Table 1

Prevalence of PEI, potential value of PERT and recommendations for less common causes of PEI

ConditionPrevalence of abnormal FEL-1Benefit of pancreatic enzyme supplementationRecommendation
DM83 84 158 162–164Type 1: 26%–44%
Type 2: 12%–20%
One RCT showing reduction in frequency of hypoglycaemiaStatement 2.4: Patients with DM may have PEI; however, the exact prevalence is not clear. Those with relevant symptoms should be offered PERT and investigated for a pancreatic pathology (grade 2C; 94% agreement)
Elderly populations87 165 16611.5%–20% in patients 50–80 years of age
1.5% in patients over 90 years of age
No treatment studies reportedStatement 2.5.1: Ageing populations may have an increased prevalence of PEI and, therefore, should be considered for testing, particularly if presenting with unexplained weight loss or diarrhoea (GPP; 88% agreement)
Advanced renal disease167 16810%–48%No treatment studies reportedStatement 2.5.2: Patients with renal disease and rheumatological conditions may have an increased prevalence of PEI but further studies are needed before routine testing can be recommended (GPP; 95% agreement)
Sjögren’s syndrome1694% in secondary Sicca syndromeNo treatment studies reported
Coeliac disease170–172Around 30% with diarrhoeaOne RCT showing benefit for 3 months after diagnosis. One open-label study showing benefit in those with persistent diarrhoeaStatement 2.5.3: Patients with coeliac disease on a gluten-free diet, but still experiencing diarrhoeal symptoms, should be investigated for PEI and treated with PERT if positive results are obtained. This should be reviewed at least annually as treatment may not need to be long term (grade 1B; 100% agreement)
IBS-D103 1046.1%–8.6%One open-label study showing improved pain, stool frequency and consistencyStatement 2.5.4: PEI should be considered in patients with IBS-D. The role of PERT in this group is not fully understood (grade 2C; 95% agreement).
IBD173 17419%–30%No treatment studies reportedStatement 2.5.5: Patients with inflammatory bowel disease and continued diarrhoeal symptoms should be investigated for PEI (grade 2B; 100% agreement)
HIV175 17623%–54%Open-label studies showing improvement in diarrhoea and fat malabsorptionStatement 2.5.6: Patients with HIV presenting with steatorrhoea, diarrhoea or weight loss should be investigated for PEI and offered PERT if positive results are obtained (grade 2B; 88% agreement)
Alcohol-related liver disease177–1807%–20%No treatment studies reportedStatement 2.5.7: There may be an increased prevalence of PEI in patients with alcohol-related liver disease but the role of PERT in this group has not been examined (GPP; 89% agreement)
Somatostatin analogues18124% after a median of 2.9 months of therapyNo treatment studies reportedNo statement
  • See online supplemental material for more detail.

  • FEL-1 faecal elastase-1; DM, diabetes mellitus; GPP, good practice point; IBD, inflammatory bowel disease; IBS-D, diarrhoea-predominant irritable bowel syndrome; PEI, pancreatic enzyme insufficiency; PERT, pancreatic enzyme replacement therapy; RCT, randomised controlled trial.