The goal of this observational study is to determine the prevalence of pancreatic steatosis in patients with fatty liver and determine the prevalence of exocrine pancreatic insufficiency (EPI) in these patients.

Participants with fatty liver and metabolic syndrome will undergo fecal elastase measurement and endoscopic ultrasound (EUS).

The purpose of this study is to evaluate the association between non-alcoholic fatty liver disease and non-alcoholic pancreatic steatosis and to describe cytokine levels in the context of a global epidemic of obesity and metabolic syndrome, which could represent a new treatment target in previously underdiagnosed patients with pancreatic insufficiency and pancreatic steatosis.

Patients over 18 years old with a diagnosis of MAFLD (Metabolic Dysfunction-Associated Fatty Liver Disease) will undergo the following assessments:

• Exocrine Pancreatic Insufficiency Questionnaire (PEI-Q)
• Measurement of weight, height, and abdominal circumference
• Fecal elastase (Fel-1)
• Pro-inflammatory and anti-inflammatory cytokines in serum
• Hydrogen and methane breath tests to evaluate small intestinal bacterial overgrowth (SIBO)
• Endoscopic ultrasound with sedation
• Fibroscan Exocrine pancreatic insufficiency (EPI) will be defined as a fecal elastase-1 (Fel-1) concentration of < 100 µg/g or Fel-1 between 100 and 200 µg/g with alterations in additional pancreatic pathology tests, such as serum albumin, vitamin E, vitamin D, vitamin A, folic acid, iron, transferrin, calcium, magnesium, and/or malnutrition identified through anthropometric measurements conducted by an expert nutritionist. Fel-1 ≥ 200 µg/g will be considered normal.

Additionally, for those patients with fecal elastase levels below 200 µg/g, the following measurements will be conducted:

• Proteinogram
• Vitamin E, vitamin D, vitamin A, vitamin K
• Folic acid, B12
• Calcium, magnesium, zinc
• Iron profile
• Nutritional assessment with anthropometry

For those with exocrine pancreatic insufficiency (EPI):

• IgG4
• Alpha-1 antitrypsin
• Endoscopic ultrasound (EUS) with biopsies

Inclusion Criteria:

• Patients over 18 years old with a diagnosis of Metabolic Dysfunction-Associated Fatty Liver Disease (MAFLD).

Exclusion Criteria:

• - Alcohol consumption >20 g/day in women, >30 g/day in men
• Chronic hepatitis B or C infection
• Autoimmune liver diseases: autoimmune hepatitis, primary biliary cholangitis, primary sclerosing cholangitis
• Hereditary hemochromatosis
• Wilson's disease
• Alpha-1 antitrypsin deficiency
• Celiac disease
• Uncontrolled thyroid disease
• Active or chronic infectious disease
• Active cancer or ongoing treatment
• Chronic renal insufficiency
• Pregnancy/lactation
• Insufficient data
• Patients who do not complete follow-up

Patients over 18 years old with a diagnosis of Metabolic Dysfunction-Associated Fatty Liver Disease (MAFLD).

The data sets, including the redacted study protocol, redacted statistical analysis plan, and individual participant data supporting the results reported in this article, will be made available within 3 months from initial request to researchers who provide a methodologically sound proposal. The data will be provided after its de-identification, in compliance with applicable privacy laws, data protection, and requirements for consent and anonymization.