RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA BANGALORE

ANNEXURE - II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. Name of the Candidate & : Dr. KRISHNA CHAITANYA NUNNA Address DEPT. OF RADIODIAGNOSIS (In block letters) M.R.MEDICAL COLLEGE, GULBARGA-585105.

Permanent Address : 12-17-75/12, SONTIVARI STREET, REPALLE, GUNTUR DISTRICT, ANDHRA PRADESH-522265

2. Name of the Institution : H.K.E SOCIETY’S MAHADEVAPPA RAMPURE MEDICAL COLLEGE, GULBARGA-585105

3. Course of Study and Subject : M.D.RADIODIAGNOSIS 4. Date of Admission to Course : 15.07.2013 5. Title of the Topic : ROLE OF MR CHOLANGIO- PANCREATICOGRAPHY IN PATIENTS WITH PANCREATICOBILIARY DISEASES 6. Brief resume of the intended work 6.1 Need for the study:

Magnetic resonance cholangiopancreatography (MRCP) is a technique that has evolved over the past two decades. It has now an established role in the investigation of many biliary disorders, serving as a non-invasive alternative to endoscopic retrograde cholangiopancreatography (ERCP).

MRCP is prinicipally used to examine diseases of the liver, gallbladder, bile ducts, pancreas and pancreatic duct. These may include tumors, stones, inflammation or infection. It is also used to evaluate patients with pancreatitis to detect the underlying cause. It may help to diagnose unexplained abdominal pain.

It also helps in identification of congenital anomalies of the cystic and hepatic ducts. MRCP is useful in the demonstration of post-surgical biliary anatomy and in the detection of biliary complications, with a 100% sensitivity in the diagnosis of anastomotic strictures and a 90% sensitivity for choledocholithiasis. MRCP can assist detection of Anomalous pancreaticobiliary junction.

MRCP can produce images comparable to those obtained by a more invasive exam called endoscopic retrograde cholangiopancreatography (ERCP) without its associated risks including pancreatitis, or inflammation of the pancreas, perforation of pancreatic and bile ducts and bowel, and the risks for intravenous sedation required for ERCP. MRCP has potentially two major advantages in neoplastic pancreatico-biliary obstruction. Firstly, MRCP can directly reveal extraductal tumor whereas ERCP depicts only the duct lumen. Second, MRCP lacks the major complication rate of approximately 3% associated with ERCP such as sepsis, bleeding, bile leak and death. MRCP is more sensitive than ERCP in demonstrating these fluid collections and may show their connection with the pancreatic duct. MRCP can help delineate these Cystic pancreatic tumours more clearly.

MRI may not always distinguish whether edema fluid is caused by infection, inflammation or cancer. It generally cannot detect calcium present in soft tissues such as tumors.

However the application of MRCP in the differential diagnosis of pancreatico biliary diseases needs further evaluation. This study would help in describing the features of pancreaticobiliary diseases on MRCP. It is a sensitive, very reliable non invasive imaging modality that helps in detection, diagnosis of the disease and provides valuable information of therapeutic and prognostic significance. Overall the purpose of this study will be to prospectively assess the accuracy of MR imaging.

6.2 Review of Literature:

1.Kiran R. Nandalur, Hero K. Hussain: MRCP by using the respiratory- triggered isotropic 3D fast-recovery FSE sequence with parallel imaging demonstrates excellent diagnostic capabilities for possible biliary disease, although it is limited for stones 3 mm or smaller in size1.

2.Katsuyoshi Ito, MD, Teruyuki Torigoe, MD : Twelve healthy volunteers and three patients with acute pancreatitis were included. MRCP with a spatially selective IR pulse was repeatedly performed every 15 seconds during a total of 10 minutes (total of 40 images). The study concluded that physiologic flow of the pancreatic juice can be visualized noninvasively with serial MRCP by using a spatially selective IR pulse.2

3.Mi-Suk Park, MD, Tae Kyoung Kim, MD: MRCP and ERCP images in 50 patients (27 with cholangiocarcinoma and 23 with benign cause of stricture) were retrospectively reviewed to assess the appearance of bile duct strictures. Final diagnosis was based on surgical or biopsy findings. Study concluded that accuracy of MRCP is comparable with that of ERCP. Regardless of modality, a lengthy segment of extrahepatic bile duct stricture with irregular margin and asymmetric narrowing suggests cholangiocarcinoma, and a short segment with regular margin and symmetric narrowing suggests benign cause.3 4.Aaron Sodickson, MD, PhD, Koenraad J. Mortele, MD: The 3D FRFSE sequence shows promise for improved visibility of the pancreatic duct and biliary tree, compared with the conventional 2D SSFSE thin-section and thick-slab approach, while permitting the entire MRCP examination to be performed in a single breath hold.4

5.Tomoaki Ichikawa, MD, Hironobu Sou, MD, Tsutomu Araki, MD :. The duct-penetrating sign on MRCP images was more helpful to distinguish inflammatory pancreatic mass from conventional pancreatic carcinoma than were the enhancement patterns on CT and MR images.5

