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VOLUME 55 , ISSUE 1 ( January-March, 2021 ) > List of Articles

REVIEW ARTICLE

Fatty Pancreas: Clinical Implications

Jimil Shah, Anupam K Singh, Surinder Rana

Citation Information : Shah J, Singh AK, Rana S. Fatty Pancreas: Clinical Implications. J Postgrad Med Edu Res 2021; 55 (1):21-26.

DOI: 10.5005/jp-journals-10028-1427

License: CC BY-NC 4.0

Published Online: 01-03-2021

Copyright Statement:  Copyright © 2021; The Author(s).


Abstract

The fatty pancreas is a newly recognized entity with limited available literature on its risk factors, pathogenesis, diagnosis, and management. Obesity and metabolic syndrome both are emerging pandemic in recent times and the fatty pancreas is closely linked with both of them. Though obesity is one of the most important risk factors for the development of a fatty pancreas, it is not perquisite for the development of same. Radiological investigations are the most commonly used modality for the diagnosis of the fatty pancreas; however, criteria to define fatty pancreas are still not present. Studies have shown that fatty pancreas is associated with metabolic syndrome, acute/chronic pancreatitis, pancreatic exocrine insufficiency, and the development of pancreatic carcinoma. However, none of the associations is proved to have a cause–effect relationship and it requires further exploration in future studies. Though the pathophysiological mechanism of the fatty pancreas is unclear, one can assume that similar to the nonalcoholic fatty liver disease the pathological changes of the fatty pancreas may be reversible. However, the effect of lifestyle modification, weight reduction, and medical therapy in reversing fatty pancreas and its sequelae still requires further exploration in future studies.


