2d-swe in Metabolic Syndrome: Beyond Masld, Interrrogating the Pancreas

2d-swe in Metabolic Syndrome: Beyond Masld, Interrrogating the Pancreas | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article 2d-swe in Metabolic Syndrome: Beyond Masld, Interrrogating the Pancreas Chitty Suvarna Duggireddy, Rashmi Dixit, Sapna Singh, Sandeep Garg, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7296594/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Oct, 2025 Read the published version in Abdominal Radiology → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose The purpose of this study was to evaluate hepatic and pancreatic steatosis on grey-scale ultrasound and assess its association with hepatic and pancreatic stiffness using ultrasound 2D-SWE in patients with metabolic syndrome (MS). Methods One hundred-and-thirty-one adult patients with metabolic syndrome were included in the study. Grey scale ultrasound of liver and pancreas was performed to evaluate grades of hepatic steatosis (HS) and pancreatic steatosis (PS) respectively. Subsequently, 2D-SWE was performed to obtain liver and pancreatic stiffness in kPa and m/s. Grades of HS and PS were correlated with BMI, biochemical parameters, hepatic and pancreatic stiffness values. Results Moderate correlation was found between HS grade and BMI, while the correlation of PS grade with BMI was poor. On SWE, hepatic and pancreatic stiffness showed strong and moderate correlation with BMI, respectively. Among biochemical parameters, triglycerides showed highest correlation with HS grade and hepatic stiffness, while fasting blood glucose showed highest correlation with PS grade and pancreatic stiffness. The stiffness values of both organs showed statistically significant difference in participant groups with and without steatosis (p < 0.001). Mean hepatic and pancreatic stiffness values showed strong positive correlation with grade of HS (Ʈ=0.84) and PS (Ʈ=0.82), respectively. Conclusion Metabolic syndrome is associated with both hepatic and pancreatic steatosis with consequent increase in hepatic and pancreatic stiffness values respectively. These show positive correlation with the grade of steatosis. 2D-SWE along with biochemical parameters, can be utilized in the screening of MS patients for early detection and surveillance of further disease progression to prevent potential complications. Metabolic syndrome-associated steatotic liver disease (MASLD) Hepatic steatosis (HS) Pancreatic steatosis (PS) Hepatic stiffness Pancreatic stiffness Non-alcoholic fatty pancreatic disease (NAFPD) Non-alcoholic fatty liver disease (NAFLD) 2D-shear wave elastography (2D-SWE) Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 INTRODUCTION Metabolic dysfunction-associated steatotic liver disease (MASLD) [earlier referred as non-alcoholic fatty liver disease (NAFLD)] is one of the most common diffuse liver diseases worldwide and is strongly associated with metabolic syndrome (MS). In some patients, it may progress through metabolic dysfunction-associated steatohepatitis (MASH) [previously referred to as non-alcoholic steatohepatitis (NASH)] to fibrosis, cirrhosis and even hepatocellular carcinoma. Recently, the terminology of NAFLD and NASH were reconsidered owing to their reliance on exclusionary confounders and stigmatizing terms such as “non-alcoholic” and “fatty”. A multisociety Delphi consensus statement on new fatty liver disease nomenclature was released in December 2023 replacing the term NAFLD by MASLD and including the presence of atleast one out of five cardiometabolic risk factors (CMRFs) to the definition. The CMRFs include high BMI, presence of type-2 diabetes mellitus (T2DM), hypertension, deranged triglycerides (TG) and HDL-cholesterol with exact criteria being defined separately for adults and pediatric population. A new category termed metabolic and alcohol related/ associated steatotic liver disease (MetALD) was introduced to describe those with MASLD who consume greater amounts of alcohol per day/week [weekly intake 140-350g female and 210-420g male; daily intake 20-50g female and 30-60g male]. Fatty liver with no metabolic parameters and no known cause is termed cryptogenic steatotic liver disease. Steatotic liver disease (SLD) is chosen as the over-arching term to include various etiologies of hepatic steatosis. Roughly around 98% of all NAFLD cases satisfy the definition of MASLD [ 1 ] . Besides hepatic changes, it has been reported that MS may be commonly associated with pancreatic changes as well. Non-alcoholic fatty pancreatic disease (NAFPD) is the term used for fatty accumulation in the pancreas in the presence of MS and is usually associated with MASLD. However, no consensus was available regarding the modification of use of the term NAFPD, thus it is being used as such. Presence of atleast one of the components of the metabolic syndrome is associated with 37% increased prevalence of fatty pancreas. While hepatic steatosis (HS) is well studied, pancreatic steatosis (PS) is less extensively studied. Excessive accumulation of fat in pancreas interferes with its physiological functions resulting in both exocrine and endocrine failure, thus fatty pancreas has role in many clinical implications such as type-2 diabetes mellitus, pancreatic exocrine insufficiency, acute pancreatitis and pancreatic cancer. Replacement of more than 25% of pancreatic parenchyma by fat is associated with severe increased risk of generalized atherosclerosis [ 2 ] . Similar to MASLD, NAFPD also show progression to non-alcoholic steatopancreatitis (NASP) and all these processes increase pancreatic echogenicity and stiffness. Non-invasive assessment of pancreatic disease, besides hepatic disease is important in this scenario so as to allow complete evaluation of organ damage consequent to metabolic dysfunction. Ultrasound is best suited to fulfil this purpose due to its low cost, non-invasiveness and ubiquitous availability. Ultrasound based 2D shear wave elastography (2D-SWE) facilitates assessment of both anatomical information and tissue stiffness [ 3 ] . It has been extensively in use to study hepatic changes in MASLD, but has not often been used to study pancreatic changes in NAFPD/ metabolic syndrome [ 4 ] . The study has been undertaken to comprehensively evaluate hepatic and pancreatic steatosis on grey-scale ultrasound and assess its association with hepatic and pancreatic stiffness using ultrasound 2D-SWE in patients of MS. MATERIALS AND METHODS This cross-sectional study was approved by the institutional review board and ethics committee. All participants gave written informed consent. The inclusion criteria were adults (i.e., over 18 years of age) with one or more of the following cardiometabolic risk factors: high BMI, presence of T2DM, hypertension, deranged TG & HDL-cholesterol. Participants were excluded from the study if they had one of the following: consumption of greater amounts of alcohol per day/week [weekly intake 140-350g female and 210-420g male; daily intake 20-50g female and 30-60g male], any focal lesion in liver/ pancreas/ spleen, abdominal lymphadenopathy, cardiac failure, previous history of hepatic/ pancreatic disease, history of surgical procedures on liver/ pancreas and pregnancy. One hundred and forty consecutive participants who met the inclusion and exclusion criteria were taken up for ultrasound elastography, however nine participants had to be excluded due to poor pancreatic visualization mainly due to obesity. Thus, a total of 131 participants including 53 males and 78 females were recruited for this study. Demographic features such as age, gender, weight, and height of the participants were recorded. Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared (kg/m 2 ). Biochemical parameters including serum albumin(g/L), aspartate transaminase (IU/L), alanine transaminase (IU/L), alkaline phosphatase (IU/L), platelet count (x lacs/mm 3 ), fasting blood glucose [FBG](mg/dl), HbA1c (%) and lipid profile including total cholesterol (mg/dl), HDL cholesterol (mg/dl), LDL cholesterol (mg/dl) and triglycerides (mg/dl) done within one month of the ultrasound examination and were recorded. Presence of diabetes was recorded in participants with FBG ≥ 126 mg/dl or HbA1c ≥ 6.5% and hypertension if blood pressure exceeded 140/90 mm Hg. AST (IU/L), platelet count (x 10 9 /L) were used to calculate AST to Platelet ratio index (APRI) using APRI online calculator tool. FIB-4 score was similarly calculated using ALT and platelet count. The cut-offs for APRI and FIB-4 scores were taken as 0.45 and 1 respectively. Ultrasound examination : Patients were kept fasting for 6–8 hours before the ultrasound examination. A routine grey scale ultrasound of upper abdomen was performed in all subjects using GE LOGIQ S8 ultrasound system with curvilinear (C1-6) probe. Qualitative assessment of liver echogenicity and grading of HS was done as suggested by Saadeh S et al [ 5 ] (Image 1). With the patient in supine position and both hands placed overhead, probe was placed in the epigastric region and pancreas was visualized. Qualitative assessment of pancreatic echogenicity and grading of pancreatic steatosis was done as suggested by Paul J et al [ 2 ] (Image 2). Subsequently, hepatic stiffness was measured in the right lobe of liver using intercostal approach, with the subject lying in slight lateral decubitus (30 o ) position and right arm in extension [ 6 ] . Keeping scanning pressure as minimum, a rectangular or square shaped ROI box was positioned 1.5-2 cm below liver capsule after carefully excluding hepatic vessels and biliary radicles. Patient was asked to hold breath at neutral breathing and elastography map was obtained. Efforts were made to achieve a homogenous colour map. Different colours on the map indicate varying degrees of tissue