Fat maldigestion with steatorrhoea is the main problem in the management of exocrine pancreatic insufficiency (EPI).¹ When uncoated pancreatic enzyme extracts are used for therapy, inhibition of gastric acid secretion is frequently needed to avoid acid mediated lipase inactivation.^2–4 Modern pancreatic enzyme preparations in the form of enteric coated mini-microspheres were developed to avoid this problem but fat maldigestion still persists in a relevant proportion of patients with this therapy. Patients with EPI frequently have low pancreatic bicarbonate secretion which may become insufficient to neutralise the acidity of the chyme emptied from the stomach.⁵ Bile acids precipitate at acidic pH, and lipase is only released from coated spheres once the pH is higher than 5.0, which occurs in distal segments of the gut in some EPI patients.^6,7

We hypothesise that potent inhibition of gastric acid secretion, by avoiding bile acid precipitation and allowing lipase release within the proximal gut, may improve the therapeutic efficacy of enteric coated pancreatic enzymes for EPI. To test this hypothesis, a prospective, …