Diagnosis and treatment of pancreatic exocrine insufficiency

Table 1 The ¹³C-mixed triglycerides breath test according to Domínguez-Muñoz et al[44]

The patient fasts from midnight

Twenty minutes before the test, 10 mg of metoclopramide is ingested

A baseline breath sample is taken

At time 0, 250 mg of 13C-mixed triglycerides mixed with 16 g of fat on a piece of toasted bread is ingested, together with a glass (200 mL) of water

Breath samples are taken every 15 (or 30) min for 6 h

Finally, 13CO2/12CO2 is measured in collected breath samples by mass spectrometry or isotope-selective nondispersive infrared spectrometry

Table 2 Pancreatic enzyme replacement therapy: How we do it

PERT is started at 50000 lipase units per main meal and 25000 lipase units per snack

The basic concepts of the pathophysiology of PEI and how PERT works are explained to the patient. It is emphasized that PERT should be taken with meals and that the dose should be adjusted to the fat content of the meal

If maldigestion persists, proton pump inhibitors can be added, and the dose is increased to 80000 lipase units per main meal and 40000 lipase units per snack

If PERT is still ineffective, despite the optimization described above, small intestinal bacterial overgrowth is considered, and the evidence for a diagnosis of PEI is revised

PEI: Pancreatic exocrine insufficiency; PERT: Pancreatic enzyme replacement therapy.