6.Dave, MD, MPH, B. Joseph Elmunzer, MD: MRCP has high sensitivity and very high specificity for diagnosis of Primary sclerosing cholangitis. In many cases of suspected PSC, MRCP is sufficient for diagnosis, and, thus, the risks associated with ERCP can be avoided.6

7.H Irie, H Honda, T Tajima : Half-Fourier rapid acquisition with relaxation enhancement (RARE) MRCP has the highest contrast and spatial resolution among the four techniques studied and may play an important role in diagnosing pancreatic abnormalities.7

8.Hiroki Haradome, MD, Tomoaki Ichikawa, MD : MRCP findings and those of a combination of unenhanced and arterial phase computed tomography (CT) and arterial phase MR imaging were retrospectively compared in 29 patients who were pathologically proven to have adenomyomatosis of the gallbladder and in 18 patients with pathologically proven gallbladder carcinoma. The pearl necklace sign, which indicates the presence of Rokitansky-Aschoff sinuses within the thickened gallbladder wall, was specifically detected at MRCP for adenomyomatosis of the gallbladder.8

9.Enrique Lopez Hänninen, MD, Holger Amthauer, MD: Sixty-six patients suspected of having pancreatic tumors underwent MR imaging (unenhanced and contrast material–enhanced MR, MRCP, and contrast-enhanced MR angiography). Study concluded that unenhanced and contrast-enhanced MR imaging with MRCP and MR angiography offers potential as a noninvasive tool for assessment of patients suspected of having pancreatic tumors.9

10.AOTO, MD RERNST, MD,L GHULMIYYAH, MD,HUGHES, MD: MRCP appears to be a valuable and safe technique for the evaluation of pregnant patients with acute pancreaticobiliary disease. MRCP can determine the aetiology and save the patient from unnecessary endoscopic retrograde cholangiopancreatography by excluding a biliary pathology.10 6.3 Objectives of the Study

1. To describe the features of pancreatico-biliary diseases on MRCP.

2. Outlining the extent in terms of involvement of adjacent structures, vessels and soft tissues.

3. To help in deciding further course of management.

4. To identify the anatomical variants.

5. Comparing MRCP to ERCP whenever necessary.

6. To prove the Magnetic Resonance Cholangio-Pancreatography (MRCP) is one of the best imaging modality for evaluation of pancreatico-biliary disease

7 MATERIAL AND METHODS

7.1 Source of Data:

After informed & written consent from the patient has been obtained, the study will be done on patients presenting with features suggestive of pancreatico- biliary diseases attending the OPD or admitted in various wards of Basaveshwar teaching & General Hospital and Sangameshwar teaching hospital, Gulbarga attached to M.R. Medical College, Gulbarga.

The source of data for this study will be patients referred to the Department of Radiodiagnosis, basaveswara teaching and general hospital gulbarga for MRCP. This consists of a study of 50 patients from September 2013 to march 2015.

7.2 Methods of collection of data (including sampling procedure)

Types of Study: Prospective study

Sample size: The study will be conducted on a minimum of 50 sample patients (by random sampling technique 50 samples are selected) features suggestive of pancreaticobiliary diseases who are referred to the department of radiodiagnosis, Basaveshwar teaching & General Hospital, Gulbarga attached to M.R. Medical college, Gulbarga during the period of November 2013 to August 2015. But the scope for increasing the number of cases depending on the availability of patients within the study period. For evaluation of the pancreaticobiliary diseases , MRCP will be performed using a 1.5 tesla MRI scanner .(Philips achieva).

Inclusion criteria: All patients who are detected to have any of the following pancreaticobiliary diseases on MRCP: 1. Acute and chronic pancreatitis 2. Pancreatic cancer 3. Cystic disease of bile duct (choledochal cyst, choledochocele) 4. Stones and strictures of the pancreas 5. Sclerosing cholangitis 6. Primary Biliary Cirrhosis 7. Anatomic variants such as pancreas divisum, aberrant cystic duct and other duct anomalies 8. Biliary Diseases 9. Post-surgical biliary complications 10. Pancreas Divisum 11. Cholangiocarcinoma Exclusion Criteria 1. Cardiac pacemakers 2. Ferromagnetic aneurysm clips 3. Intraorbital metallic foreign bodies 4. Severe claustrophobia 5. Metallic orthopedic implants

7.3 Does the study require any investigation or intervention to be conducted on patients or other humans or animals? If so please describe briefly.