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  1. Ward ZJ, Bleich SN, Cradock AL, et al. Projected U.S. State-level prevalence of adult obesity and severe obesity. N Engl J Med 2019;381(25):2440–2450. DOI: 10.1056/NEJMsa1909301.
  2. Luhar S, Timæus IM, Jones R, et al. Forecasting the prevalence of overweight and obesity in India to 2040. PLoS ONE 2020;15(2):e0229438. DOI: 10.1371/journal.pone.0229438.
  3. Ahirwar R, Mondal PR. Prevalence of obesity in India: a systematic review. Diabetes Metab Syndr 2019;13(1):318–321. DOI: 10.1016/j.dsx.2018.08.032.
  4. Kaur J. A comprehensive review on metabolic syndrome. Cardiol Res Pract 2014;2014:943162. DOI: 10.1155/2014/943162.
  5. Lee L, Sanders RA. Metabolic syndrome. Pediatr Rev 2012;33(10):459–468. DOI: 10.1542/pir.33-10-459.
  6. Bi Y, Wang J-L, Li M-L, et al. The association between pancreas steatosis and metabolic syndrome: a systematic review and meta-analysis. Diabetes Metab Res Rev 2019;35(5):e3142. DOI: 10.1002/dmrr.3142.
  7. Dite P, Blaho M, Bojkova M, et al. Nonalcoholic fatty pancreas disease: clinical consequences. Dig Dis 2020;38(Suppl. 2):143–149. DOI: 10.1159/000505366.
  8. Smits MM, van Geenen EJM. The clinical significance of pancreatic steatosis. Nat Rev Gastroenterol Hepatol 2011;8(3):169–177. DOI: 10.1038/nrgastro.2011.4.
  9. Ogilvie RF. The islands of langerhans in 19 cases of obesity. J Pathol Bacteriol 1933;37(3):473–481. DOI: 10.1002/path.1700370314.
  10. Olsen TS. Lipomatosis of the pancreas in autopsy material and its relation to age and overweight. Acta Pathol Microbiol Scand [A] 1978;86A(1-6):367–373. DOI: 10.1111/j.1699-0463.1978. tb02058.x.
  11. Feigelson J, Pécau Y, Poquet M, et al. Imaging changes in the pancreas in cystic fibrosis: a retrospective evaluation of 55 cases seen over a period of 9 years. J Pediatr Gastroenterol Nutr 2000;30(2):145–151. DOI: 10.1097/00005176-200002000-00010.
  12. Lesmana CRA, Pakasi LS, Inggriani S, et al. Prevalence of non-alcoholic fatty pancreas disease (NAFPD) and its risk factors among adult medical check-up patients in a private hospital: a large cross sectional study. BMC Gastroenterol 2015;15(1):174. DOI: 10.1186/s12876-015-0404-1.
  13. Zhou J, Li M-L, Zhang D-D, et al. The correlation between pancreatic steatosis and metabolic syndrome in a Chinese population. Pancreatol 2016;16(4):578–583. DOI: 10.1016/j.pan.2016.03.008.
  14. Wilson JS, Somer JB, Pirola RC. Chronic ethanol feeding causes accumulation of serum cholesterol in rat pancreas. Exp Mol Pathol 1984;41(3):289–297. DOI: 10.1016/0014-4800(84)90016-9.
  15. Altinel D, Basturk O, Sarmiento JM, et al. Lipomatous pseudohypertrophy of the pancreas. Pancreas 2010;39:392–397.
  16. Patel S, Bellon EM, Haaga J, et al. Fat replacement of the exocrine pancreas. AJR Am J Roentgenol 1980;135(4):843–845. DOI: 10.2214/ajr.135.4.843.
  17. Mathur A, Zyromski NJ, Pitt HA, et al. Pancreatic steatosis promotes dissemination and lethality of pancreatic cancer. J Am Coll Surg 2009;208(5):989–994. DOI: 10.1016/j.jamcollsurg.2008.12.026; discussion 994-996.
  18. Kölbel G, Majer MC, Hess CF, et al. The internal echo pattern of the normal pancreas. An assessment of the aging process and body weight dependence by sonographic gray-scale analysis. ROFO Fortschr Geb Rontgenstr Nuklearmed 1987;146(04):415–419. DOI: 10.1055/s-2008-1048513.
  19. Marks WM, Filly RA, Callen PW. Ultrasonic evaluation of normal pancreatic echogenicity and its relationship to fat deposition. Radiology 1980;137(2):475–479. DOI: 10.1148/radiology.137.2.7433680.