hardness. Cooler colours (green and blue) represent softer tissue while warmer ones (red) indicate stiffer tissue. Twelve SWE measurements (in m/s and kPa) were obtained within the ROI box and expressed as mean and median values (Image 3). Pancreatic stiffness at head of pancreas was measured with the subject in supine position, probe in epigastric region and ROI in head of pancreas following similar precautions as for hepatic elastography [ 7 ] . Five 2D-SWE measurements (in m/s and kPa) were taken during suspended respiration and expressed as mean and median with IQR/M. (Image 4). The measurements for both hepatic and pancreatic stiffness were considered reliable when the IQR/M (Interquartile range/ median) value was ≤ 30% for kPa or ≤ 15% for m/s as suggested by the manufacturer and also stated in the ultrasound liver elastography consensus statement by Barr RG et al [ 8 ] . Liver biopsy was done in 18 participants for patient management. Hepatic and pancreatic stiffness values, APRI and FIB-4 scores were compared among participants with different histopathological findings. STATISTICAL ANALYSIS The data obtained was entered in MS-Excel and analyzed using Statistical Package of the Social Sciences (SPSS) software version 25. Data were statistically described in terms of mean (SD), median (IQR) or percentages when appropriate. Chi-square test was used to evaluate the association between gender and PS grade. Kruskal-Wallis test was used to determine the statistical significance of association between steatosis grade and stiffness values. Correlation of BMI and biochemical parameters with HS/PS grades was evaluated by Kendall’s Tau Rank and that with stiffness values was evaluated using Spearman’s rank correlation. For all statistical tests, p-value < 0.05 was taken to indicate a significant difference. For Kendall’s Tau coefficient, values of 0.26, 0.49, 0.71 were taken as cut-offs for moderate, strong and very strong correlation respectively. RESULTS Demographic and clinical data : A total of 131 adult participants between the age group of 22 to 61 years (mean age 41.3 ± 7.7 years) were included in the study. The group consisted 53(40.46%) males and 78(59.54%) females. All the participants had one or more CMRFs fulfilling the MASLD criteria. The distribution of participants according to the presence of CMRFs and BMI was represented in Table 1 and Table 2 respectively. Table 1 Distribution of participants based on the status of cardiometabolic risk factors/ (n = 131). Cardiometabolic risk factor Normal Deranged n % n % BMI (> 23 kg/m 2 ) 6 4.58% 125 95.42% Blood pressure (> 130/85) 43 32.82% 88 67.18% FBS (> 100 mg/dl) 43 32.82% 88 67.18% HbA1c (> 5.7%) 46 35.11% 85 64.89% HDL-C (≤ 40 mg/dl-males) (≤ 50 mg/dl females) 92 70.23% 39 29.77% TG (> 150 mg/dl) 31 23.66% 100 76.34% Table 2 Distribution of participants based on BMI (in kg/m 2 ) (n = 131). BMI (in kg/m 2 ) (WHO classification for Asian population) Males (n = 53) Females (n = 78) Total n % Underweight and normal (≤ 22.9) 1 5 6 4.58% Overweight (23-24.9) 1 6 7 5.34% Pre-obese (25-29.9) 8 10 18 13.74% Obese I (30–40) 37 36 73 55.72% Obese II (40.1–50) 6 20 26 19.85% Obese III (> 50) 0 1 1 0.76% Total 53 78 131 100% Mean ± SD 33.62 ± 5.05 35.21 ± 8.14 34.57 ± 7.08 (p = 0.172) Hepatic and pancreatic steatosis : On grey-scale ultrasound, normal liver echogenicity was seen in 27(20.6%) participants, while 104(79.4%) had HS, out of which 43(41.3%) were male and 61(58.6%) were female. Grade 1, 2 and 3 HS were seen in 17.5%, 35.1% and 26.7% of the participants. Normal pancreatic echogenicity was evident in 36(27.48%) participants, while 95(72.52%) had PS, of these 39(41%) were male participants and 56(59%) were female. Grade 1 and 2 PS were seen in 43.5% and 29% of the participants with none having grade 3 PS. No significant difference was found between males and females in terms of grades of HS and PS (p = 0.71 and p = 0.96 respectively). The distribution of BMI (kg/m 2 ) among various grades of HS and PS is depicted in Fig. 1 and Fig. 2 respectively. Among the participants with HS and/or PS, biochemical parameters such as AST, ALT, ALP, FBG, HbA1c, total cholesterol, LDL cholesterol and triglycerides were higher compared to those without HS or PS. These parameters showed moderate to strong correlation with HS grade and only poor to moderate correlation with PS grade. Among them, serum triglycerides (Ʈ=0.57) were observed to have strong positive correlation with HS grade with mean values of 140 ± 16.25 mg/dl, 169.9 ± 26.8 mg/dl, 172.8 ± 33.1 mg/dl and 302 ± 96 mg/dl in participants with grade 0,1,2 and 3 HS respectively. FBG (Ʈ=0.34) showed modest correlation with PS grade with mean values of 99.01 ± 16.28 mg/dl, 122.23 ± 31.10 mg/dl and 134.84 ± 33.53 mg/dl in participants with grade 0, 1 and 2 PS respectively. Hepatic and pancreatic stiffness : In our study, no significant difference was found between males and females in terms of overall hepatic stiffness (p = 0.809 for kPa and 0.767 for m/s) and pancreatic stiffness (p = 0.946 for kPa and 0.767 for m/s). The correlation of hepatic and pancreatic stiffness values with BMI is depicted in Fig. 3 and with the biochemical parameters is depicted in Fig. 4 . The mean hepatic and pancreatic stiffness values showed an increasing trend with increase in the grade of HS and PS respectively (Table 3 ). Table 3 Comparison of hepatic stiffness values among grades of HS and pancreatic stiffness values among grades of PS (n = 131). kPa m/sec Range Mean ± SD Range Mean ± SD HS GRADE HEPATIC STIFFNESS Grade 0 (n = 27) 1.46–4.46 3.32 ± 0.58 0.7–1.22 1.02 ± 0.10 Grade 1 (n = 23) 5.02–7.82 6.24 ± 1.02 1.29–1.56 1.42 ± 0.11 Grade 2 (n = 46) 7.14–9.24 8.02 ± 1.3 1.53–1.79 1.65 ± 0.16 Grade 3 (n = 35) 6.83–18.24 13.89 ± 1.89 1.51–2.47 2.14 ± 0.31 P-value < 0.001 < 0.001 PS GRADE PANCREATIC STIFFNESS Grade 0 (n = 36) 1.42–4.81 3.07 ± 0.5 0.69–1.27 1.01 ± 0.07 Grade 1 (n = 57) 5.04–6.87 5.83 ± 1.06 1.3–1.55 1.4 ± 0.12 Grade 2 (n = 38) 7.15–15.06 8.41 ± 1.01 1.47–2.24 2.24 ± 0.10 Grade 3 (n = 0) - - - - P-value < 0.001 < 0.001 The hepatic and pancreatic stiffness were also correlated with each other and the results were depicted in Fig. 5 . The participants were categorized into three groups -participants with normal liver echogenicity, those with MASLD but normal APRI/FIB-4 score and those with MASLD with elevated APRI/FIB-4 scores. No discordance was found between APRI and FIB-4 scores in the participants with elevated scores. The distribution of hepatic and pancreatic stiffness values among these three groups were depicted in Table 4 . Table 4 Distribution of hepatic stiffness based on fatty liver status and biochemical parameters(n = 131). Parameter Normal (n = 27) NAFLD with normal APRI and FIB-4 score (n = 46) NAFLD with elevated APRI and FIB-4 score (n = 58) Liver stiffness kPa 3.32 ± 1.06 8.16 ± 3.14 10.75 ± 3.6 m/s 1.03 ± 0.18 1.62 ± 0.28 1.88 ± 0.30 Pancreatic stiffness kPa 3.07 ± 0.5 5.39 ± 2.25 6.31 ± 2.29 m/s 1.01 ± 0.07 1.32 ± 0.30 1.44 ± 0.25 Liver biopsy was done in 18 participants, of these, one had a normal liver, two had MASLD and fifteen showed changes of MASH. The distribution of mean hepatic and pancreatic stiffness values among these three groups were depicted in Table 5 . Table 5 Distribution of hepatic and pancreatic stiffness based on liver biopsy status. (n = 18). Parameter Normal (n = 1) MASLD (n = 2) MASH (n = 15) Liver stiffness kPa 2.72 5.97 ± 0.19 15.49 ± 2.41 m/s 0.95 1.38 ± 0.01 2.27 ± 0.17 Pancreatic stiffness kPa 5.22 6.33 ± 1.16 7.09 ± 1.48 m/s 1.32 1.43 ± 0.16 1.56 ± 0.17 DISCUSSION Metabolic syndrome (MS) is a cluster of conditions that increases the risk of T2DM, stroke and cardiac disease. It is defined by the presence of one or more CMRFs which include central obesity, hypertension, T2DM and dyslipidemia. Due to dyslipidemia and insulin resistance, increased subcutaneous and visceral fat accumulation occurs along with ectopic fat deposition in organs like heart, liver and pancreas resulting in cardiac lipomatosis, MASLD and NAFPD respectively. Due to its high prevalence, associated complications and high health care expenditure, correct assessment, grading, surveillance for MASLD, and its association with NAFPD is pertinent. In recent years, non-invasive liver disease assessment (NILDA) is becoming central to liver disease severity assessment and are expected to replace liver biopsy as a diagnostic tool in many clinical scenarios [ 9 ] . NILDAs have been developed to assess the severity of steatosis, fibrosis and portal hypertension and are of two types, namely blood-based [APRI, FIB-4, NFS] and imaging-based tests [TE (transient elastography), SWE, MRE (MR elastography)]. Unlike liver stiffness which has been extensively studied, there are only a very few studies in literature that have evaluated pancreatic stiffness on ultrasound. Ultrasound elastography is being widely used in gastroenterology mostly related to hepatic pathologies. Among pancreatic diseases, it has been mainly used for evaluating pancreatitis and pancreatic masses either by transabdominal or endoscopic approach. Very limited studies have been done previously for evaluation of pancreatic stiffness by SWE. MS is associated with ectopic fat deposition in pancreas with consequent release of inflammatory factors that accelerate β-cell apoptosis or inhibit insulin secretion resulting in insulin resistance [ 10 ] . Further, fatty infiltration of pancreas contributes to increased stiffness through associated metabolic and inflammatory changes that promote fibrogenesis. Hence, we assessed pancreatic steatosis and pancreatic stiffness, besides hepatic steatosis and hepatic stiffness in patients with MS using 2D-SWE for comprehensive patient evaluation. A total of 131 participants with MS were included in the present study. Out