A case report highlights exocrine pancreatic insufficiency (EPI) as a potentially overlooked cause of persistent diarrhea after Billroth II gastrectomy. A 49-year-old man developed chronic diarrhea, steatorrhea, weight loss, hypoalbuminemia, and micronutrient deficiencies years after surgery for gastric cancer, despite unrevealing endoscopic, imaging, and stool evaluations. A nutrition-focused assessment raised suspicion for fat malabsorption, and fecal pancreatic elastase was 23.8 µg/g, consistent with severe EPI. Pancreatic enzyme replacement therapy (PERT), combined with nutritional intervention, rapidly improved stool consistency and steatorrhea, while serum albumin and body weight subsequently recovered.

For nurse practitioners and physician associates evaluating patients with persistent postgastrectomy diarrhea, particularly when steatorrhea, weight loss, or nutritional abnormalities are present, this case underscores the value of considering EPI even when structural testing is unrevealing. Fecal elastase offered a noninvasive way to confirm the diagnosis and guide treatment. The authors emphasize that routine PERT is not indicated after gastrectomy. However, persistent diarrhea with evidence of fat malabsorption should prompt evaluation for a potentially reversible cause. Because this is a single case report, broader studies are needed to define the role of EPI screening and PERT after gastric surgery.

Reference: Kang M, Ju DL, Kim S, Song J, Kim Y. Exocrine pancreatic insufficiency as an overlooked cause of chronic diarrhea after Billroth II gastrectomy identified through nutrition-focused assessment: a case report. Clin Nutr Res. 2026 Apr;15(2):117-121. doi: 10.7762/cnr.2026.0012. Epub 2026 Apr 30. PMID: 42136406; PMCID: PMC13176657.

A retrospective population-based study of 210 patients receiving first-line chemotherapy for advanced pancreatic cancer examined whether pancreatic enzyme replacement therapy (PERT) dose was associated with skeletal muscle loss. Among 81 PERT users, patients were classified as receiving a low estimated dose (<75,000 USP lipase units/day) or high dose (≥75,000 units/day). Muscle loss occurred in 88% of the low-dose group compared with 58% of the high-dose group and 67% of patients not receiving PERT. After adjustment for disease stage, chemotherapy regimen, and tumor response, low-dose PERT was associated with 5.4-fold greater odds of muscle loss compared with high-dose PERT. Mean changes in muscle, adipose tissue, and weight, however, did not differ significantly between dose groups.

These findings suggest that when exocrine pancreatic insufficiency (EPI) is suspected in patients with advanced pancreatic cancer, simply prescribing PERT may not be enough. Adequate dosing and ongoing assessment of use may be important. Patients in the low-dose group were initially prescribed a median 60,000 units/day and consumed an estimated 44,931 units/day, compared with 120,000 and 138,889 units/day, respectively, in the high-dose group. Because the study was retrospective, patients were not randomized by dose and investigators lacked detailed symptoms, dietary intake, and adherence data, so the findings cannot establish that higher-dose PERT directly prevents muscle loss. Still, the results support closer attention to PERT dosing, follow-up, and nutritional status in patients with pancreatic cancer and suspected EPI.

Reference: Klassen PN, Mazurak VC, Baracos V, et al. Dose optimization of pancreatic enzyme replacement therapy is essential to mitigate muscle loss in patients with advanced pancreatic cancer and exocrine pancreatic insufficiency. Clin Nutr. 2024 Aug;43(8):1900-1906. doi: 10.1016/j.clnu.2024.06.037. Epub 2024 Jul 4. PMID: 38991415.

A systematic literature review of 71 publications highlights the substantial clinical and quality-of-life burden associated with exocrine pancreatic insufficiency (EPI) across conditions including chronic pancreatitis, cystic fibrosis, acute pancreatitis, diabetes, and pancreatic surgery. Reported prevalence varied widely according to the underlying disease and diagnostic approach, and EPI was consistently associated with malabsorption-related symptoms such as weight loss, diarrhea, steatorrhea, and impaired nutritional status. Studies examining patient-reported outcomes also found lower quality-of-life scores among patients with EPI, particularly in physical functioning and gastrointestinal symptoms.

Treatment with pancreatic enzyme replacement therapy (PERT) was associated with improvements in symptoms and quality-of-life measures and reduced weight loss in several studies, although outcomes and assessment methods varied. The review also identified a meaningful economic burden, with higher treatment costs and greater healthcare resource use reported among patients with EPI and those with more severe disease. However, relatively few studies focused exclusively on EPI, particularly for quality-of-life and economic outcomes, highlighting the need for more standardized research to better define the full burden of disease and impact of treatment.

Reference: Chu P, Mioc J, Henry O, O'Donovan P. The clinical, economic, and humanistic burden of treatments for exocrine pancreatic insufficiency and cost-effectiveness of treatments: A systematic literature review. Medicine (Baltimore). 2024 Aug 16;103(33):e39224. doi: 10.1097/MD.0000000000039224. PMID: 39151540; PMCID: PMC11332733.