Pancreatic steatosis is associated with exocrine pancreatic dysfunction in children with MASLD: a prospective cross-sectional study

This study aimed to evaluate the relationship between pancreatic steatosis and fecal elastase (FE) levels in children with hepatic steatosis, compare clinical, metabolic, and imaging findings according to metabolic dysfunction-associated steatotic liver disease (MASLD) status, and determine whether this relationship persists within children with MASLD. This prospective cross-sectional study was conducted in the Pediatric Gastroenterology and Pediatric Endocrinology Departments of Kayseri City Hospital. Participants were classified according to the presence of MASLD. Clinical characteristics, anthropometric measurements, metabolic parameters, ultrasonographic findings, and FE levels were compared between groups. FE levels were categorized as normal (> 200 µg/g), low (100–200 µg/g), and severely low (< 100 µg/g). For binary analyses, low FE was defined as ≤ 200 µg/g. Logistic regression analyses were performed to identify factors associated with low FE levels and high-grade pancreatic steatosis. Analyses were also performed within the MASLD group. Receiver operating characteristic curve analyses were used to assess the discriminatory performance of clinical, metabolic, and imaging-based parameters. A total of 163 children were included; 92 were classified as having MASLD and 71 were classified as non-MASLD. Pancreatic steatosis was significantly more frequent in the MASLD group than in the non-MASLD group (93.5% vs. 40.8%), and low FE levels were also more prevalent (59.8% vs. 15.5%; p < 0.001). In multivariable analysis of the overall cohort, pancreatic steatosis grade (OR: 1.97, 95% CI: 1.20–3.23, p = 0.007) and waist circumference (WC) ≥95th percentile (OR: 3.31, 95% CI: 1.24–8.87, p = 0.017) were independently associated with low FE levels. Within the MASLD group, pancreatic steatosis grade was significantly associated with low FE levels. Pancreatic steatosis grade showed the highest discriminatory performance for low FE levels among the evaluated parameters (AUC = 0.76). Pancreatic steatosis was more frequent in children with MASLD, and its severity was associated with low FE levels both in the overall cohort and within the MASLD group. Imaging-based pancreatic findings showed moderate discriminatory performance for low FE levels but should not be interpreted as validated diagnostic thresholds. Pancreatic steatosis may represent a clinically relevant feature of pediatric MASLD in relation to possible subclinical alterations in exocrine pancreatic function.