Fatty Pancreas Disease: An Updated Review of Risk Factors, Diagnosis, Clinical Associations and Management

Fat accumulation within the pancreas is increasingly detected during abdominal imaging, but whether an imaging phenotype constitutes a clinically actionable disease remains uncertain. This critical narrative review evaluates the determinants, biological interpretation, diagnostic assessment, clinical associations and management of fatty pancreas disease, integrating contemporary epidemiological, imaging, pathological, mechanistic and longitudinal evidence. The literature was critically selected from accessible scholarly sources, with emphasis on studies published from 2007 to 13 August 2026 and earlier foundational work when necessary. The synthesis distinguishes physiological intrapancreatic lipid from excessive, potentially harmful deposition and contrasts two influential 2026 international consensus frameworks. Age, visceral adiposity, metabolic dysfunction and selected genetic or pancreatic factors are recurrent correlates, but substantial heterogeneity in body composition and fat compartmentalisation limits any single causal model. Quantitative magnetic resonance imaging, particularly proton density fat fraction techniques, provides the most defensible non-invasive assessment; nevertheless, sampling methods, thresholds and clinically relevant severity categories remain inadequately validated. Cohort studies associate greater pancreatic fat with incident diabetes, pancreatitis and pancreatic cancer, although residual confounding, reverse causality and inconsistent endpoint ascertainment complicate causal interpretation. Histopathology and experimental work support several biologically plausible pathways, but do not establish that removing pancreatic fat alone prevents pancreatic disease. Weight loss and metabolic treatment can reduce pancreatic fat, yet benefits specific to pancreatic fat reduction have not been isolated from broader improvements in metabolic health. No pharmacological or procedural treatment is established solely for asymptomatic fatty pancreas, and incidental imaging findings do not independently justify pancreatic cancer surveillance. The review proposes a phenotype-aware clinical approach centred on established risk-factor management, diagnostic restraint and appropriately designed prospective trials. The immediate priorities are harmonised imaging acquisition, validation against meaningful clinical outcomes and intervention studies capable of distinguishing a causal target from a correlated metabolic marker.