Sudan University of Science and Technology Collage of Graduate Studies Assessment of Pancreas in Diabetic Patients using Ultrasound ﺗﻘﯿﯿﻢ اﻟﺒﻨﻜﺮﯾﺎس ﻟﺪى ﻣﺮﺿﻰ اﻟﺴﻜﺮي ﺑﺎﺳﺘﺨﺪام اﻟﻤﻮﺟﺎت ﻓﻮق اﻟﺼﻮﺗﯿﮫ Thesis Submitted for Partial Fulfillment of the Requirement of MSc Degree in Medical Diagnostic Ultrasound Presented by: Mona Abdalbagi Hamed Mohammed Hamed Supervisor: Dr: Asma Ibrahim Ahmed Elamin 2017 ﺑﺴﻢ ﷲ اﻟﺮﺣﻤﻦ اﻟﺮﺣﯿﻢ 8 7 £ ¢ ¡ ~ } | { z y x w v u t s M L ª © ¨ §¦ ¥ ¤ ﺻﺪق ﷲ اﻟﻌﻈﯿﻢ ﺳﻮرة اﻻﺳﺮاء اﻵﯾﺔ( 111) I Dedication To my father and mother whom encouraged me join in M.sc of ultrasound. They supplied me with all my needs and followed me step by step. They never show unwillingness or annoyance to my needs. To my brothers and sisters who helped me a lot. To my friends whom always support and helped me all the time. II Acknowledgement First I am grateful to Allah as he helped me to gain knowledge to finish this research. He also gave me health and patience to overcome the difficulties. So I am thankful to him all my life. Secondly my thanks also to my supervisor Dr. Asma Ibrahim who devoted her time and generously gave his knowledge and experience to me without limits, I would like to express my gratitude to Ustaz: Abdurrahman Hassan, And the whole staff of the collage of medical radiological science, SUST for their great help and Support. My thanks extended to Ultrasound departments which is the place where I took all my samples. And my colleagues who helped me to finished my research. Finally I would like to thank everybody whom helped me in preparing and finishing this study. III ﻣﻠﺨﺺ اﻟﺪراﺳﮫ ھﺬه اﻟﺪراﺳﺔ وﺻﻔﯿﺔ ﻣﺴﺘﻘﺒﻠﯿﺔ أﺟﺮﯾﺖ ﻓﻰ ﻣﺴﺘﺸﻔﻰ اﻟﺸﺮطﮫ وﻣﺮﻛﺰ اﻟﻤﺘﻜﺎﻣﻞ اﻟﺼﺤﻲ ﻓﻰ اﻟﻔﺘﺮة ﻣﻦ دﯾﺴﻤﺒﺮ2016 اﻟﻰ ﻣﺎرس 2017 . اﻟﮭﺪف ﻣﻦ ھﺬه اﻟﺪراﺳﺔ ھﻮ ﺗﻘﯿﯿﻢ اﻟﺒﻨﻜﺮﯾﺎس ﻟﻠﻤﺮﺿﻰ اﻟﻤﺼﺎﺑﯿﻦ ﺑﺎﻟﺴﻜﺮى اﻟﻨﻮع اﻟﺜﺎﻧﻲ ﺑﻮاﺳﻄﺔ ﺟﮭﺎزاﻟﻤﻮﺟﺎت ﻓﻮق اﻟﺼﻮﺗﯿﺔ .اﺳﺘﺒﻌﺪت اﻟﺪراﺳﺔ اﻟﻤﺮﺿﻰ اﻟﻤﺼﺎﺑﯿﻦ ﺑﺎﻻﻧﻮاع اﻻﺧﺮى ﻣﻦ اﻟﺴﻜﺮى . اﺗﺒﻌﺖ اﻟﺪراﺳﺔ اﻟﺒﺮﺗﻮﻛﻮل اﻟﻌﺎﻟﻤﻰ ﻻﻧﺠﺎز ﻓﺤﺺ اﻟﺒﻨﻜﺮﯾﺎس ﺑﻮاﺳﻄﺔ اﻟﻤﻮﺟﺎت ﻓﻮق اﻟﺼﻮﺗﯿﺔ .ﺗﻢ ﺟﻤﻊ اﻟﺒﯿﺎﻧﺎت وﺗﺼﻨﯿﻔﮭﺎ وﺗﺤﻠﯿﻠﮭﺎ ﺑﻮاﺳﻄﺔ ﺑﺮﻧﺎﻣﺞ اﻟﺘﺤﻠﯿﻞ اﻻﺣﺼﺎﺋﻰ .ووﺟﺪت اﻟﺪراﺳﺔ أن اﻟﻤﺮﺿﻰ اﻻﻧﺎث اﻛﺜﺮ ﻣﻦ اﻟ ّﺬﻛﻮر ﺑﻮاﻗﻊ 52 % و 48 % ﺑﺎﻟﺘﺮﺗﯿﺐ ,واﻛﺜﺮ اﻟﻔﺌﺎت اﻟﻌﻤﺮﯾﺔ اﺻﺎﺑﺔ ھﻢ 61- 68ﺳﻨﮫ وﯾﻤﺜﻠﻮن %26. اظﮭﺮت ﻧﺘﺎﺋﺞ اﻟﺪراﺳﺔ ان ﻣﺮﺿﻰ اﻟﺴﻜﺮى ﻣﻦ اﻟﻨﻮع اﻟﺜﺎﻧﻲ ﯾﺘﻌﺮﺿﻮن اﻟﻰ ﺗﻐﯿﺮات ﻓﻰ راس وﺟﺴﻢ واظﮭﺮت ان ھﻨﺎك ﻋﻼﻗﮫ طﺮدﯾﮫ ﺑﯿﻦ ﺟﺴﻢ اﻟﺒﻨﻜﺮﯾﺎس وﻛﻞ ﻣﻦ ﻋﻤﺮ ﺣﯿﺚ ﯾﺰﯾﺪ 0.0099 ﺳﻢ ﻣﻊ ﻛﻞ ﺳﻨﮫ و 0.00380ﺳﻢ ﻋﻨﺪ زﯾﺎدة واﺣﺪ ﻛﯿﻠﻮ ﺟﺮام وﻋﻜﺴﯿﮫ ﻣﻊ ﻓﺘﺮة اﺣﺘﻀﺎن اﻟﻤﺮض ﺣﯿﺚ ﯾﻨﻘﺺ ﻣﻘﺪار 0.005ﺳﻢ ﻣﻊ ﻛﻞ ﺗﻘﺪم ﺳﻨﮫ ﻓﻲ ﻋﻤﺮ اﻟﻤﺮض . وﺑﮭﺬه اﻟﻨﺘﺎﺋﺞ ﺗﻮﺻﻠﺖ اﻟﺪراﺳﺔ اﻟﻰ ان اﻟﺠﺴﻢ اﻛﺜﺮ ﺗﺄﺛﺮاً ﻣﻦ اﻟﺮاس ﺑﺎﻟﻤﺮض واﯾﻀﺎ ﺗﻮﺻﻠﺖ اﻟﺪراﺳﮫ اﻟﻰ ان اﻟﺒﻨﻜﺮﯾﺎس ﯾﻨﻘﺺ ﻓﻰ ﺣﺠﻤﮫ ﻋﻨﺪ اﻟﻤﺮﺿﻰ وﯾﺰﯾﺪ اﻟﻨﻘﺼﺎن ﺑﺰﯾﺎدة ﻓﺘﺮة اﺣﺘﻀﺎن اﻟﻤﺮض .اﯾﻀﺎ اظﮭﺮت ﻧﺘﺎﺋﺞ اﻟﺪراﺳﺔ اﻟﻰ ان اﻟﺒﻨﻜﺮﯾﺎس ﯾﺼﺒﺢ اﻛﺜﺮ ﺑﯿﺎﺿﺎ ﺑﺎﻟﺘﺼﻮﯾﺮ ﺑﺎﻟﻤﻮﺟﺎت ﻓﻮق اﻟﺼﻮﺗﯿﺔ ﻣﻊ زﯾﺎدة ﻓﺘﺮة اﺣﺘﻀﺎن اﻟﻤﺮض ﻣﻘﺎرﻧﮫ ﺑﺎﻟﺒﻨﻜﺮﯾﺎس اﻟﻄﺒﯿﻌﻰ. أوﺻﺖ اﻟﺪراﺳﺔ ﺑﺎﺳﺘﺨﺪام اﻟﻤﻮﺟﺎت ﻓﻮق اﻟﺼﻮﺗﯿﺔ ﺑﺼﻮرة روﺗﯿﻨﯿﺔ ﻓﻰ وﺣﺪات ﻣﻌﺎﻟﺠﺔ ﻣﺮﺿﻰ اﻟﺴﻜﺮى. IV Abstract A prospective and descriptive study was performed at Alribat hospital and Almutakamil Health during the period from December to march 2017. It has been done on 50 patients with type II diabetes and compared with 25 non diabetic patients. Aloka SSD- 500 (Japan) and ESAOTE Pie Medical