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Pancreatic Steatosis: What Should Gastroenterologists Know?

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Pancreatic Steatosis: What Should Gastroenterologists Know? JOP. J Pancreas (Online) 2015 May 20; 16(3):227-231. REVIEW ARTICLE Pancreatic Steatosis: What Should Gastroenterologists Know? Varayu Prachayakul1, Pitulak Aswakul2 1Siriraj Gastrointestinal Endoscopy Center, Department of Internal Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand 2Liver and Digestive Institute, Department of Internal Medicine, Samitivej Sukhumvit Hospital, Bangkok, 10120, Thailand ABSTRACT pancreas,When hyperechoic or pancreatic pancreatic steatosis. parenchyma Diagnosis isof observed this condition on endoscopic mostly relies or transabdominal on imaging tools ultrasound, such as magnetic fat infiltration resonance of the imaging, pancreas com is suspected. This condition was first reported by Ogilvie in 1993 and is termed fatty pancreas, pancreatic lipomatosis, non-alcoholic fatty hypotheses regarded the etiology of this condition, listing factors such as viral infections, toxins, and congenital syndromes as possible- causes.puted tomography, Metabolic syndrome or ultrasonography and diabetes rather mellitus than histology. correlated Although with this the condition. condition However, is rare, it otherhas clinical etiologies significance. should alsoThere be are considered multiple creatic steatosis and worsened severity and prognosis of pancreatic cancer, increased complications after pancreatic surgery, and acute pancreatitisto aid specific were treatment. reported. In Gastroenterologistsaddition to a correlation should between be well pancreaticinformed about steatosis this andcondition metabolic for better syndrome, care of relationships these patients. between pan- INTRODUCTION clinical and basic science studies published regarded this Multiple terms have been used to describe fat accumulation to only human studies available in English articles, was in the pancreas, such as pancreatic steatosis, fatty pancreas, carriedcondition. out A for PubMed-library the period between based 2005 search and , Decemberrestricted 2014 . The following individual and combined keywords were used: fatty pancreas, pancreatic steatosis, pancreatic pancreaspancreatic (NAFP). lipomatosis, Gastroenterologists fatty infiltration, should belipomatous informed ofpseudohypertrophy this condition and of itspancreas, clinical andcorrelations. non-alcoholic Here, fatty we pancreas, NAFP. The referenced obtained from the articles’ review the literature regarding this pancreatic condition in fat infiltration, pancreatic lipomatosis, non-alcoholic-fatty terms of epidemiology, characteristics in imaging studies, citations were also reviewed for other potential sources of including treatment and prevention. This condition was articles were obtained. All the case report and case series, etiology, clinical significance, and clinical correlation retrospectiveinformation. From cohort a totalstudies, of cross958 articles section , andonly prospective 94 related higher incidence of fatty pancreas was observed in obese studies which all the abstracts and a total of 72 full text comparedfirst reported to lean in 1993 cadavers by Ogilvie (17% vs.[1] who revealed that a manuscripts were reviewed. Figure 1 shows the diagram to the present, the true incidence of fatty pancreas was still . 9%, respectively). Up forCLINICAL demonstration PRESENTATION, of the review process DIAGNOSIS [5] AND Choi CW et al. et al. IMAGING STUDIES unclarified, however, there were only two studies from evaluation for some[2] and other Seppe reasons PS who had[3] demonstratethe evidence Most of the patients who had pancreatic steatosis or ofas highhyperechogenic as 27.8-46% pancreas. of the patients While who Wong underwent VW et EUSal . fatty pancreas were asymptomatic. They were diagnosed a handful of case reports presented with pancreatic reported that 16.1% of Hongkong-Chinese population by abnormal imaging studies of the pancreas. Only MRIhad pancreatictechnique) steatosis(cut-off level at higher than 10% imaging studies after surgery such as pancreatic of pancreatic fat infiltration which diagnosed by Fat-water transplantationbulging or mass-like or chemotherapy. lesion or abnormal There is pancreaticno gold Received December[4]. 