Unmasking Hidden Pancreatic Exocrine Insufficiency Pei in Diabetes: The Case for Early Detection and Treatment

Abstract

Background:

The pancreas serves both endocrine and exocrine functions essential for maintaining glucose and nutrient homeostasis. Emerging evidence indicates a significant overlap between diabetes mellitus and pancreatic exocrine insufficiency (PEI), yet the clinical recognition of this association remains limited.

Aim: This dissertation systematically reviews existing literature to evaluate the relationship between endocrine and exocrine pancreatic dysfunction and to establish the need for active screening of diabetic patients for PEI to prevent nutritional deficiencies and improve glycemic control through pancreatic enzyme replacement therapy (PERT).

Methods: A comprehensive search was performed using Medline, TRIPdatabase, Cochrane Library, and Embase via the NHS Wales e-Library for Health. Studies published in the past 20 years on human subjects were included. The selected studies investigated the prevalence of PEI among diabetic patients, correlations with biochemical markers, diagnostic accuracy of fecal elastase-1 testing, and therapeutic outcomes of PERT.

Results:

Multiple studies have demonstrated a wide prevalence range of PEI—26–74% in type 1 diabetes and 10–56% in type 2 diabetes—depending on diagnostic methods. Type 1 diabetics consistently exhibited lower fecal elastase concentrations than type 2 diabetics. Although the fecal elastase-1 test offers a non-invasive and cost-effective diagnostic option, its sensitivity decreases for mild-to-moderate PEI. Evidence regarding the clinical benefits of PERT in diabetics remains inconclusive, with randomized trials showing minimal improvement in glycemic parameters. Nevertheless, unrecognized PEI contributes to malabsorption, micronutrient deficiencies, and erratic glycemic control, exacerbating diabetes-related complications.

Conclusion:

PEI is a prevalent but underdiagnosed comorbidity in diabetes. Routine screening for PEI using fecal elastase-1 testing may aid in the early identification of patients at risk for malnutrition and poor glycemic outcomes. Further large-scale randomized controlled trials are warranted to clarify the therapeutic benefits of PERT in diabetic populations