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Majority of patients with <jats:styled-content style=\"fixed-case\">PEI<\/jats:styled-content> were undiagnosed or undertreated. Inadequately treated or subclinical severe <jats:styled-content style=\"fixed-case\">PEI<\/jats:styled-content> causes malnutrition and may pose the patients at risk of premature atherosclerosis and cardiovascular events. Indication of pancreatic enzyme replacement therapy (<jats:styled-content style=\"fixed-case\">PERT<\/jats:styled-content>) is patients with severe <jats:styled-content style=\"fixed-case\">PEI<\/jats:styled-content>, as indicated by the presence of steatorrhea, diarrhea, weight loss, fecal fat &gt;\u20097\u2009g\/day, <jats:sup>13<\/jats:sup><jats:styled-content style=\"fixed-case\">C<\/jats:styled-content>\u2010mixed triglyceride breath test &lt;\u200929%, fecal elastase &lt;\u2009100\u2009ug\/g stool, imaging or endoscopic findings of pancreatic ductal dilatation or calculi, and eight endosonographic criteria of <jats:styled-content style=\"fixed-case\">CP<\/jats:styled-content>. The mainstay treatment of <jats:styled-content style=\"fixed-case\">PEI<\/jats:styled-content> is <jats:styled-content style=\"fixed-case\">PERT<\/jats:styled-content>. Dietary fat restriction is unnecessary. <jats:styled-content style=\"fixed-case\">PERT<\/jats:styled-content> with lipase &gt;\u200940\u2009000\u2009<jats:styled-content style=\"fixed-case\">U<\/jats:styled-content> per meal is recommended. Enteric\u2010coating may be preferred to conventional enzymes because of the availability of high\u2010dose preparations and no need of acid suppression co\u2010therapy. Administration of enzymes with meals is proven to be the most effective regimen. Response to <jats:styled-content style=\"fixed-case\">PERT<\/jats:styled-content> should be measured by the improvement of patients' symptoms, nutritional status, and, in selected cases, by fecal fat or <jats:sup>13<\/jats:sup><jats:styled-content style=\"fixed-case\">C<\/jats:styled-content>\u2010mixed triglyceride breath test. Patients unresponsive to <jats:styled-content style=\"fixed-case\">PERT<\/jats:styled-content> should be checked for compliance, increase the dose of lipase to 90\u2009000 units\/meal or co\u2010therapy with proton pump inhibitor. In patient with previous gastrointestinal surgery that may interfere enzyme\u2010food mixing, opening the capsules and administering the enzyme granules with meals. Finally, search for small intestinal bacterial overgrowth syndrome and other causes of small bowel malabsorption.<\/jats:p>","DOI":"10.1111\/jgh.12406","type":"journal-article","created":{"date-parts":[[2013,11,20]],"date-time":"2013-11-20T05:21:47Z","timestamp":1384924907000},"page":"99-102","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":41,"title":["Maldigestion from pancreatic exocrine insufficiency"],"prefix":"10.1111","volume":"28","author":[{"given":"Supot","family":"Pongprasobchai","sequence":"first","affiliation":[{"name":"Division of Gastroenterology Department of Medicine Faculty of Medicine Siriraj Hospital Mahidol University  Bangkok Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2013,11,19]]},"reference":[{"key":"e_1_2_7_2_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.cgh.2007.01.004"},{"key":"e_1_2_7_3_1","first-page":"158","article-title":"Oral pancreatic enzyme substitution therapy in chronic pancreatitis: is clinical response an appropriate marker for evaluation of therapeutic efficacy?","volume":"11","author":"Dominguez\u2010Munoz JE","year":"2010","journal-title":"JOP"},{"key":"e_1_2_7_4_1","doi-asserted-by":"publisher","DOI":"10.1097\/00006676-199401000-00021"},{"key":"e_1_2_7_5_1","doi-asserted-by":"publisher","DOI":"10.1007\/BF01393767"},{"key":"e_1_2_7_6_1","first-page":"759","article-title":"Increased prevalence of aortic calcification in chronic pancreatitis","volume":"91","author":"Gullo L","year":"1996","journal-title":"Am. 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