic fibrosis, pancreatic cancer, acute necrotizing pancreatitis, and prior pancreatic surgery. Symptoms such as steatorrhea, diarrhea, bloating, weight loss, and nutritional deficiencies can support the diagnosis but are not specific on their own. The guideline notes that fecal elastase and 13C-mixed triglyceride breath testing are the main noninvasive tools used in practice. Imaging cannot diagnose EPI directly and direct pancreatic function tests are not recommended for routine EPI diagnosis.

The guideline also stresses that EPI should always be treated with pancreatic enzyme replacement therapy (PERT) as first-line management because it improves fat and protein absorption, symptoms, nutritional status, body weight, and quality of life. Small enteric-coated pancreatin pellets are preferred. Adult starting doses generally begin around 40,000 to 50,000 units of lipase with main meals and half that with snacks, taken with food. If response is incomplete, clinicians should first check adherence and administration, then consider dose escalation, adding a proton pump inhibitor, and evaluating for other conditions that can mimic or coexist with EPI. Overall, the guideline highlights the need for long-term monitoring of symptoms, weight, nutritional markers, vitamins, and bone health. It also calls attention to persistent evidence gaps and the need for more high-quality prospective research across pancreatic and extra-pancreatic causes of EPI.

Reference: Dominguez-Muñoz JE, Vujasinovic M, de la Iglesia D, et al. European guidelines for the diagnosis and treatment of pancreatic exocrine insufficiency: UEG, EPC, EDS, ESPEN, ESPGHAN, ESDO, and ESPCG evidence-based recommendations. United European Gastroenterol J. 2025 Feb;13(1):125-172. doi: 10.1002/ueg2.12674. Epub 2024 Dec 5. PMID: 39639485; PMCID: PMC11866322.

Chronic pancreatitis is described as a progressive fibro-inflammatory disease in which ongoing pancreatic injury leads to irreversible structural damage, loss of exocrine and endocrine function, and a heavy burden of malnutrition. The review emphasizes that malnutrition in chronic pancreatitis is not driven by a single cause. Instead, it results from a combination of exocrine pancreatic insufficiency, chronic inflammation, pain-related reduced oral intake, gastrointestinal dysmotility, small intestinal bacterial overgrowth, and pancreatogenic diabetes. These overlapping problems can lead to weight loss, steatorrhea, sarcopenia, vitamin and mineral deficiencies, osteoporosis, and poorer quality of life. As a result, nutritional decline is both a complication of the disease and a contributor to worse outcomes.

The article argues that diagnosis and management require a broad, integrated approach. Exocrine pancreatic insufficiency should not be diagnosed from a single test alone, but through a combination of symptoms, nutritional findings, clinical history, and pancreatic function testing. Fecal elastase-1 is commonly used in practice despite its limitations in milder disease. Treatment centers on pancreatic enzyme replacement therapy. It also includes high-protein, high-energy nutrition, regular screening and replacement of micronutrient deficiencies, bone health assessment, and individualized dietary strategies rather than automatic long-term fat restriction. The review further highlights the importance of multidisciplinary care, including dietitians and psychosocial support, to improve nutrition, reduce complications, and support long-term quality of life.

Reference: Bruni A, Colecchia L, Dell'Anna G, et al. Nutritional Management in Chronic Pancreatitis: From Exocrine Pancreatic Insufficiency to Precision Therapy. Nutrients. 2025 Aug 22;17(17):2720. doi: 10.3390/nu17172720. PMID: 40944111; PMCID: PMC12430654.

This systematic review and meta-analysis examined the development of exocrine pancreatic insufficiency (EPI) after acute pancreatitis (AP), along with risk factors and use of pancreatic enzyme replacement therapy (PERT). Across 64 studies involving 24,111 patients, EPI was common after AP, affecting 48% of patients at discharge and 22% during follow-up. Rates ranged from about 24% to 35% within the first year and persisted in 27% of patients more than 5 years later. EPI increased with AP severity, but importantly, it could still occur after mild AP. Symptoms varied, with weight loss, diarrhea, abdominal pain, and steatorrhea among the most frequently reported. The analysis also found that alcohol-related AP and necrosectomy were significantly associated with higher odds of developing EPI.

The authors conclude that EPI after AP is both common and underrecognized, and that follow-up screening appears justified even in patients with mild disease. They note that fecal elastase-1 may be a practical first-line screening tool, especially because it can be measured while patients are taking PERT, although interpretation still requires caution. Evidence on PERT after AP remains limited, but existing data suggest it is generally well tolerated and may improve quality of life in some patients. Overall, the review supports closer long-term monitoring after AP, especially in patients with alcohol-induced disease, severe AP, or necrosectomy. It also highlights the need for better standardization of EPI diagnosis and more research on optimal timing and use of PERT.

Reference: Eperjesi O, Bucur M, Rancz A, et al. Risk factors for pancreatic exocrine insufficiency after acute pancreatitis: A systematic review and meta-analysis. Pancreatology. 2026 Mar 3:S1424-3903(26)00121-3. doi: 10.1016/j.pan.2026.03.001. Epub ahead of print. PMID: 41807143.