YES. The study requires the use of MRCP on the patients as part of evaluation of the suspected pancreaticobiliary diseases.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes. 8. LIST OF REFERENCES:

1. Possible Biliary Disease: Diagnostic Performance of High-Spatial-Resolution Isotropic 3D T2-weighted MRCP Kiran R. Nandalur, MD, Hero K. Hussain, MD, William J. Weadock, MD, Erik J. Wamsteker, MD, Timothy D. Johnson, PhD, Asra S. Khan, MD, Anthony R. D'Amico, MD, 2008, Vol. 249: 883- 890, 10.1148/ radiol. 2493080389 Radiographics. 2. The Secretory Flow of Pancreatic Juice in the Main Pancreatic Duct: Visualization by Means of MRCP with Spatially Selective Inversion-Recovery Pulse.Katsuyoshi Ito, MD, , Teruyuki Torigoe, MD, Tsutomu Tamada, MD, Koji Yoshida, RT, Koichi Murakami, RT, and Mayumi Yoshimura, MT. Radiology, 2011, Vol.261: 582-586, 10.1148/radiol.11110162. 3. Differentiation of Extrahepatic Bile Duct Cholangiocarcinoma from Benign Stricture: Findings at MRCP versus ERCP.Mi-Suk Park, MD, Tae Kyoung Kim, MD,Kyoung Won Kim, MD, Sung Won Park, MD, Jeong Kyung Lee, MD, Jung-Sun Kim, MD, Jean Hwa Lee, MD, Kyoung Ah Kim, MD, Ah Young Kim, MD, Pyo Nyun Kim, MD, Moon-Gyu Lee, MD, and ,Hyun Kwon Ha, MD. Radiology, 2004, Vol.233: 234-240, 10.1148/radiol.2331031446. 4. Three-dimensional Fast-Recovery Fast Spin-Echo MRCP: Comparison with Two- dimensional Single-Shot Fast Spin-Echo Techniques.Aaron Sodickson, MD, PhD, Koenraad J. Mortele, MD, Matthew A. Barish, MD, Kelly H. Zou, PhD, Steven Thibodeau, BS, RT, and Clare M. C. Tempany, MD Radiology, 2006, Vol.238: 549-559, 10.1148/radiol.2382032065. 5. Duct-penetrating Sign at MRCP: Usefulness for Differentiating Inflammatory Pancreatic Mass from Pancreatic Carcinomas. Tomoaki Ichikawa, MD, Hironobu Sou, MD, Tsutomu Araki, MD, Ali S. Arbab, MD, Takeharu Yoshikawa, MD, Keiichi Ishigame, MD, Hiroki Haradome, MD, and Junichi Hachiya, MD. Radiology, 2001, Vol.221: 107-116, 10.1148/radiol.2211001157. 6. Primary Sclerosing Cholangitis: Meta-Analysis of Diagnostic Performance of MR Cholangiopancreatography.Maneesh Dave, MD, MPH, B. Joseph Elmunzer, MD, Ben A. Dwamena, MD, and Peter D. R. Higgins, MD, PhD, MSc. Radiology, 2010, Vol.256: 387-396, 10.1148/radiol.10091953. 7. Optimal MR cholangiopancreatographic sequence and its clinical application.H Irie, H Honda, T Tajima, T Kuroiwa, K Yoshimitsu, K Makisumi, and K Masuda. Radiology, 1998, Vol.206: 379-387, 10.1148/radiology.206.2.9457189 8. The Pearl Necklace Sign: An Imaging Sign of Adenomyomatosis of the Gallbladder at MR Cholangiopancreatography.Hiroki Haradome, MD, Tomoaki Ichikawa, MD, Hironobu Sou, MD, Takeharu Yoshikawa, MD, Akihisa Nakamura, MD, Tutomu Araki, MD, and Junichi Hachiya, MD. Radiology, 2003, Vol.227: 80-88, 10.1148/radiol.2271011378 9. Prospective Evaluation of Pancreatic Tumors: Accuracy of MR Imaging with MR Cholangiopancreatography and MR Angiography.Enrique Lopez Hänninen, MD, Holger Amthauer, MD, Norbert Hosten, MD, jens Ricke, MD, Michael Böhmig, MD, Jan Langrehr, MD, Rainer Hintze, MD, Peter Neuhaus, MD, Bertram Wiedenmann, MD, Stefan Rosewicz, MD, and Roland Felix, MD. Radiology, 2002, Vol.224: 34-41, 10.1148/radiol.2241010798. 10. The role of MR cholangiopancreatography in the evaluation of pregnant patients with acute pancreaticobiliary disease.AOTO, MD RERNST, MD, L GHULMIYYAH, MD,HUGHES, MD,G SAADE, MD and G CHALJUB, MD. 2009 Apr;82(976):279-85.doi: 10.1259/bjr/88591536.Epub 2008 Nov 24. PMID:19029218 9. Signature of Candidate :

10. Remarks of the Guide : This study differentiates, describes and classifies pancreaticobiliary diseases. based on their features on MRCP. 11. Name & Designation of (in block letters) 11.1 Guide Dr.SHRISHAIL S.PATIL M.D.R.D. ASSOCIATE PROFESSOR DEPARTMENT RADIODIAGNOSIS M.R.MEDICAL COLLEGE, GULBARGA

11.2 Signature

11.3 Co-guide

11.4 Signature

11.5 Head of the Dr.SURESH B.MASIMADE Department M.D.R.D. PROFESSOR & H.O.D., DEPARTMENT OF RADIODIAGNOSIS MAHADEVAPPA RAMPURE MEDICAL COLLEGE, GULBARGA

11.6 Signature

12. 12.1 Remarks of the Chairman & Principal

12.2 Signature