Pancreatic lipomatosis

Last revised by Joel Hng on 14 Mar 2023

Pancreatic lipomatosis refers to fat accumulation in the pancreatic parenchyma. This finding is most often associated with obesity and aging. It tends to be the most common pathological condition involving the pancreas. The condition may occasionally simulate a mass-like lesion particularly when fatty replacement is uneven 1

Many terms have been used in the literature to refer to similar conditions. Recognizing these differences, one nomenclature proposes that the general terms for pancreatic fat accumulation include pancreatic lipomatosis, fatty pancreas, and pancreatic steatosis 8,9. The most extreme variant is lipomatous pseudohypertrophy, characterized by pancreatic enlargement, but some consider this a distinct entity 8.

The entity can be divided by etiology 8:

  • fatty replacement: death of acinar cells with subsequent replacement with adipocytes

  • fatty infiltration or nonalcoholic fatty pancreas disease: pancreatic accumulation of adipocytes in association with obesity/metabolic syndrome

The majority of pancreatic fatty deposits have no clinical significance. However, excessive fatty deposits may cause loss of pancreatic function, causing maldigestion of nutrients. This may lead to symptoms of chronic diarrhea, steatorrhea, and weight loss, without any abdominal pain or signs of diabetes mellitus due to low insulin production 20. Symptomatic fatty pancreas is only reported in several case reports 20.

  • even pancreatic lipomatosis

  • uneven pancreatic lipomatosis 3,9

    • type 1a: preferential fatty replacement of the head, sparing the uncinate process and peribiliary region

    • type 1b: preferential fatty replacement of head, neck, and body, sparing the uncinate process and peribiliary region

    • type 2a: preferential fatty replacement of head, including uncinate process, and sparing the peribiliary region

    • type 2b: total fatty replacement of the pancreas except for the peribiliary region

Several etiologies are well established 8:

Less established etiologies include the following 8:

On ultrasound, fatty pancreas has hyperechoic parenchyma 20.

On CT scan, fatty pancreas has hypodense parenchyma 20. On unenhanced CT, the pancreas would show similar density to surrounding retroperitoneal fat (negative attenuation values). On contrast-enhanced CT, pancreatic parenchyma would show higher density (positive attenuation values) due to enhancement of pancreatic parenchyma between fatty infiltration areas 1.

Imaging differential considerations include:

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