  20. Glaser J, Stienecker K. Pancreas and aging: a study using ultrasonography. Gerontology 2000;46(2):93–96. DOI: 10.1159/000022141.
  21. Kul S, Karadeniz A, Dursun İ, et al. Non-alcoholic fatty pancreas disease is associated with increased epicardial adipose tissue and aortic intima-media thickness. Acta Cardiol Sin 2019;35:118–125.
  22. Lee JS, Kim SH, Jun DW, et al. Clinical implications of fatty pancreas: correlations between fatty pancreas and metabolic syndrome. World J Gastroenterol 2009;15(15):1869–1875. DOI: 10.3748/wjg.15.1869.
  23. Catanzaro R, Cuffari B, Italia A, et al. Exploring the metabolic syndrome: nonalcoholic fatty pancreas disease. World J Gastroenterol 2016;22(34):7660–7675. DOI: 10.3748/wjg.v22.i34.7660.
  24. Idilman IS, Tuzun A, Savas B, et al. Quantification of liver, pancreas, kidney, and vertebral body MRI-PDFF in non-alcoholic fatty liver disease. Abdom Imaging 2015;40(6):1512–1519. DOI: 10.1007/s00261-015-0385-0.
  25. Lingvay I, Esser V, Legendre JL, et al. Noninvasive quantification of pancreatic fat in humans. J Clin Endocrinol Metab 2009;94(10):4070–4076. DOI: 10.1210/jc.2009-0584.
  26. Lee Y, Lingvay I, Szczepaniak LS, et al. Pancreatic steatosis: harbinger of type 2 diabetes in obese rodents. Int J Obes 2010;34(2):396–400. DOI: 10.1038/ijo.2009.245.
  27. Tushuizen ME, Bunck MC, Pouwels PJ, et al. Pancreatic fat content and beta-cell function in men with and without type 2 diabetes. Diabetes Care 2007;30(11):2916–2921. DOI: 10.2337/dc07-0326.
  28. Zenker M, Mayerle J, Reis A, et al. Genetic basis and pancreatic biology of Johanson-Blizzard syndrome. Endocrinol Metab Clin North Am 2006;35(2):243–253. DOI: 10.1016/j.ecl.2006.02.013, vii–viii.
  29. Myers KC, Bolyard AA, Otto B, et al. Variable clinical presentation of Shwachman-Diamond syndrome: update from the North American Shwachman-Diamond syndrome registry. J Pediatr 2014;164(4):866–870. DOI: 10.1016/j.jpeds.2013.11.039.
  30. Johansson BB, Torsvik J, Bjørkhaug L, et al. Diabetes and pancreatic exocrine dysfunction due to mutations in the carboxyl ester lipase gene-maturity onset diabetes of the young (CEL-MODY): a protein misfolding disease. J Biol Chem 2011;286(40):34593–34605. DOI: 10.1074/jbc.M111.222679.
  31. Papakonstantinou O, Ladis V, Kostaridou S, et al. The pancreas in beta-thalassemia major: MR imaging features and correlation with iron stores and glucose disturbances. Eur Radiol 2007;17(6):1535–1543. DOI: 10.1007/s00330-006-0507-8.
  32. Makay O, Kazimi M, Aydin U, et al. Fat replacement of the malignant pancreatic tissue after neoadjuvant therapy. Int J Clin Oncol 2010;15(1):88–92. DOI: 10.1007/s10147-009-0001-9.
  33. Fernandes-Santos C, Evangelista Carneiro R, de Souza Mendonca L, et al. Rosiglitazone aggravates nonalcoholic fatty pancreatic disease in C57BL/6 mice fed high-fat and high-sucrose diet. Pancreas 2009;38(3):e80–e86. DOI: 10.1097/MPA.0b013e3181987d9d.
  34. Sasaki M, Nakanuma Y, Ando H. Lipomatous pseudohypertrophy of the pancreas in a patient with cirrhosis due to chronic hepatitis B. Pathol Int 1998;48(7):566–568. DOI: 10.1111/j.1440-1827.1998.tb03951.x.
  35. Chehter EZ, Longo MA, Laudanna AA, et al. Involvement of the pancreas in AIDS: a prospective study of 109 post-mortems. AIDS 2000;14(13):1879–1886. DOI: 10.1097/00002030-200009080-00001.
  36. Walters MN-I, Leak PJ, Joske RA, et al. Murine infection with reovirus. Br J Exp Pathol 1965;46:200–212.
