Pancreatic Fat Infiltration: A Key Marker in The Metabolic Continuum

Background and aims: Pancreatic fat infiltration (PFI) is strongly associated with obesity, insulin resistance, and cardiometabolic risk. However, its impact on pancreatic stiffness remains unclear. This study aimed to evaluate the relationship between PFI, pancreatic stiffness measured by transabdominal 2D-SWE elastography, and cardiometabolic risk factors (CMRF). Methods: This cross-sectional study included patients with and without PFI, identified by abdominal ultrasound. Exclusion criteria included a history of pancreatic or liver disease and alcohol consumption >20 g/day. CMRFs were assessed, and pancreatic stiffness was measured using transabdominal 2D-SWE elastography. In patients with PFI, additional assessments included hepatic 2D-SWE elastography, attenuation imaging for hepatic fat quantification, and evaluation of insulin resistance. Results: A total of 205 patients were included, 103 with PFI and 102 without. Patients with PFI were older and had a higher prevalence of CMRFs, including increased waist circumference (84.5%), overweight/obesity (79.6%), hypertriglyceridemia (62.7%), metabolic syndrome (59.4%), and insulin resistance (53.9%). Hepatic steatosis was present in 61% of patients with PFI but absent in those without. Pancreatic stiffness was significantly higher in patients with PFI compared with those without (7.35 KPa [IQR: 6.30–8.79] vs. 5.3 KPa [IQR: 4.5–6.1]; P <0.001). A stiffness threshold of ≥6 KPa demonstrated 85% sensitivity and an 86% negative predictive value for detecting PFI. Among CMRFs, hyperglycemia was significantly associated with increased pancreatic stiffness, and type 2 diabetes (T2D) emerged as the strongest predictor of elevated stiffness. Conclusions: PFI is a relevant metabolic marker associated with central obesity, insulin resistance, and increased pancreatic stiffness. These findings support the potential of transabdominal 2D-SWE as a non-invasive tool for detecting early pancreatic structural, particularly in patients with T2D. Longitudinal studies are warranted to clarify its role in predicting pancreatic dysfunction and metabolic disease progression.