Aquila – Japanese company – (3.5 -5 Megahertz) curve linear probe are used. The data was analyzed by using SPSS. The study was aimed to determine the echogenicity changes in the pancreas and to evaluate changes in the size of the head and the body of the pancreas in type2 diabetic patients by measuring the antero posterior diameter of head and body of the pancreas. The data was collected, classified, analyzed by using SPSS. The analysis of the results found that the male patients (48%) and (52%) females, most affected age group was in age from 61-68 years (26%). Pancreas ultrasound of sample showed that most of the patients developed abnormal pancreas findings in head and body of pancreas. Direct relations noted between body measurement and patient weight 0.0038cm for any one Kilogram increased, increased by 0.0099cm for any one year increased in age and inverse with duration of diabetes which decreased by 0.005cm for any one year increased in duration. The result represent that body more affected than the head of pancreas, also the pancreas become more hyperechoic than normal and all these findings increase with increase duration of illness. The study recommended utilization of ultrasound in diabetic patients' management and follow up. V List of Tables Table No Title Page (4-1) shows the gender (sex) frequency distribution 24 (4-2 ) Frequency distribution of patients according to age. 25 (4-3) Frequency distribution of patient according to pancreas 25 echogenicity (4-4) shows the Mean ± Std. Deviation for patient related variables 26 (4-5) Relation between patient gender and size of head and body of 27 pancreas (4-6) shows sample t-test for Equality of Means between head and body 27 of pancreas (4-7) show dimensions of the head of pancreas as function of age 28 (4-8) show dimensions of the body of pancreas as function of age 29 VI List of Figures Figure Title page No (2-1) Demonstrates the normal segmentations of pancreas 5 (2-2) Demonstrate pancreas relation to adjacent 6 (2-3) Demonstrate blood supply and lymphatic drainage of pancreas 7 (2-4) Demonstrate pancreas development 9 (2-5) Sonogram transverse scan of the pancreas 15 (3-1) Transverse plane of pancreas 21 (3-2) Sagital plane of pancreas 22 (4-1) Gender distribution 24 (4-2) Distribution of patients according to age 25 (4-3) Distribution of patient according to pancreas echogenicity 26 (4-4) Shows diagram of mean between head and body of pancreas in both male 28 and female diabetic patient (4-5) Scatter plot show dimensions of the head of pancreas as function of age 29 (4-6) Show dimensions of the body of pancreas as function of age 30 (4-7) Show mean between head and body of diabetic pancreas 30 (4-8) Show relation between body of diabetic pancreas and patient weight 31 (4-9) Show relation between body of diabetic pancreas and patient age 31 (4-10) Show relation between body of diabetic pancreas and duration of diabetes 32 (4-11) Show relation between head of diabetic pancreas and patient age 32 (4-12) Box plot shows measure the head of pancreas in control and diabetic group. 33 (4-13) Box plot shows measure the body of pancreas in control and diabetic group. 