Skip to main content

Initiating Pancreatic Enzyme Replacement Therapy (PERT) — History and Physical Exam — Clinical Pathway: All Settings

Clinical Pathway for Pancreatic Enzyme Replacement Therapy (PERT) in Children with or at Risk for Exocrine Pancreatic Insufficiency (EPI)

History and Physical Exam

Assess patient for clinical features consistent with EPI and for previous PERT use. Review all current/previous pancreatic enzyme therapy orders. Prominent signs of EPI include:

  • Poor weight gain/linear growth
  • Steatorrhea, loose/frequent stools especially after meals or snacks
  • Foul smelling stools
  • Flatulence
  • Abdominal pain associated with eating
  • Voracious appetite
  • Rectal prolapse
  Considerations Specific Examples
Birth History
  • Gestational age
  • Intrauterine growth status
  • Evaluates for prenatal causes of growth failure
HPI Constitutional Fatigue
Eyes Night blindness
Feeding history
  • Adequate caloric intake
  • GERD symptoms
GI symptoms
  • Bloating, cramping, postprandial distension
  • Steatorrhea
  • Bulky stools
  • Increased frequency of bowel movements
  • Oil droplets in toilet
Growth pattern
  • Poor weight gain/weight loss
  • Linear growth failure
  • Delayed sexual maturity
Family History Family history of disorders related to EPI Known gene mutations or inherited disorders
Past Medical History Abdominal injuries Blunt trauma disrupting the pancreas
Previous surgeries
  • Abdominal surgeries
  • Pancreatectomy
Past illnesses
  • Known pancreatic disorder
  • Recurrent/chronic pancreatitis
  • Disordered bleeding/clotting
Medication history
  • Exposure to chemotherapy or other toxic medications
  • Previous PERT use

Physical Exam

Anthropometric Measurements
  • Height, weight, BMI
  • Evaluate for malnutrition
General Appearance Well-nourished vs wasted
HEENT Syndromic facies, Bitot spots
Cardiovascular Signs of congenital heart disease
Respiratory Work of breathing
Abdominal
  • Abdominal tenderness
  • Hepatosplenomegaly
Musculoskeletal Rickets
Skin and Hair
  • Jaundice, acrodermatitis, ecchymoses
  • Alopecia, dry scaly skin, hair depigmentation
Neurological exam
  • Ataxia
  • Peripheral neuropathy
  • Pseudotumor cerebri

 

Jump back to top