of these, HS was seen in 104(79.4%) participants and PS in 95(72.52%) participants which was roughly in agreement with previous studies [ 11 ][ 12 ][ 13 ] . None of the participants in underweight category had hepatic or pancreatic steatosis. The mean BMI showed an increasing trend with increase in grade of HS and PS with a statistically significant difference among various grades (p < 0.001). While BMI showed a moderate correlation with HS grade(Ʈ=0.59), it only showed poor correlation with PS grade(Ʈ=0.24) [ 11 ][ 14 ][ 15 ] . This is in agreement with the fact that obesity is a critical criterion of MS and with increase in obesity, ectopic fat deposition occurs both in liver and pancreas. Additionally, in obese individuals, disruption in equilibrium among hepatic fat synthesis, oxidation and export results in hepatic steatosis, thus obesity affects liver more than pancreas [ 16 ] . With increase in the grade of HS/PS, the hepatic enzymes (AST, ALT, ALP), FBS, HbA1c, TC, LDL-C, triglycerides showed increasing trend and serum albumin, platelet count and HDL cholesterol showed decreasing trend. Statistically significant difference was found among all HS grades in terms of all biochemical parameters(p < 0.001), showing a moderate to strong correlation with HS grade and poor to moderate correlation with PS grade. Among them, serum triglycerides were observed to have highest correlation with HS grade ((Ʈ=0.57) which is in agreement with the fact that dyslipidemia is a risk factor of MASLD. In patients with metabolic syndrome, IR mediated enhanced hepatic uptake of FFAs, activation of denovo lipogenesis and altered triglyceride export results in hepatic steatosis and triggers inflammation resulting in MASH [ 16 ] . On the other hand, FBG was shown to have highest correlation with PS grade (Ʈ=0.34) which depicts the common role of IR in NAFPD. IR results in intracellular fat accumulation in pancreas which appears as increased echogenicity on grey-scale ultrasound. Fat accumulated in both exocrine and endocrine cells of pancreas further causes increased IR and T2DM with increased FBG levels. Similar findings have been reported in earlier studies [ 11 ][ 17 ][ 18 ][ 19 ] . In our study, no statistically significant difference was found in terms of hepatic and pancreatic stiffness values among different age or gender groups. A strong positive correlation was found between BMI and hepatic stiffness (ρ = 0.67, p < 0.001), while it showed a moderate positive correlation with pancreatic stiffness (ρ = 0.3, p < 0.001). Hepatic stiffness showed moderate to strong correlation with biochemical parameters, among which triglycerides showed strongest positive correlation, while serum albumin had shown weak and negative correlation. Pancreatic stiffness showed moderate correlation with FBS and only weak correlation with other biochemical parameters. It has been suggested that IR plays role in fat accumulation, inflammation and subsequent fibrogenesis in both liver and pancreas reflecting as increased stiffness [ 20 ] . Hepatic stiffness values were observed to be high among MASLD patients with elevated APRI and FIB- 4 scores. This is in agreement with the fact that progression of liver disease to fibrosis results in reduced liver function and thus elevated APRI and FIB-4 scores, supporting use of these blood tests as a part of NILDAs [ 9 ] . Further, our study also suggests the role for SWE in assessment of hepatic stiffness in MS patients, providing another non-invasive tool for monitoring the patients for disease progression and timely management. In the absence of HS, mean hepatic stiffness values were 3.32 ± 0.58 kPa and 1.02 ± 0.10 m/sec, whereas in those with HS, the values were 9.38 ± 1.4 kPa and 1.74 ± 0.19 m/sec (p < 0.001). The mean liver stiffness values also showed an increasing trend with increase in the HS grade with a statistically significant difference between the four groups (p < 0.001). HS grade showed strong positive correlation with liver stiffness values in kPa (Ʈ=0.84) and m/s (Ʈ=0.85) (p < 0.001) [ 21 ][ 22 ][ 23 ] . The mean pancreatic stiffness values were 3.07 ± 0.5 kPa and 1.01 ± 0.07 m/sec in participants with absence of PS and 6.69 ± 1.04 kPa and 1.49 ± 0.11 m/sec in those with PS(p < 0.001). The pancreatic stiffness values showed an increasing trend with increase in PS grade with a statistically significant difference among various grades of PS (p < 0.001) with a strong positive correlation [ 24 ] . In NAFPD, excessive fat accumulation incites inflammation and fibrogenesis resulting in non-alcoholic steatopancreatitis (NASP), further increasing pancreatic stiffness. A moderate positive correlation between hepatic and pancreatic stiffness values was also observed in both kPa (Ʈ=0.35) and m/s (Ʈ=0.39). Since MS affects both liver and pancreas, it is important to monitor changes in both these organs for patient surveillance. Among the participants in whom liver biopsy was performed, the hepatic and pancreatic stiffness values were observed to be highest among participants with MASH followed by those with MASLD. It has been suggested that excessive hepatic fat accumulation incites release of hepatokines, activation of stellate cells and fibroblasts resulting in its progression to MASH, liver cirrhosis and fibrosis with further increase in liver stiffness. Assessment of liver stiffness can thus help in evaluating liver function decline. The main limitation of the study was that biopsy could not be performed in most of the patients due to ethical considerations for diagnosis of MASLD/MASH or NAFPD/NASP. The participants were not uniformly distributed among all grades of hepatic and pancreatic steatosis. CONCLUSION In recent years, incidence of MS has increased with consumption of processed foods as they promote fatty acid synthesis and reduce gut microbiome diversity. Obesity and IR form a vicious cycle causing hepatic and pancreatic fat deposition with further progression to fibrosis and other complications. The present study highlights that, in patients of MS, both HS and PS occur and with increase in grade of steatosis, stiffness also increases in both these organs which can be evaluated on 2D-SWE. Thus, along with biochemical parameters, 2D-SWE of liver and pancreas can be utilized in screening of MS patients for early detection and surveillance of further disease progression to prevent potential complications. Abbreviations Metabolic syndrome-associated steatotic liver disease (MASLD), Hepatic steatosis (HS), Pancreatic steatosis (PS); Non-alcoholic fatty pancreatic disease (NAFPD); Non-alcoholic fatty liver disease (NAFLD); 2D-shear wave elastography (2D-SWE); metabolic dysfunction-associated steatohepatitis (MASH); non-alcoholic steatopancreatitis (NASP); Body mass index (BMI); Declarations Author Contribution Dr. Duggireddy made substantial contributions to the conception of the work; the acquisition, analysis and interpretation of data; drafted the work.Dr. Dixit made substantial contributions to the conception of the work; analysis and interpretation of data; revised it critically for important intellectual content.Dr. Singh, Dr. Garg and Dr. Sachdeva reviewed the work; contributed with professional and intellectual input. References Rinella ME, Lazarus JV, Ratziu V, Francque SM, Sanyal AJ, Kanwal F et al. 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Sehgal R, Mittal J, Singh I. Correlation of Hepatic Steatosis with Hepatic Fibrosis in NAFLD Patients by Fibroscan. Asian J. Med. Res. 2020;9(3):1-7. Kim J, Albakheet SS, Han K, Yoon H, Lee MJ, Koh H et al. Quantitative MRI assessment of pancreatic steatosis using proton density fat fraction in pediatric obesity. Korean journal of radiology. 2021;22(11):1886. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Oct, 2025 Read the published version in Abdominal Radiology → Version 1 posted Editorial decision: Revision requested 04 Sep, 2025 Reviews received at journal 24 Aug, 2025 Reviews received at journal 18 Aug, 2025 Reviewers agreed at journal 13 Aug, 2025 Reviewers agreed at journal 13 Aug, 2025 Reviewers agreed at journal 11 Aug, 2025 Reviewers invited by journal 11 Aug, 2025 Editor assigned by journal 05 Aug, 2025 Submission checks completed at journal 05 Aug, 2025 First submitted to journal 05 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7296594","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":502199317,"identity":"dfebed22-6f72-4bda-a1e7-23d38fa01620","order_by":0,"name":"Chitty Suvarna Duggireddy","email":"data:image/png;base64,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","orcid":"","institution":"Maulana Azad Medical College","correspondingAuthor":true,"prefix":"","firstName":"Chitty","middleName":"Suvarna","lastName":"Duggireddy","suffix":""},{"id":502199318,"identity":"2a9532b7-1b86-4010-9361-35b3e8457b97","order_by":1,"name":"Rashmi Dixit","email":"","orcid":"","institution":"Maulana Azad Medical College","correspondingAuthor":false,"prefix":"","firstName":"Rashmi","middleName":"","lastName":"Dixit","suffix":""},{"id":502199319,"identity":"eba3c97c-0a18-49ac-a0be-08d5dd259e72","order_by":2,"name":"Sapna Singh","email":"","orcid":"","institution":"Maulana Azad Medical College","correspondingAuthor":false,"prefix":"","firstName":"Sapna","middleName":"","lastName":"Singh","suffix":""},{"id":502199320,"identity":"c666c0d4-da88-4304-86cd-dd349e1f5a01","order_by":3,"name":"Sandeep Garg","email":"","orcid":"","institution":"Maulana Azad Medical College","correspondingAuthor":false,"prefix":"","firstName":"Sandeep","middleName":"","lastName":"Garg","suffix":""},{"id":502199321,"identity":"f775d63d-ccef-4887-8e4c-c6e0eb2f0ec9","order_by":4,"name":"Sanjeev Sachdeva","email":"","orcid":"","institution":"Maulana Azad Medical College","correspondingAuthor":false,"prefix":"","firstName":"Sanjeev","middleName":"","lastName":"Sachdeva","suffix":""}],"badges":[],"createdAt":"2025-08-05 05:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7296594/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7296594/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00261-025-05244-9","type":"published","date":"2025-10-24T16:16:25+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89386141,"identity":"6ae09668-06b4-4923-9f51-6355b7e0b25a","added_by":"auto","created_at":"2025-08-19 12:34:30","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":20639,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of BMI (kg/m\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003e) among participants with different grades of hepatic steatosis/ fatty liver showing a statistically significant moderate correlation. (Ʈ=0.59, p\u0026lt;0.001).