Pancreatic steatosis endosonographic criteria: A histology-validated EUS diagnostic study

Background and Objectives: Pancreatic steatosis (PS) is increasingly recognized as a clinically significant condition. Although EUS is commonly used to evaluate PS, existing diagnostic criteria lack histologic validation. This study aimed to establish histology-validated EUS criteria for diagnosing PS. Methods: Patients undergoing EUS before pancreatic surgery were prospectively enrolled. Two experienced endosonographers independently assessed predefined EUS features, with interobserver agreement evaluated. Histologic confirmation of PS was obtained from surgical specimens. Features significantly associated with histologic PS were used to develop the pancreatic steatosis endosonographic criteria (PSEC). Results: Of 132 enrolled patients, 96 completed the study. Histologic PS was confirmed in 27.10% of cases. EUS features independently associated with PS included hyperechoic parenchyma (odds ratio [OR]: 51.96), obscured main pancreatic duct margin (OR: 10.88), obscured “salt-and-pepper” appearance (OR: 8.25), and absence of hyperechoic foci or strands (OR: 5.11). Based on these findings, the PSEC were established, consisting of 1 major criterion (hyperechoic parenchyma) and 3 minor criteria (obscured salt-and-pepper appearance, obscured main pancreatic duct margin, and absence of hyperechoic foci or strands). The optimal diagnostic threshold was defined as either 1 major plus 1 minor criterion or 3 minor criteria. This model achieved an area under the receiver operating characteristic curve of 0.84 (95% confidence interval [CI]: 0.8–0.9), sensitivity of 84.60%, specificity of 87.10%, positive predictive value of 71%, and negative predictive value of 93.80%, with substantial interobserver agreement. Conclusion: PSEC represents the first histology-validated EUS criteria for PS, demonstrating robust diagnostic performance and practical applicability in clinical practice.