34 VII LIST OF ABBREVIATIONS DM : Diabetes mellitus US : Ultra Sound IVC : Inferior Vana Cava SMA : Superior Mesenteric Artery IDDM : Insulin Dependent Diabetes mellitus NIDDM : Non Insulin Dependent Diabetes mellitus VIII LIST OF CONTENTS Topic page No I اﻻﯾﮫ Dedication II Acknowledgment III Abstract (Arabic) IV Abstract (English) V List of tables VI List of figures VII List of abbreviations VIII List of contents IX CHAPTER ONE 1-1Introduction 1 1-2 Problem of study 2 1-3Objectives 2 1-3-1 General Objective 2 1-3-2 Specific Objectives 2 1-4 Over view of study 3 CHAPETR TWO 2-1.Anatomy 4 2-1-1Structure 4 2-1-2Relation 5 2-1-3Blood supply 6 2-1-4Lymphatic 6 2-1-5Variation 7 2-2 Development 8 2-3 Physiology 9 2-4 Pathology 11 2-4-1Diabetes 11 2-4-2Cystic fibrosis 12 IX 2-4-3Pancreatitis 12 2-4-4Pancreatic Neoplasm 13 2-5 Pancreatic Sonographic Appearance 14 2-Background studies 16 Chapter Three 3-1Materials 19 3-1-1Study Group 19 3-1-2 Ultrasound unit used 19 3-2Methods 19 3-2-1 Ultrasound Technique 19 3-2-2 Data collection 21 3-2-3Data analysis 21 Chapter Four Result 22 Chapter Five 5-1 Discussion 33 5-2Conclusion 36 5-3 Recommendations 37 References 38 Appendices X Chapter One Introduction 1-1 Introduction Diabetes mellitus (DM) comprises a group of common metabolic disorders that share the phenotype of hyperglycemia. (Mealey and Ocampo, (2007)) There are two types of DM: type I which is an autoimmune disorder with infiltration of inflammatory cells in Islets of Langerhans and distraction of pancreatic beta cells and type II which is characterized with disturbance in insulin secretion, peripheral resistance to insulin and overproduction of glucose by liver. Pancreas as the insulin-producing gland is changed and destroyed in the process that leads to diabetes. (Hekmatnia et al. 2007) The pancreas lies retroperitoneally in roughly the transpyloric plane. For descriptive purposes it is divided into head, neck, body and tail, It’s macroscopically is lobulated and is contained within a finecapsule; these lobules are made up of alveoli of serous secretory cells draining via their ductinto the principal ducts. Between these alveoli lie the insulin-secretin.The main duct of the pancreas (Wirsung) runs the length of the gland and usually opens at the ampulla of Vater in common with the common bile duct; occasionally it drains separately into the duodenum. An islet of Langerhans.The accessory duct (of Santorini) passes from the lower part of the head in front of the main duct, communicates with it, and then opens into the duodenum above it. Occasionally it is absent. (Snell 2003) The pancreas is one of the juices and enzymes production organ, this enzymes help in digesting fat, protein, and carbohydrates before being absorbed by the intestine. The pancreas also produces insulin, which is important in regulating the Glucose concentration in the blood. Any system dysfunction or irregularity occurs 1 to the pancreas may lead to several diseases such as diabetes mellitus, acute Pancreatitis, chronic pancreatitis, pancreatic enzyme deficiency as well as pancreas tumor.