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7296594/v1/fe2c8d4d6e95c67b0caafcca.png"},{"id":89384720,"identity":"c413de42-8b7d-4c5f-96b5-7355b90ac7d7","added_by":"auto","created_at":"2025-08-19 12:26:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":23094,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of BMI (kg/m\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003e) among participants with different grades of pancreatic steatosis showing a statistically significant poor correlation. (Ʈ=0.24, p\u0026lt;0.001).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7296594/v1/04cef286fbcc80f4b63c5a99.png"},{"id":89386143,"identity":"cf4a5390-3cb4-4725-a6da-c93c560be23a","added_by":"auto","created_at":"2025-08-19 12:34:30","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":73831,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStatistical correlation between BMI (kg/m\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003e) and liver stiffness (Fig. 3a), pancreatic stiffness (Fig. 3b) on 2D-SWE (kPa) showing strong positive correlation (ρ = 0.7, p\u0026lt;0.001) and moderate positive correlation (ρ = 0.33, p\u0026lt;0.001) respectively.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7296594/v1/d245db5a1852a6675791b0ce.png"},{"id":89384721,"identity":"1b367954-a395-47ef-919a-de554c60f28c","added_by":"auto","created_at":"2025-08-19 12:26:30","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":59640,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStatistical correlation between liver stiffness and triglycerides (mg/dl) showing strong positive correlation (ρ = 0.67, p\u0026lt;0.001) (Fig.4a). Moderate positive correlation (ρ = 0.43, p\u0026lt;0.001) between pancreatic stiffness and fasting blood sugar (mg/dl) (Fig.4b).S\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7296594/v1/84b8a0da66b6dc39e06bb9d9.png"},{"id":89386142,"identity":"6cd1d10a-6595-4b67-afa7-33bbc389ea6d","added_by":"auto","created_at":"2025-08-19 12:34:30","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":28740,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStatistical correlation between liver stiffness and pancreatic stiffness moderate positive correlation (ρ = 0.5, p\u0026lt;0.001) respectively.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-7296594/v1/da5420d67e3bcf2f97966276.png"},{"id":94490732,"identity":"9255f887-c7c4-43bb-8f77-b756e1f2ab65","added_by":"auto","created_at":"2025-10-27 17:14:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1532415,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7296594/v1/acf6eb80-9beb-441a-b4c1-c07f69162a7d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003e2d-swe in Metabolic Syndrome: Beyond Masld, Interrrogating the Pancreas\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eMetabolic dysfunction-associated steatotic liver disease (MASLD) [earlier referred as non-alcoholic fatty liver disease (NAFLD)] is one of the most common diffuse liver diseases worldwide and is strongly associated with metabolic syndrome (MS). In some patients, it may progress through metabolic dysfunction-associated steatohepatitis (MASH) [previously referred to as non-alcoholic steatohepatitis (NASH)] to fibrosis, cirrhosis and even hepatocellular carcinoma. Recently, the terminology of NAFLD and NASH were reconsidered owing to their reliance on exclusionary confounders and stigmatizing terms such as \u0026ldquo;non-alcoholic\u0026rdquo; and \u0026ldquo;fatty\u0026rdquo;. A multisociety Delphi consensus statement on new fatty liver disease nomenclature was released in December 2023 replacing the term NAFLD by MASLD and including the presence of atleast one out of five cardiometabolic risk factors (CMRFs) to the definition. The CMRFs include high BMI, presence of type-2 diabetes mellitus (T2DM), hypertension, deranged triglycerides (TG) and HDL-cholesterol with exact criteria being defined separately for adults and pediatric population. A new category termed metabolic and alcohol related/ associated steatotic liver disease (MetALD) was introduced to describe those with MASLD who consume greater amounts of alcohol per day/week [weekly intake 140-350g female and 210-420g male; daily intake 20-50g female and 30-60g male]. Fatty liver with no metabolic parameters and no known cause is termed cryptogenic steatotic liver disease. Steatotic liver disease (SLD) is chosen as the over-arching term to include various etiologies of hepatic steatosis. Roughly around 98% of all NAFLD cases satisfy the definition of MASLD \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eBesides hepatic changes, it has been reported that MS may be commonly associated with pancreatic changes as well. Non-alcoholic fatty pancreatic disease (NAFPD) is the term used for fatty accumulation in the pancreas in the presence of MS and is usually associated with MASLD. However, no consensus was available regarding the modification of use of the term NAFPD, thus it is being used as such. Presence of atleast one of the components of the metabolic syndrome is associated with 37% increased prevalence of fatty pancreas.\u003c/p\u003e\u003cp\u003eWhile hepatic steatosis (HS) is well studied, pancreatic steatosis (PS) is less extensively studied. Excessive accumulation of fat in pancreas interferes with its physiological functions resulting in both exocrine and endocrine failure, thus fatty pancreas has role in many clinical implications such as type-2 diabetes mellitus, pancreatic exocrine insufficiency, acute pancreatitis and pancreatic cancer. Replacement of more than 25% of pancreatic parenchyma by fat is associated with severe increased risk of generalized atherosclerosis \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Similar to MASLD, NAFPD also show progression to non-alcoholic steatopancreatitis (NASP) and all these processes increase pancreatic echogenicity and stiffness.\u003c/p\u003e\u003cp\u003eNon-invasive assessment of pancreatic disease, besides hepatic disease is important in this scenario so as to allow complete evaluation of organ damage consequent to metabolic dysfunction. Ultrasound is best suited to fulfil this purpose due to its low cost, non-invasiveness and ubiquitous availability. Ultrasound based 2D shear wave elastography (2D-SWE) facilitates assessment of both anatomical information and tissue stiffness \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. It has been extensively in use to study hepatic changes in MASLD, but has not often been used to study pancreatic changes in NAFPD/ metabolic syndrome \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe study has been undertaken to comprehensively evaluate hepatic and pancreatic steatosis on grey-scale ultrasound and assess its association with hepatic and pancreatic stiffness using ultrasound 2D-SWE in patients of MS.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eThis cross-sectional study was approved by the institutional review board and ethics committee. All participants gave written informed consent.\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria were adults (i.e., over 18 years of age) with one or more of the following cardiometabolic risk factors: high BMI, presence of T2DM, hypertension, deranged TG \u0026amp; HDL-cholesterol. Participants were excluded from the study if they had one of the following: consumption of greater amounts of alcohol per day/week [weekly intake 140-350g female and 210-420g male; daily intake 20-50g female and 30-60g male], any focal lesion in liver/ pancreas/ spleen, abdominal lymphadenopathy, cardiac failure, previous history of hepatic/ pancreatic disease, history of surgical procedures on liver/ pancreas and pregnancy. One hundred and forty consecutive participants who met the inclusion and exclusion criteria were taken up for ultrasound elastography, however nine participants had to be excluded due to poor pancreatic visualization mainly due to obesity. Thus, a total of 131 participants including 53 males and 78 females were recruited for this study.\u003c/p\u003e\n\u003cp\u003eDemographic features such as age, gender, weight, and height of the participants were recorded. Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared (kg/m\u003csup\u003e2\u003c/sup\u003e).