Exocrine Pancreatic Insufficiency: Seen but Not Recognized?

David A. Johnson, MD

Disclosures

May 21, 2014

In This Article

Making the Diagnosis

How do you make the diagnosis?

When I was a fellow, we did what were called "tube tests," which was when we induced secretions by secretin or CCK and collected the pancreatic juice and analyzed it for quantitative amounts of the secretions. It's not a practical test anymore.

For the most part, we make the diagnosis on a clinical basis, combined with either blood tests (a serum trypsin level less than 20 µg/L) or fecal elastase, which is a test that I use more frequently. A fecal elastase less than 200 µg/g of stool is the typical standard for thinking about pancreatic insufficiency.

It is also important to make some type of structural assessment, such as the endoscopic ultrasound, although I don't personally use it. It does not expose patients to radiation and gives you a nice parenchymal evaluation, as well as ductal anatomy.

Magnetic resonance cholangiopancreatography (MRCP) is better than a CT of the pancreas for evaluating ductal anatomy. Remember that MRCP does not show calcium, so if you are looking for calcific change, a CT may be better.

An endoscopic retrograde cholangiopancreatography (ERCP) is best for determining the ductal anatomy, but it is associated with obvious risks for complications, such as infection and pancreatitis.

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