Whitcomb David C, Duggan Sinead N, Martindale Robert, Lowe Mark, Stallings Virginia A, Conwell Darwin, Barkin Jodie A, Papachristou Georgios I, Husain Sohail Z, Forsmark Christopher E, Kaul Vivek
Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
Department of Cell Biology and Molecular Physiology, University of Pittsburgh, Pittsburgh, Pennsylvania.
Gastro Hep Adv. 2022 Nov 15;2(3):395-411. doi: 10.1016/j.gastha.2022.11.008. eCollection 2023.
Exocrine pancreatic insufficiency (EPI) is a clinically defined syndrome based on the physician's assessment of a patient's maldigestion. However, current clinical definitions are inadequate in determining (1) the threshold of reduced pancreatic digestive enzyme secretion that determines "pancreatic insufficiency" in an individual patient; (2) the role of pancreatic function tests; (3) effects of differing metabolic needs, nutrition intake, and intestinal function/adaptation (4) when pancreatic enzyme replacement therapy is needed; and (5) how to monitor and titrate multiple therapies. Experts and key opinion leaders were invited to to discuss and help clarify mechanistic issues critical to defining EPI and to address misconceptions and barriers limiting advancements in patient care. Clinically EPI is defined as inadequate delivery of pancreatic digestive enzymes to meals to meet nutritional needs and is reversed with appropriate treatment. A new mechanistic definition of EPI was proposed that includes the disorders and : (1) EPI is a disorder caused by failure of the pancreas to deliver a minimum/threshold level of specific pancreatic digestive enzymes to the intestine in concert with ingested nutrients, followed by enzymatic digestion of a series of individual snacks and meals over time to meet nutritional and metabolic needs, given (a) the specific macronutritional and micronutritional needs; (b) nutrient intake; (c) exocrine pancreatic function; and (d) intestinal anatomy, function, diseases, and adaptative capacity. (2) EPI is characterized by variable deficiencies in micronutrients and macronutrients, especially essential fats and fat-soluble vitamins, by gastrointestinal symptoms of nutrient maldigestion and by improvement or correction of nutritional state with lifestyle changes, disease treatment, optimized diet, dietary supplements, and/or administration of adequate pancreatic enzyme replacement therapy. EPI is complex and individualized and multidisciplinary approaches are needed to optimize therapy. Better pancreas function tests and biomarkers are needed to diagnose EPI and guide treatment.
外分泌性胰腺功能不全（EPI）是一种基于医生对患者消化功能不良评估的临床定义综合征。然而，目前的临床定义在确定以下方面存在不足：（1）决定个体患者“胰腺功能不全”的胰腺消化酶分泌减少阈值；（2）胰腺功能测试的作用；（3）不同代谢需求、营养摄入以及肠道功能/适应性的影响；（4）何时需要胰腺酶替代疗法；（5）如何监测和调整多种治疗方法。邀请了专家和关键意见领袖来讨论并帮助阐明对定义EPI至关重要的机制问题，并解决限制患者护理进展的误解和障碍。临床上，EPI被定义为胰腺消化酶无法充分输送至餐食以满足营养需求，而适当治疗可使其逆转。提出了一种新的EPI机制定义，包括以下紊乱情况：（1）EPI是一种由胰腺未能将特定胰腺消化酶的最低/阈值水平与摄入的营养物质协同输送至肠道所导致的紊乱，随后随着时间推移，对一系列单独的零食和餐食进行酶消化以满足营养和代谢需求，这取决于（a）特定的宏量营养素和微量营养素需求；（b）营养摄入；（c）外分泌性胰腺功能；以及（d）肠道解剖结构、功能、疾病和适应能力。（2）EPI的特征是微量营养素和宏量营养素存在不同程度的缺乏，尤其是必需脂肪酸和脂溶性维生素，伴有营养物质消化不良的胃肠道症状，并且通过生活方式改变、疾病治疗、优化饮食、膳食补充剂和/或给予足够的胰腺酶替代疗法，营养状况可得到改善或纠正。EPI是复杂且个体化的，需要多学科方法来优化治疗。需要更好的胰腺功能测试和生物标志物来诊断EPI并指导治疗。