\u003c/p\u003e\n\u003cp\u003eBiochemical parameters including serum albumin(g/L), aspartate transaminase (IU/L), alanine transaminase (IU/L), alkaline phosphatase (IU/L), platelet count (x lacs/mm\u003csup\u003e3\u003c/sup\u003e), fasting blood glucose [FBG](mg/dl), HbA1c (%) and lipid profile including total cholesterol (mg/dl), HDL cholesterol (mg/dl), LDL cholesterol (mg/dl) and triglycerides (mg/dl) done within one month of the ultrasound examination and were recorded. Presence of diabetes was recorded in participants with FBG\u0026thinsp;\u0026ge;\u0026thinsp;126 mg/dl or HbA1c\u0026thinsp;\u0026ge;\u0026thinsp;6.5% and hypertension if blood pressure exceeded 140/90 mm Hg. AST (IU/L), platelet count (x 10\u003csup\u003e9\u003c/sup\u003e/L) were used to calculate AST to Platelet ratio index (APRI) using APRI online calculator tool. FIB-4 score was similarly calculated using ALT and platelet count. The cut-offs for APRI and FIB-4 scores were taken as 0.45 and 1 respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUltrasound examination\u003c/strong\u003e:\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003ePatients were kept fasting for 6\u0026ndash;8 hours before the ultrasound examination. A routine grey scale ultrasound of upper abdomen was performed in all subjects using GE LOGIQ S8 ultrasound system with curvilinear (C1-6) probe. Qualitative assessment of liver echogenicity and grading of HS was done as suggested by Saadeh S et al \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e (Image 1).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003eWith the patient in supine position and both hands placed overhead, probe was placed in the epigastric region and pancreas was visualized. Qualitative assessment of pancreatic echogenicity and grading of pancreatic steatosis was done as suggested by Paul J et al \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e (Image 2).\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eSubsequently, \u003cstrong\u003ehepatic stiffness\u003c/strong\u003e was measured in the right lobe of liver using intercostal approach, with the subject lying in slight lateral decubitus (30\u003csup\u003eo\u003c/sup\u003e) position and right arm in extension \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Keeping scanning pressure as minimum, a rectangular or square shaped ROI box was positioned 1.5-2 cm below liver capsule after carefully excluding hepatic vessels and biliary radicles. Patient was asked to hold breath at neutral breathing and elastography map was obtained. Efforts were made to achieve a homogenous colour map. Different colours on the map indicate varying degrees of tissue hardness. Cooler colours (green and blue) represent softer tissue while warmer ones (red) indicate stiffer tissue. Twelve SWE measurements (in m/s and kPa) were obtained within the ROI box and expressed as mean and median values (Image 3).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cstrong\u003ePancreatic stiffness\u003c/strong\u003e at head of pancreas was measured with the subject in supine position, probe in epigastric region and ROI in head of pancreas following similar precautions as for hepatic elastography \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Five 2D-SWE measurements (in m/s and kPa) were taken during suspended respiration and expressed as mean and median with IQR/M. (Image 4).\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eThe measurements for both hepatic and pancreatic stiffness were considered reliable when the IQR/M (Interquartile range/ median) value was \u0026le;\u0026thinsp;30% for kPa or \u0026le;\u0026thinsp;15% for m/s as suggested by the manufacturer and also stated in the ultrasound liver elastography consensus statement by Barr RG et al \u003csup\u003e[\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eLiver biopsy was done in 18 participants for patient management. Hepatic and pancreatic stiffness values, APRI and FIB-4 scores were compared among participants with different histopathological findings.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eSTATISTICAL ANALYSIS\u003c/h2\u003e\n \u003cp\u003eThe data obtained was entered in MS-Excel and analyzed using Statistical Package of the Social Sciences (SPSS) software version 25. Data were statistically described in terms of mean (SD), median (IQR) or percentages when appropriate. Chi-square test was used to evaluate the association between gender and PS grade. Kruskal-Wallis test was used to determine the statistical significance of association between steatosis grade and stiffness values. Correlation of BMI and biochemical parameters with HS/PS grades was evaluated by Kendall\u0026rsquo;s Tau Rank and that with stiffness values was evaluated using Spearman\u0026rsquo;s rank correlation. For all statistical tests, p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was taken to indicate a significant difference. For Kendall\u0026rsquo;s Tau coefficient, values of 0.26, 0.49, 0.71 were taken as cut-offs for moderate, strong and very strong correlation respectively.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eDemographic and clinical data\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eA total of 131 adult participants between the age group of 22 to 61 years (mean age 41.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7 years) were included in the study. The group consisted 53(40.46%) males and 78(59.54%) females. All the participants had one or more CMRFs fulfilling the MASLD criteria. The distribution of participants according to the presence of CMRFs and BMI was represented in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e respectively.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDistribution of participants based on the status of cardiometabolic risk factors/ (n\u0026thinsp;=\u0026thinsp;131).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eCardiometabolic risk factor\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eDeranged\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (\u0026gt;\u0026thinsp;23 kg/m\u003c/strong\u003e\u003csup\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sup\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.58%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e95.42%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlood pressure (\u0026gt;\u0026thinsp;130/85)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32.82%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67.18%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eFBS (\u0026gt;\u0026thinsp;100 mg/dl)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32.82%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67.18%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHbA1c (\u0026gt;\u0026thinsp;5.7%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35.11%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64.89%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eHDL-C (\u0026le;\u0026thinsp;40 mg/dl-males)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u0026le;\u0026thinsp;50 mg/dl females)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e70.23%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29.77%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTG (\u0026gt;\u0026thinsp;150 mg/dl)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.66%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e76.34%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDistribution of participants based on BMI (in kg/m\u003csup\u003e2\u003c/sup\u003e) (n\u0026thinsp;=\u0026thinsp;131).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eBMI (in kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003cp\u003e(WHO classification for Asian population)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eMales\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;78)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnderweight and normal\u003c/strong\u003e (\u0026le;\u0026thinsp;22.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4.58%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverweight\u003c/strong\u003e (23-24.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.34%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-obese\u003c/strong\u003e (25-29.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.74%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eObese I\u003c/strong\u003e (30\u0026ndash;40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e55.72%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eObese II\u003c/strong\u003e (40.1\u0026ndash;50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.85%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eObese III\u003c/strong\u003e (\u0026gt;\u0026thinsp;50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.76%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e53\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e78\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e131\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e100%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e33.62\u0026thinsp;\u0026plusmn;\u0026thinsp;5.05\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e35.21\u0026thinsp;\u0026plusmn;\u0026thinsp;8.14\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e34.57\u0026thinsp;\u0026plusmn;\u0026thinsp;7.08 (p\u0026thinsp;=\u0026thinsp;0.172)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eHepatic and pancreatic steatosis\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eOn grey-scale ultrasound, normal liver echogenicity was seen in 27(20.6%) participants, while 104(79.4%) had HS, out of which 43(41.3%) were male and 61(58.6%) were female. Grade 1, 2 and 3 HS were seen in 17.5%, 35.1% and 26.7% of the participants. Normal pancreatic echogenicity was evident in 36(27.48%) participants, while 95(72.52%) had PS, of these 39(41%) were male participants and 56(59%) were female. Grade 1 and 2 PS were seen in 43.5% and 29% of the participants with none having grade 3 PS. No significant difference was found between males and females in terms of grades of HS and PS (p\u0026thinsp;=\u0026thinsp;0.71 and p\u0026thinsp;=\u0026thinsp;0.96 respectively). The distribution of BMI (kg/m\u003csup\u003e2\u003c/sup\u003e) among various grades of HS and PS is depicted in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e respectively.