  37. Rosso E, Casnedi S, Pessaux P, et al. The role of ‘fatty pancreas’ and of BMI in the occurrence of pancreatic fistula after pancreaticoduodenectomy. J Gastrointest Surg 2009;13(10):1845–1851. DOI: 10.1007/s11605-009-0974-8.
  38. Saisho Y, Butler AE, Meier JJ, et al. Pancreas volumes in humans from birth to age one hundred taking into account sex, obesity, and presence of type-2 diabetes. Clin Anat N Y N 2007;20(8):933–942. DOI: 10.1002/ca.20543.
  39. Lopez JM, Bombi JA, Valderrama R, et al. Effects of prolonged ethanol intake and malnutrition on rat pancreas. Gut 1996;38(2):285–292. DOI: 10.1136/gut.38.2.285.
  40. Khoury T, Asombang AW, Berzin TM, et al. The clinical implications of fatty pancreas: a concise review. Dig Dis Sci 2017;62(10):2658–2667. DOI: 10.1007/s10620-017-4700-1.
  41. Kim HJ, Byun JH, Park SH, et al. Focal fatty replacement of the pancreas: usefulness of chemical shift MRI. AJR Am J Roentgenol 2007;188(2):429–432. DOI: 10.2214/AJR.05.1095.
  42. Navina S, Acharya C, DeLany JP, et al. Lipotoxicity causes multisystem organ failure and exacerbates acute pancreatitis in obesity. Sci Transl Med 2011;3(107):107ra110. DOI: 10.1126/scitranslmed.3002573.
  43. Dixon WT. Simple proton spectroscopic imaging. Radiology 1984;153(1):189–194. DOI: 10.1148/radiology.153.1.6089263.
  44. Sijens PE, Edens MA, Bakker SJL, et al. MRI-determined fat content of human liver, pancreas and kidney. World J Gastroenterol 2010;16(16):1993–1998. DOI: 10.3748/wjg.v16.i16.1993.
  45. Kühn J-P, Berthold F, Mayerle J, et al. Pancreatic steatosis demonstrated at MR imaging in the general population: clinical relevance. Radiology 2015;276(1):129–136. DOI: 10.1148/radiol.15140446.
  46. Wong VW-S, Wong GL-H, Yeung DK-W, et al. Fatty pancreas, insulin resistance, and β-cell function: a population study using fat-water magnetic resonance imaging. Am J Gastroenterol 2014;109(4):589–597. DOI: 10.1038/ajg.2014.1.
  47. Hannukainen JC, Borra R, Linderborg K, et al. Liver and pancreatic fat content and metabolism in healthy monozygotic twins with discordant physical activity. J Hepatol 2011;54(3):545–552. DOI: 10.1016/j.jhep.2010.07.029.
  48. Yu H, Shimakawa A, McKenzie CA, et al. Multiecho water-fat separation and simultaneous R2* estimation with multifrequency fat spectrum modeling. Magn Reson Med 2008;60(5):1122–1134. DOI: 10.1002/mrm.21737.
  49. Reeder SB, Hu HH, Sirlin CB. Proton density fat-fraction: a standardized MR-based biomarker of tissue fat concentration. J Magn Reson Imaging JMRI 2012;36(5):1011–1014. DOI: 10.1002/jmri.23741.
  50. Kato S, Iwasaki A, Kurita Y, et al. Three-dimensional analysis of pancreatic fat by fat-water magnetic resonance imaging provides detailed characterization of pancreatic steatosis with improved reproducibility. PLoS ONE 2019;14(12):e0224921. DOI: 10.1371/journal.pone.0224921.
  51. Hu HH, Kim H-W, Nayak KS, et al. Comparison of fat-water MRI and single-voxel MRS in the assessment of hepatic and pancreatic fat fractions in humans. Obes Silver Spring Md 2010;18:841–847.
  52. Al-Haddad M, Khashab M, Zyromski N, et al. Risk factors for hyperechogenic pancreas on endoscopic ultrasound: a case-control study. Pancreas 2009;38(6):672–675. DOI: 10.1097/MPA.0b013e3181a9d5af.
  53. Sepe PS, Ohri A, Sanaka S, et al. A prospective evaluation of fatty pancreas by using EUS. Gastrointest Endosc 2011;73(5):987–993. DOI: 10.1016/j.gie.2011.01.015.
