International Multidisciplinary Consensus Report on Definitions, Diagnostic Criteria, and Management of Fatty Pancreas: A Joint Statement Endorsed by EPC, APA, EASD, EASL, ESGAR, ESGE, ESP, ESPCG, ESPEN, ESPGHAN, IAP, JPS, KPBA, LAPSG, and UEG Vujasinovic, M., Demir, I. E., Marchegiani, G., et al. International multidisciplinary consensus report on definitions, diagnostic criteria, and management of fatty pancreas: A joint statement endorsed by EPC, APA, EASD, EASL, ESGAR, ESGE, ESP, ESPCG, ESPEN, ESPGHAN, IAP, JPS, KPBA, LAPSG, and UEG. United European Gastroenterology Journal, 14, e70185. https://doi.org/10.1002/ueg2.70185
Fat accumulation in the pancreas has long been considered a largely incidental finding.[1] Despite increasing clinical interest, this condition has shown terminological inconsistency, heterogeneous diagnostic criteria, and a lack of standardised imaging thresholds — limiting both research and application in clinical practice.[2] Published in early 2026, this international multidisciplinary consensus report, endorsed by 15 societies including ESGAR, represents the first systematic effort to define, characterise, and provide guidance on fatty pancreas. The document involved 84 experts across gastroenterology, radiology, pathology, endocrinology, surgery, and nutrition, comprising 16 consensus statements, all achieving agreement — ranging from 86% to 100% — in a single Delphi round. What is the new terminology? The panel reached 87% consensus on adopting fatty pancreas as the single, inclusive, standardised term for all forms of fat accumulation in the pancreas, regardless of aetiology. The term "non-alcoholic fatty pancreas disease" was explicitly discouraged: unlike fatty liver disease, fatty pancreas does not follow a steatohepatitis-like progression, and the negative construction adds unnecessary complexity. For radiologists, this standardisation has direct implications for structured reporting and consistency in clinical communication. What is the role of each imaging modality in the diagnosis of fatty pancreas? Transabdominal ultrasound (US) can suggest fatty pancreas through increased echogenicity, but its diagnostic reliability is significantly limited by operator dependency, susceptibility to confounders including fibrosis and body habitus, and the absence of validated quantitative criteria (Statement 6.1, consensus 87%). CT may assist diagnosis in advanced cases, with a proposed pancreas-to-spleen attenuation ratio below 0.7 on non-enhanced CT as a threshold. However, mild fat infiltration may produce no measurable attenuation change — the so-called "invisible fat" on CT — limiting sensitivity for early disease (Statement 6.2, consensus 97%). MRI-PDFF is identified as the most reliable tool for quantitative pancreatic fat assessment, with strong histological correlation [3] and the ability to evaluate the entire gland (Statement 6.3, consensus 100%). Measurement should be performed by placing regions of interest (ROIs) on the pancreatic head, body, and tail, avoiding non-parenchymal structures. The panel proposes a three-grade severity classification: mild (PDFF 6–15%), moderate (16–30%), and severe (>30%), although validated population-level cutoffs have not yet been established. MRI also plays a problem-solving role when focal fat mimics a mass lesion on US or CT (Statement 6.4, consensus 86%). AI-based automated MRI quantification shows promise for large-scale research but currently lacks sufficient clinical validation for routine use (Statement 6.5, consensus 100%). What are the clinical implications for radiologists? Fatty pancreas is no longer a purely incidental observation. Its associations with metabolic syndrome, type 2 diabetes mellitus, and MASLD are well-supported (evidence level 1–2). The relation to pancreatic cancer is particularly noteworthy: a pooled odds ratio of 3.23 (95% CI 1.86–5.60) was reported across systematic reviews,[4] supported by a UK Biobank cohort hazard ratio of 1.98.[5] Fatty pancreas also independently increases the risk of postoperative pancreatic fistula following pancreaticoduodenectomy, making its identification and grading on preoperative CT or MRI directly relevant to surgical planning. What remains uncertain and what are the priorities for future research? Throughout the document, a consistent limitation emerges: the majority of recommendations are based on expert consensus rather than high-quality prospective evidence. The report explicitly flags that many statements require rigorous prospective validation before adoption into routine clinical practice. Key unresolved imaging questions include the optimal CT protocol for mild fatty pancreas, universal MRI-PDFF cutoffs validated across different populations, and the role of AI tools in routine clinical workflows. Can these recommendations be applied in clinical practice? Radiologists may reasonably adopt the proposed terminology and MRI-PDFF grading framework in daily practice, provided findings are qualified with appropriately transparent language — for example, "appearances consistent with moderate fatty pancreas by current consensus criteria (MRI-PDFF 20%)". Extrapolation to high-stakes decisions such as cancer surveillance remains premature pending prospective validation. In summary, this consensus report provides radiologists with a clear terminological framework, practical imaging guidance, and a structured approach to grading fatty pancreas severity — positioning MRI-PDFF as the reference standard. | References
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