\u003c/p\u003e\n\u003cp\u003eAmong the participants with HS and/or PS, biochemical parameters such as AST, ALT, ALP, FBG, HbA1c, total cholesterol, LDL cholesterol and triglycerides were higher compared to those without HS or PS. These parameters showed moderate to strong correlation with HS grade and only poor to moderate correlation with PS grade. Among them, serum triglycerides (Ʈ=0.57) were observed to have strong positive correlation with HS grade with mean values of 140\u0026thinsp;\u003cstrong\u003e\u0026plusmn;\u003c/strong\u003e\u0026thinsp;16.25 mg/dl, 169.9\u0026thinsp;\u003cstrong\u003e\u0026plusmn;\u003c/strong\u003e\u0026thinsp;26.8 mg/dl, 172.8\u0026thinsp;\u003cstrong\u003e\u0026plusmn;\u003c/strong\u003e\u0026thinsp;33.1 mg/dl and 302\u0026thinsp;\u003cstrong\u003e\u0026plusmn;\u003c/strong\u003e\u0026thinsp;96 mg/dl in participants with grade 0,1,2 and 3 HS respectively. FBG (Ʈ=0.34) showed modest correlation with PS grade with mean values of 99.01\u0026thinsp;\u0026plusmn;\u0026thinsp;16.28 mg/dl, 122.23\u0026thinsp;\u0026plusmn;\u0026thinsp;31.10 mg/dl and 134.84\u0026thinsp;\u0026plusmn;\u0026thinsp;33.53 mg/dl in participants with grade 0, 1 and 2 PS respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHepatic and pancreatic stiffness\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eIn our study, no significant difference was found between males and females in terms of overall hepatic stiffness (p\u0026thinsp;=\u0026thinsp;0.809 for kPa and 0.767 for m/s) and pancreatic stiffness (p\u0026thinsp;=\u0026thinsp;0.946 for kPa and 0.767 for m/s). The correlation of hepatic and pancreatic stiffness values with BMI is depicted in Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e and with the biochemical parameters is depicted in Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eThe mean hepatic and pancreatic stiffness values showed an increasing trend with increase in the grade of HS and PS respectively (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of hepatic stiffness values among grades of HS and pancreatic stiffness values among grades of PS (n\u0026thinsp;=\u0026thinsp;131).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003ekPa\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003em/sec\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eHS GRADE\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003eHEPATIC STIFFNESS\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 0 (n\u0026thinsp;=\u0026thinsp;27)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1.46\u0026ndash;4.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.32\u0026thinsp;\u0026plusmn;\u003c/strong\u003e\u0026thinsp;0.58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0.7\u0026ndash;1.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.02\u0026thinsp;\u0026plusmn;\u003c/strong\u003e\u0026thinsp;0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 1 (n\u0026thinsp;=\u0026thinsp;23)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e5.02\u0026ndash;7.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e6.24\u0026thinsp;\u0026plusmn;\u003c/strong\u003e\u0026thinsp;1.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1.29\u0026ndash;1.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.42\u0026thinsp;\u0026plusmn;\u003c/strong\u003e\u0026thinsp;0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 2 (n\u0026thinsp;=\u0026thinsp;46)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e7.14\u0026ndash;9.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e8.02\u0026thinsp;\u0026plusmn;\u003c/strong\u003e\u0026thinsp;1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1.53\u0026ndash;1.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.65\u0026thinsp;\u0026plusmn;\u003c/strong\u003e\u0026thinsp;0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 3 (n\u0026thinsp;=\u0026thinsp;35)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e6.83\u0026ndash;18.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e13.89\u0026thinsp;\u0026plusmn;\u003c/strong\u003e\u0026thinsp;1.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1.51\u0026ndash;2.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.14\u0026thinsp;\u0026plusmn;\u003c/strong\u003e\u0026thinsp;0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePS GRADE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"6\"\u003e\n \u003cp\u003e\u003cstrong\u003ePANCREATIC STIFFNESS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 0 (n\u0026thinsp;=\u0026thinsp;36)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.42\u0026ndash;4.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.07\u0026thinsp;\u0026plusmn;\u003c/strong\u003e\u0026thinsp;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.69\u0026ndash;1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.01\u0026thinsp;\u0026plusmn;\u003c/strong\u003e\u0026thinsp;0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 1 (n\u0026thinsp;=\u0026thinsp;57)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.04\u0026ndash;6.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.83\u0026thinsp;\u0026plusmn;\u003c/strong\u003e\u0026thinsp;1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.3\u0026ndash;1.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.4\u0026thinsp;\u0026plusmn;\u003c/strong\u003e\u0026thinsp;0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 2 (n\u0026thinsp;=\u0026thinsp;38)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.15\u0026ndash;15.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e8.41\u0026thinsp;\u0026plusmn;\u003c/strong\u003e\u0026thinsp;1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.47\u0026ndash;2.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.24\u0026thinsp;\u0026plusmn;\u003c/strong\u003e\u0026thinsp;0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 3 (n\u0026thinsp;=\u0026thinsp;0)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe hepatic and pancreatic stiffness were also correlated with each other and the results were depicted in Fig. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003eThe participants were categorized into three groups -participants with normal liver echogenicity, those with MASLD but normal APRI/FIB-4 score and those with MASLD with elevated APRI/FIB-4 scores. No discordance was found between APRI and FIB-4 scores in the participants with elevated scores. The distribution of hepatic and pancreatic stiffness values among these three groups were depicted in Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDistribution of hepatic stiffness based on fatty liver status and biochemical parameters(n\u0026thinsp;=\u0026thinsp;131).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNAFLD with normal APRI and FIB-4 score (n\u0026thinsp;=\u0026thinsp;46)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNAFLD with elevated APRI and FIB-4 score (n\u0026thinsp;=\u0026thinsp;58)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eLiver stiffness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ekPa\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.16\u0026thinsp;\u0026plusmn;\u0026thinsp;3.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.75\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003em/s\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.03\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePancreatic stiffness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ekPa\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.39\u0026thinsp;\u0026plusmn;\u0026thinsp;2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.31\u0026thinsp;\u0026plusmn;\u0026thinsp;2.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003em/s\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eLiver biopsy was done in 18 participants, of these, one had a normal liver, two had MASLD and fifteen showed changes of MASH. The distribution of mean hepatic and pancreatic stiffness values among these three groups were depicted in Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab5\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDistribution of hepatic and pancreatic stiffness based on liver biopsy status. (n\u0026thinsp;=\u0026thinsp;18).\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNormal (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMASLD (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMASH (n\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eLiver stiffness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ekPa\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15.49\u0026thinsp;\u0026plusmn;\u0026thinsp;2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003em/s\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.27\u0026thinsp;\u0026plusmn;\u0026thinsp;0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePancreatic stiffness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ekPa\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003em/s\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.56\u0026thinsp;\u0026plusmn;\u0026thinsp;0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eMetabolic syndrome (MS) is a cluster of conditions that increases the risk of T2DM, stroke and cardiac disease. It is defined by the presence of one or more CMRFs which include central obesity, hypertension, T2DM and dyslipidemia. Due to dyslipidemia and insulin resistance, increased subcutaneous and visceral fat accumulation occurs along with ectopic fat deposition in organs like heart, liver and pancreas resulting in cardiac lipomatosis, MASLD and NAFPD respectively. Due to its high prevalence, associated complications and high health care expenditure, correct assessment, grading, surveillance for MASLD, and its association with NAFPD is pertinent. In recent years, non-invasive liver disease assessment (NILDA) is becoming central to liver disease severity assessment and are expected to replace liver biopsy as a diagnostic tool in many clinical scenarios \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. NILDAs have been developed to assess the severity of steatosis, fibrosis and portal hypertension and are of two types, namely blood-based [APRI, FIB-4, NFS] and imaging-based tests [TE (transient elastography), SWE, MRE (MR elastography)].