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

PURPOSE OF REVIEW: 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. RECENT FINDINGS: 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. SUMMARY: 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.