  54. Aubert A, Gornet J-M, Hammel P, et al. Diffuse primary fat replacement of the pancreas: an unusual cause of steatorrhea. Gastroenterol Clin Biol 2007;31(3):303–306. DOI: 10.1016/S0399-8320(07)89379-1.
  55. Midiri M, Lo Casto A, Sparacia G, et al. MR imaging of pancreatic changes in patients with transfusion-dependent beta-thalassemia major. Am J Roentgenol 1999;173(1):187–192. DOI: 10.2214/ajr.173.1.10397124.
  56. Tahtacı M, Algın O, Karakan T, et al. Can pancreatic steatosis affect exocrine functions of pancreas? Turk J Gastroenterol 2018;29(5):588–594. DOI: 10.5152/tjg.2018.17696.
  57. Lozano M, Navarro S, Pérez-Ayuso R, et al. Lipomatosis of the pancreas: an unusual cause of massive steatorrhea. Pancreas 1988;3(5):580–582. DOI: 10.1097/00006676-198810000-00012.
  58. Zyromski NJ, Mathur A, Pitt HA, et al. Obesity potentiates the growth and dissemination of pancreatic cancer. Surgery 2009;146(2):258–263. DOI: 10.1016/j.surg.2009.02.024.
  59. Lesmana CRA, Gani RA, Lesmana LA. Non-alcoholic fatty pancreas disease as a risk factor for pancreatic cancer based on endoscopic ultrasound examination among pancreatic cancer patients: a single-center experience. JGH Open 2018;2(1):4–7. DOI: 10.1002/jgh3. 12032.
  60. Rungsakulkij N, Mingphruedhi S, Tangtawee P, et al. Risk factors for pancreatic fistula following pancreaticoduodenectomy: a retrospective study in a Thai tertiary center. World J Gastrointest Surg 2017;9(12):270–280. DOI: 10.4240/wjgs.v9.i12.270.
  61. Mathur A, Pitt HA, Marine M, et al. Fatty pancreas: a factor in postoperative pancreatic fistula. Ann Surg 2007;246(6):1058–1064. DOI: 10.1097/SLA.0b013e31814a6906.
  62. Lee SE, Jang J-Y, Lim C-S, et al. Measurement of pancreatic fat by magnetic resonance imaging: predicting the occurrence of pancreatic fistula after pancreatoduodenectomy. Ann Surg 2010;251(5):932–936. DOI: 10.1097/SLA.0b013e3181d65483.
  63. Martínez J, Johnson CD, Sánchez-Payá J, et al. Obesity is a definitive risk factor of severity and mortality in acute pancreatitis: an updated meta-analysis. Pancreatol 2006;6(3):206–209. DOI: 10.1159/000092104.
  64. Zyromski NJ, Mathur A, Pitt HA, et al. A murine model of obesity implicates the adipokine milieu in the pathogenesis of severe acute pancreatitis. Am J Physiol-Gastrointest Liver Physiol 2008;295(3):G552–G558. DOI: 10.1152/ajpgi.90278.2008.
  65. Fujii M, Ohno Y, Yamada M, et al. Impact of fatty pancreas and lifestyle on the development of subclinical chronic pancreatitis in healthy people undergoing a medical checkup. Environ Health Prev Med 2019;24(1):10. DOI: 10.1186/s12199-019-0763-2.
  66. Honka H, Koffert J, Hannukainen JC, et al. The effects of bariatric surgery on pancreatic lipid metabolism and blood flow. J Clin Endocrinol Metab 2015;100(5):2015–2023. DOI: 10.1210/jc. 2014-4236.
  67. Zhao L, Jiang S, Lu F, et al. Effects of berberine and cinnamic acid on palmitic acid-induced intracellular triglyceride accumulation in NIT-1 pancreatic β cells. Chin J Integr Med 2016;22(7):496–502. DOI: 10.1007/s11655-014-1986-0.
  68. Souza-Mello V, Gregório BM, Relvas-Lucas B, et al. Pancreatic ultrastructural enhancement due to telmisartan plus sitagliptin treatment in diet-induced obese C57BL/6 mice. Pancreas 2011;40(5):715–722. DOI: 10.1097/MPA.0b013e3182153922.
  69. Jia DM, Fukumitsu KI, Tabaru A, et al. Troglitazone stimulates pancreatic growth in congenitally CCK-A receptor-deficient OLETF rats. Am J Physiol Regul Integr Comp Physiol 2001;280(5):R1332–R1340. DOI: 10.1152/ajpregu.2001.280.5.R1332.
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