2nd, There 2014 have – Accepted subsequently March 17th, been 2015 many standard for histopathological diagnosis of fatty pancreas Keywords Pancreas due to limited tissue acquisition and few studies in living Correspondence Varayu Prachayakul patients. Therefore, the diagnosis of pancreatic steatosis Department of Internal Medicine mainly depends on noninvasive imaging studies using Faculty of Medicine, Siriraj Hospital transabdominal ultrasound (US), computed tomography Mahidol University, Bangkok, 10700, Thailand Phone +66818654646 (CT), magnetic resonance imaging (MRI), and recently, Fax EUS. The typical fatty tissue characteristic revealed by E-mail [email protected] US is diffuse hyperechoic pancreatic parenchyma when +6624115013 JOP. Journal of the Pancreas - http://www.serena.unina.it/index.php/jop - Vol. 16 No. 3 – May 2015. [ISSN 1590-8577] 227 JOP. J Pancreas (Online) 2015 May 20; 16(3):227-231. Etiology steatosisMore than varies90% of from population congenital would relatedhave less to than acquired 5% of fat infiltration in pancreas [13]. The etiology of pancreatic 1) obesity and metabolic syndrome; there are some conditions. However, it can be classified into 4 groups: diagnosed as fatty pancreas from endoscopic ultrasound, MRIclinical or CTstudies scan [2-5,which 14] demonstrated regarded the that patients high bodywho masswere index(BMI) and metabolic syndrome were associated with fatty pancreas (Odd Ratio(OR) 1.05-3.13 while non alcoholic fatty liver showed a 14-fold correlation with waspancreatic a rare steatosisautosomal [15]. recessive 2) congenital disorders syndromes characterized such as cystic fibrosis, Shwachman–Diamond syndrome(which by association of pancreatic exocrine insufficiency ,due to syndrome(afat infiltration rare and genetic atrophy, disorder bone marrow characterized dysfunction by short and skeleton abnormalities) [16-20], and Johanson–Blizzard Figure 1. The diagram for demonstration of the review process sensorineural hearing lost, hypoplatic nasal alae, scalp stature, mental retardation, pancreatic insufficiency, compared to the kidneys. However, if the ultrasonographer and medications such as steroid therapy and gemcitabine would conclude that hyperechogenic pancreas found on chemotherapydefect and dental which abnormalies) all of these [21,medication 22]. 3) related toxic agents cases transabdominal ultrasonography were all fatty pancreas, they might be wrong. Gullo et al were reported case only [23-25] , and 4) other rare causes . [6] reported , a small virus infection that could cause pancreatic steatosis hyperechogenic pancreas from ultrasound was found to such as reoviral infection [26], human immunodeficiency study of 9 patients, that none of the patients who had regular MRI technique( which in the authors opinion it was through a combination of malnutrition-related and viral- have more fat infiltration in the pancreas when using a summary of etiologies of pancreatic steatosis are provided inrelated Table effects, 1. and chronic hepatitis B infection [27]. A intensity of the pancreas when compared to the spleen on aalso CT notscan very can alsosensitive). indicate pancreaticWhile hypo-attenuation fat accumulation. signal To Clinical Impact of Fatty Pancreas The prevalence of NAFP was reported to be around 16% in invasive, method to identify fat accumulation in visceral organs,our knowledge, but there MRI are is consideredalso other the techniques most accurate which , non- are more sensitive for detection of fat component in the tissue Hong Kong Chinese population [4]. There was a statistically significant correlation between NAFP and non-alcoholic reduction in signal intensity of the fat replacement of fatty liver disease (NAFLD) (odds ratio [OR]=2.22; 95% including T2-weighted imaging which shows prominent confidence interval [CI], 1.88–2.57; P<0.001), central obesity (OR = 2.16; 95% CI, 1.85–2.52; P<0.001), age (OR pancreas in opposed - phase MR imaged [7], chemical decomposition with echo asymmetry and least squares aminotransferase= 1.05; 95% CI, 1.04–1.05; and alanine P<0.001), transaminase hypertriglyceridemia level elevation shift imaging [8], fat-water MRI, and study of iterative (OR = 1.32; 95% CI, 1.13–1.55; P=0.01), aspartate excitation technique, which combines chemical shift estimation(IDEAL technique)[4-6], a spectral-spatial Data(OR =suggest 1.29; 95%that fatCI, accumulation1.13–1.70; P=0.02), in the pancreasand diabetes may mellitus (DM) (OR = 1.59; 95% CI, 1.30–1.95; P<0.001). selectivity with simultaneous slice-selective excitation in (NASH). Patel et al combination with another technique based on double-echo pancreaticlead to similar fat processescontent correlated as in non-alcoholic with a higher steatohepatitis grade of werechemical all shiftdeveloped gradient-echo for early MR and provides accurate in- anddiagnosis opposed- of . demonstrated in 2013 [28] that higher phase images simultaneously [9]. All these MRI techniques but did not correlate with body mass index (BMI) or pancreatic steatosis is histopathology which usually DM.hepatic This steatosis study also in patients demonstrated with biopsy-proven no difference NAFLD, in the acquiredfat within from internal post organs.mortem Theor surgicaldefinitive specimens. diagnosis The of distribution of fatty content among the pancreatic portions histopathology of pancreatic
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