\u003c/p\u003e\u003cp\u003eUnlike liver stiffness which has been extensively studied, there are only a very few studies in literature that \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ehave\u003c/span\u003e evaluated pancreatic stiffness on ultrasound. Ultrasound elastography is being widely used in gastroenterology mostly related to hepatic pathologies. Among pancreatic diseases, it has been mainly used for evaluating pancreatitis and pancreatic masses either by transabdominal or endoscopic approach. Very limited studies have been done previously for evaluation of pancreatic stiffness by SWE. MS is associated with ectopic fat deposition in pancreas with consequent release of inflammatory factors that accelerate β-cell apoptosis or inhibit insulin secretion resulting in insulin resistance \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Further, fatty infiltration of pancreas contributes to increased stiffness through associated metabolic and inflammatory changes that promote fibrogenesis. Hence, we assessed pancreatic steatosis and pancreatic stiffness, besides hepatic steatosis and hepatic stiffness in patients with MS using 2D-SWE for comprehensive patient evaluation.\u003c/p\u003e\u003cp\u003eA total of 131 participants with MS were included in the present study. Out of these, HS was seen in 104(79.4%) participants and PS in 95(72.52%) participants which was roughly in agreement with previous studies \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e][\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e][\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eNone of the participants in underweight category had hepatic or pancreatic steatosis. The mean BMI showed an increasing trend with increase in grade of HS and PS with a statistically significant difference among various grades (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). While BMI showed a moderate correlation with HS grade(Ʈ=0.59), it only showed poor correlation with PS grade(Ʈ=0.24) \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e][\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e][\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. This is in agreement with the fact that obesity is a critical criterion of MS and with increase in obesity, ectopic fat deposition occurs both in liver and pancreas. Additionally, in obese individuals, disruption in equilibrium among hepatic fat synthesis, oxidation and export results in hepatic steatosis, thus obesity affects liver more than pancreas \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWith increase in the grade of HS/PS, the hepatic enzymes (AST, ALT, ALP), FBS, HbA1c, TC, LDL-C, triglycerides showed increasing trend and serum albumin, platelet count and HDL cholesterol showed decreasing trend. Statistically significant difference was found among all HS grades in terms of all biochemical parameters(p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), showing a moderate to strong correlation with HS grade and poor to moderate correlation with PS grade. Among them, serum triglycerides were observed to have highest correlation with HS grade ((Ʈ=0.57) which is in agreement with the fact that dyslipidemia is a risk factor of MASLD. In patients with metabolic syndrome, IR mediated enhanced hepatic uptake of FFAs, activation of denovo lipogenesis and altered triglyceride export results in hepatic steatosis and triggers inflammation resulting in MASH \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. On the other hand, FBG was shown to have highest correlation with PS grade (Ʈ=0.34) which depicts the common role of IR in NAFPD. IR results in intracellular fat accumulation in pancreas which appears as increased echogenicity on grey-scale ultrasound. Fat accumulated in both exocrine and endocrine cells of pancreas further causes increased IR and T2DM with increased FBG levels. Similar findings have been reported in earlier studies \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e][\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e][\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e][\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn our study, no statistically significant difference was found in terms of hepatic and pancreatic stiffness values among different age or gender groups. A strong positive correlation was found between BMI and hepatic stiffness (ρ\u0026thinsp;=\u0026thinsp;0.67, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while it showed a moderate positive correlation with pancreatic stiffness (ρ\u0026thinsp;=\u0026thinsp;0.3, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Hepatic stiffness showed moderate to strong correlation with biochemical parameters, among which triglycerides showed strongest positive correlation, while serum albumin had shown weak and negative correlation. Pancreatic stiffness showed moderate correlation with FBS and only weak correlation with other biochemical parameters. It has been suggested that IR plays role in fat accumulation, inflammation and subsequent fibrogenesis in both liver and pancreas reflecting as increased stiffness \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eHepatic stiffness values were observed to be high among MASLD patients with elevated APRI and FIB- 4 scores. This is in agreement with the fact that progression of liver disease to fibrosis results in reduced liver function and thus elevated APRI and FIB-4 scores, supporting use of these blood tests as a part of NILDAs \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Further, our study also suggests the role for SWE in assessment of hepatic stiffness in MS patients, providing another non-invasive tool for monitoring the patients for disease progression and timely management.\u003c/p\u003e\u003cp\u003eIn the absence of HS, mean hepatic stiffness values were 3.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58 kPa and 1.02\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10 m/sec, whereas in those with HS, the values were 9.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 kPa and 1.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19 m/sec (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean liver stiffness values also showed an increasing trend with increase in the HS grade with a statistically significant difference between the four groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). HS grade showed strong positive correlation with liver stiffness values in kPa (Ʈ=0.84) and m/s (Ʈ=0.85) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e][\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e][\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe mean pancreatic stiffness values were 3.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 kPa and 1.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07 m/sec in participants with absence of PS and 6.69\u0026thinsp;\u0026plusmn;\u0026thinsp;1.04 kPa and 1.49\u0026thinsp;\u0026plusmn;\u0026thinsp;0.11 m/sec in those with PS(p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The pancreatic stiffness values showed an increasing trend with increase in PS grade with a statistically significant difference among various grades of PS (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) with a strong positive correlation \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. In NAFPD, excessive fat accumulation incites inflammation and fibrogenesis resulting in non-alcoholic steatopancreatitis (NASP), further increasing pancreatic stiffness. A moderate positive correlation between hepatic and pancreatic stiffness values was also observed in both kPa (Ʈ=0.35) and m/s (Ʈ=0.39). Since MS affects both liver and pancreas, it is important to monitor changes in both these organs for patient surveillance.\u003c/p\u003e\u003cp\u003eAmong the participants in whom liver biopsy was performed, the hepatic and pancreatic stiffness values were observed to be highest among participants with MASH followed by those with MASLD. It has been suggested that excessive hepatic fat accumulation incites release of hepatokines, activation of stellate cells and fibroblasts resulting in its progression to MASH, liver cirrhosis and fibrosis with further increase in liver stiffness. Assessment of liver stiffness can thus help in evaluating liver function decline.\u003c/p\u003e\u003cp\u003eThe main limitation of the study was that biopsy could not be performed in most of the patients due to ethical considerations for diagnosis of MASLD/MASH or NAFPD/NASP. The participants were not uniformly distributed among all grades of hepatic and pancreatic steatosis.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn recent years, incidence of MS has increased with consumption of processed foods as they promote fatty acid synthesis and reduce gut microbiome diversity. Obesity and IR form a vicious cycle causing hepatic and pancreatic fat deposition with further progression to fibrosis and other complications. The present study highlights that, in patients of MS, both HS and PS occur and with increase in grade of steatosis, stiffness also increases in both these organs which can be evaluated on 2D-SWE. Thus, along with biochemical parameters, 2D-SWE of liver and pancreas can be utilized in screening of MS patients for early detection and surveillance of further disease progression to prevent potential complications.