Are we missing early pancreatic dysfunction? Expanding faecal elastase testing beyond pancreatic disease

Pancreatic exocrine insufficiency (PEI) has long been associated with intrinsic pancreatic disease, yet emerging evidence shows it is under-recognized in patients with nonspecific gastrointestinal symptoms. This review summarizes prevalence data, evaluates the performance and utility of faecal elastase-1 (FE-1), highlights the co-existence of PEI with other luminal conditions, and explores the presence of early pancreatic dysfunction among a subset of patients with irritable bowel syndrome (IBS)-type symptoms. Updates from the 2025 European guidelines are discussed.

Population studies estimate PEI prevalence at 11-21% in unselected gastroenterology cohorts. PEI is reported across coeliac disease, inflammatory bowel disease and functional gastrointestinal disorders, where overlapping symptoms can delay diagnosis. A 2025 meta-analysis of FE-1 performance demonstrated high sensitivity for moderate-severe PEI. Cohort data indicates repeat sampling can clarify borderline results. PEI may be an early marker of pancreatic dysfunction in a subset of patients with IBS-type symptoms. Identifying this group may offer opportunities for lifestyle modification with potential long-term benefit.

Collectively, these findings expand the relevance of PEI beyond classical pancreatic disease. Broader, proactive FE-1 testing may allow earlier recognition, which might allow intervention at a potentially modifiable stage of pancreatic dysfunction, accepting the limitations of the test.