Fatty Pancreas as a Reversible Cause of Exocrine Pancreatic Insufficiency: A Case Series

Abstract

Fatty Pancreas (FP) is a common finding of endoscopic ultrasound (EUS) that is associated with ectopic fat accumulation within the pancreas. Past literature has suggested a link between FP and exocrine pancreatic insufficiency (EPI), often a predictor of chronic pancreatitis and Type II Diabetes Mellitus (DMII). However, there is little published data on the reversibility of FP and the preventative ability of advanced chronic conditions. A 65-year-old female patient presented with history of DMII and Obesity (BMI=32), with no prior pancreatitis, complaining of postprandial bloating and dull epigastric pain. A full lab panel revealed an elevated A1c level (7.5%) and a fecal elastase level of 142μg/g, suggestive of EPI. EUS demonstrated hyperechogenic pancreas and liver, implicating a diagnosis of FP and fatty liver disease (FLD). The patient was started on pancreatic enzyme replacement therapy (PERT), with diet and exercise. As a result of therapy, the patient lost 42 lbs. (BMI=24.5), with complete symptom cessation. Repeat labs revealed a reduced A1c level (6.4%) and a normal fecal elastase level (386μg/g), while EUS demonstrated a complete resolution of hyperechogenic pancreas. A 57-year-old female patient presented with history of overweight (BMI=29.8), with no prior pancreatitis, complaining of dull epigastric pain and bloating. A full lab panel revealed an elevated A1c level (6.5%) and a fecal elastase level of 164μg/g, suggestive of EPI. EUS demonstrated diffusely hyperechogenic pancreas and liver, indicative of FP and FLD, respectively. The patient was started on PERT, with diet and exercise. As a result of therapy, the patient lost 24 lbs. (BMI=26), with complete symptom cessation. Repeat labs revealed a normal fecal elastase level (243μg/g), while EUS demonstrated a complete resolution of hyperechogenic pancreas. Due to lack of diet and exercise, the patient regained 20 lbs. Fecal elastase level decreased to 184μg/g, prompting re-initiation of PERT, and EUS demonstrated a recurrence of FP. Both patients achieved complete symptom cessation and normalization of labs following the introduction of PERT and weight loss therapies. In both cases, a diagnosis of EPI (fecal elastase<200μg/g) was reversed as the patients' FP was treated. With this reversal, the potential of developing more advanced conditions was significantly reduced. These cases show that FP has both acute and chronic implications and can be reversed and monitored.