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMetabolic syndrome-associated steatotic liver disease (MASLD), Hepatic steatosis (HS), Pancreatic steatosis (PS); Non-alcoholic fatty pancreatic disease (NAFPD); Non-alcoholic fatty liver disease (NAFLD); 2D-shear wave elastography (2D-SWE); metabolic dysfunction-associated steatohepatitis (MASH); non-alcoholic steatopancreatitis (NASP); Body mass index (BMI);\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDr. Duggireddy made substantial contributions to the conception of the work; the acquisition, analysis and interpretation of data; drafted the work.Dr. Dixit made substantial contributions to the conception of the work; analysis and interpretation of data; revised it critically for important intellectual content.Dr. Singh, Dr. Garg and Dr. Sachdeva reviewed the work; contributed with professional and intellectual input.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eRinella ME, Lazarus JV, Ratziu V, Francque SM, Sanyal AJ, Kanwal F et al. A multi-society Delphi consensus statement on new fatty liver disease nomenclature. Annals of Hepatology. 2023:101133.\u003c/li\u003e\n \u003cli\u003ePaul J, Shihaz AV. Pancreatic steatosis: a new diagnosis and therapeutic challenge in gastroenterology. Arquivos de gastroenterologia. 2020 May 20;57:216-20.\u003c/li\u003e\n \u003cli\u003eSigrist RM, Liau J, El Kaffas A, Chammas MC, Willmann JK. Ultrasound elastography: review of techniques and clinical applications. Theranostics. 2017;7(5):1303.\u003c/li\u003e\n \u003cli\u003eLesmana CR, Gani RA, Lesmana LA. Non-alcoholic fatty pancreas disease, pancreatic cancer, and impact of endoscopic ultrasound examination on screening and surveillance. GASTROENTEROLOGY. 2017.\u003c/li\u003e\n \u003cli\u003eSaadeh S, Younossi ZM, Remer EM, Gramlich T, Ong JP, Hurley M et al. The utility of radiological imaging in nonalcoholic fatty liver disease. Gastroenterology. 2002;123(3):745-50.\u003c/li\u003e\n \u003cli\u003eFurlan A, Tublin ME, Yu L, Chopra KB, Lippello A, Behari J. Comparison of 2D shear wave elastography, transient elastography, and MR elastography for the diagnosis of fibrosis in patients with nonalcoholic fatty liver disease. American Journal of Roentgenology. 2020;214(1):W20-6.\u003c/li\u003e\n \u003cli\u003eDubois M, Ronot M, Houssel-Debry P, Brun V, Rayar M, Auger M et al. Performance of B-mode ratio and 2D shear wave elastography for the detection and quantification of hepatic steatosis and fibrosis after liver transplantation. European Journal of Gastroenterology \u0026amp; Hepatology. 2020;32(2):222-30.\u003c/li\u003e\n \u003cli\u003eBarr RG, Wilson SR, Rubens D, Garcia-Tsao G, Ferraioli G. Update to the society of radiologists in ultrasound liver elastography consensus statement. Radiology. 2020;296(2):263-74.\u003c/li\u003e\n \u003cli\u003eMilani I, Leonetti F, Capoccia D. 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Journal of Translational Gastroenterology. 2023 Dec 25;1(2):74-86.\u003c/li\u003e\n \u003cli\u003eSabry M, Youssef T, Shaker M, Salama MM, Assem N, Anwar CA. Portal venous and hepatic artery hemodynamic variation in non-alcoholic fatty liver disease. Egyptian Liver Journal. 2021;11(1):1-6.\u003c/li\u003e\n \u003cli\u003eMansour-Ghanaei R, Mansour-Ghanaei F, Naghipour M, Joukar F. Biochemical markers and lipid profile in nonalcoholic fatty liver disease patients in the PERSIAN Guilan cohort study (PGCS), Iran. Journal of Family Medicine and Primary Care. 2019;8(3):923.\u003c/li\u003e\n \u003cli\u003eNavale S, Vala D, Gupta M. Grading of Nonalcoholic fatty liver disease on ultrasound and its correlation with lipid profile. International Journal of Contemporary Medicine Surgery and Radiology. 2019;4(3):C187-92.\u003c/li\u003e\n \u003cli\u003eZhao X, An X, Yang C, Sun W, Ji H, Lian F. The crucial role and mechanism of insulin resistance in metabolic disease. Frontiers in endocrinology. 2023 Mar 28;14:1149239.\u003c/li\u003e\n \u003cli\u003eGupta N, Raj K, Chandra R, Malik A, Bagri N, Thakur M. Relationship between grey scale sonographic grades of fatty liver and shear wave elastographic values: an observational study.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eInternational Journal of Research in Medical Sciences\u003c/strong\u003e. 2019;7(2):526-531.\u003c/li\u003e\n \u003cli\u003eJamialahmadi T, Nematy M, Jangjoo A, Goshayeshi L, Rezvani R, Ghaffarzadegan K et al. Measurement of liver stiffness with 2D-shear wave elastography (2D-SWE) in bariatric surgery candidates reveals acceptable diagnostic yield compared to liver biopsy. Obesity surgery. 2019;29:2585-92.\u003c/li\u003e\n \u003cli\u003eSehgal R, Mittal J, Singh I. Correlation of Hepatic Steatosis with Hepatic Fibrosis in NAFLD Patients by Fibroscan. Asian J. Med. Res. 2020;9(3):1-7.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eKim J, Albakheet SS, Han K, Yoon H, Lee MJ, Koh H et al. Quantitative MRI assessment of pancreatic steatosis using proton density fat fraction in pediatric obesity. Korean journal of radiology. 2021;22(11):1886.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"abdominal-radiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aima","sideBox":"Learn more about [Abdominal Radiology](http://link.springer.com/journal/261)","snPcode":"261","submissionUrl":"https://submission.springernature.com/new-submission/261/3","title":"Abdominal Radiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Metabolic syndrome-associated steatotic liver disease (MASLD), Hepatic steatosis (HS), Pancreatic steatosis (PS), Hepatic stiffness, Pancreatic stiffness, Non-alcoholic fatty pancreatic disease (NAFPD), Non-alcoholic fatty liver disease (NAFLD), 2D-shear wave elastography (2D-SWE)","lastPublishedDoi":"10.21203/rs.3.rs-7296594/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7296594/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eThe purpose of this study was to evaluate hepatic and pancreatic steatosis on grey-scale ultrasound and assess its association with hepatic and pancreatic stiffness using ultrasound 2D-SWE in patients with metabolic syndrome (MS).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eOne hundred-and-thirty-one adult patients with metabolic syndrome were included in the study. Grey scale ultrasound of liver and pancreas was performed to evaluate grades of hepatic steatosis (HS) and pancreatic steatosis (PS) respectively. Subsequently, 2D-SWE was performed to obtain liver and pancreatic stiffness in kPa and m/s. Grades of HS and PS were correlated with BMI, biochemical parameters, hepatic and pancreatic stiffness values.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eModerate correlation was found between HS grade and BMI, while the correlation of PS grade with BMI was poor. On SWE, hepatic and pancreatic stiffness showed strong and moderate correlation with BMI, respectively. Among biochemical parameters, triglycerides showed highest correlation with HS grade and hepatic stiffness, while fasting blood glucose showed highest correlation with PS grade and pancreatic stiffness. The stiffness values of both organs showed statistically significant difference in participant groups with and without steatosis (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Mean hepatic and pancreatic stiffness values showed strong positive correlation with grade of HS (Ʈ=0.84) and PS (Ʈ=0.82), respectively.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eMetabolic syndrome is associated with both hepatic and pancreatic steatosis with consequent increase in hepatic and pancreatic stiffness values respectively. These show positive correlation with the grade of steatosis. 2D-SWE along with biochemical parameters, can be utilized in the screening of MS patients for early detection and surveillance of further disease progression to prevent potential complications.\u003c/p\u003e","manuscriptTitle":"2d-swe in Metabolic Syndrome: Beyond Masld, Interrrogating the Pancreas","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-19 12:26:25","doi":"10.21203/rs.3.rs-7296594/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-04T22:19:10+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-25T03:24:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-18T22:30:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"331778818881096027481454103884255086152","date":"2025-08-13T12:29:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183505958195757401164883342052776577994","date":"2025-08-13T12:09:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"173260548441704753153518981223442997110","date":"2025-08-11T12:57:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-11T11:52:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-05T12:20:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-05T12:19:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"Abdominal Radiology","date":"2025-08-05T05:24:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"abdominal-radiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aima","sideBox":"Learn more about [Abdominal Radiology](http://link.springer.com/journal/261)","snPcode":"261","submissionUrl":"https://submission.springernature.com/new-submission/261/3","title":"Abdominal Radiology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"d81f1735-6d5d-47f3-bfed-e1a74efeb395","owner":[],"postedDate":"August 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-27T16:39:06+00:00","versionOfRecord":{"articleIdentity":"rs-7296594","link":"https://doi.org/10.1007/s00261-025-05244-9","journal":{"identity":"abdominal-radiology","isVorOnly":false,"title":"Abdominal Radiology"},"publishedOn":"2025-10-24 16:16:25","publishedOnDateReadable":"October 24th, 2025"},"versionCreatedAt":"2025-08-19 12:26:25","video":"","vorDoi":"10.1007/s00261-025-05244-9","vorDoiUrl":"https://doi.org/10.1007/s00261-025-05244-9","workflowStages":[]},"version":"v1","identity":"rs-7296594","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7296594","identity":"rs-7296594","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}