Risk factors for pancreatic exocrine insufficiency after acute pancreatitis: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES: Pancreatic exocrine insufficiency (PEI) may develop after acute pancreatitis (AP). The incidence and predisposing factors are not well described, nor is optimal pancreatic enzyme replacement (PERT) in this setting. We aimed to investigate the proportion, risk factors, and effect of PERT in patients with PEI after AP. METHODS: The study protocol was registered on PROSPERO (CRD42024516403). We systematically searched three databases (PubMed, EMBASE, and CENTRAL) on November 08, 2025. We included studies reporting on risk factors and PERT efficacy in PEI associated with AP. Pooled proportion and odds ratios (OR) with the 95% confidence intervals (CI) were calculated using a random-effects model. RESULTS: We identified 64 eligible articles. PEI occurred in 22% (CI:17-27%) of the 24111 analyzed AP patients. The rate was high at discharge at 48% (CI: 19-79%) but decreased and stabilized at 26% (CI: 17-39%) after the 1st year of follow-up. The rates of PEI were 10% (CI: 5-20%), 24% (CI:13-40%), and 31% (CI: 18-47%) after mild, moderately severe, and severe AP, respectively. The proportion of severe PEI reached 21% (CI: 13-31%) overall, and even following mild AP, severe PEI was observed in 10% (CI:4-22%) of cases. The odds were significantly higher for alcoholic (vs. biliary) AP (OR = 1.89, CI: 1.06-3.37) cases. Necrosis did not significantly increase the risk of PEI (OR = 2.12, CI: 0.54-8.28), but necrosectomy did (OR = 3.09, CI:1.79-5.31). CONCLUSION: PEI affects one in five AP patients in the long term. Alcoholic AP and necrosectomy are risk factors for AP-induced PEI. PEI can develop even after mild AP.