Zaborienė, Inga

Introduction Pancreas bifidum, also known as bifid or fish-tail pancreas, is a rare developmental anomaly characterized by duplication of the pancreatic duct. This differs from pancreas divisum, in which the dorsal and ventral ducts fail to fuse. Most cases are asymptomatic and found incidentally on CT, MRI, or MRCP [1]. Unlike pancreas divisum (4-14 % prevalence) [2], pancreas bifidum is extremely rare, with fewer than 30 cases reported [3]. Case Presentation A 63-year-old male presented with jaundice, epigastric pain, nausea, and weakness. Laboratory tests revealed hyperbilirubinemia, elevated inflammatory markers, and renal impairment. The patient was diagnosed with acute cholangitis complicated by sepsis due to obstruction of a previously placed biliary stent. Contrast-enhanced CT showed biliary stent obstruction and duplication of the pancreatic body and tail with homogeneous enhancement; both ducts were dilated (3.0 mm and 5.1 mm). An indeterminate lesion in the pancreatic head was also detected. MRCP confirmed two pancreatic ducts converging normally into the duodenum. Biliary obstruction was treated with endoscopic stent replacement and antibiotics, with clinical improvement. The bifid pancreas was considered an incidental benign finding, while further evaluation was recommended for the pancreatic head lesion. Discussion The anatomical configuration of a bifid pancreas, with two ducts extending through the body and tail and merging near the head, may complicate imaging interpretation and affect diagnosis by mimicking pathology, particularly in the presence of ductal dilatation or atypical lesions [2,4]. Most cases are incidental, although some present with acute pancreatitis [4]. MRCP plays the main role in evaluating congenital pancreatic duct anomalies, while CT helps assess parenchymal changes and exclude neoplastic processes [1,3,4]. These findings highlight the importance of accurate imaging interpretation in distinguishing rare pancreatic duct variants from pathological conditions. Conclusions Recognition of pancreas bifidum on imaging prevents misclassification and unnecessary treatment. Accurate imaging interpretation is essential. Asymptomatic patients can be managed conservatively, whereas ductal dilatation or atypical lesions, particularly in the pancreatic head, require further evaluation.

Pratarmė. Mieli studentai, Gastroenterologija yra viena įdomiausių ir greičiausiai besiplėtojančių medicinos sričių. Dėl mokslo ir technologijų pažangos XXI a. gastroenterologija apima vis platesnį kepenų ir virškinamojo kanalo ligų, gydymo metodų spektrą. Tai neabejotinai viena įvairiapusiškiausių specialybių, kur akivaizdi klinikinių įgūdžių, molekulinių ir ultragarsinių tyrimų bei sudėtingų endoskopinių intervencijų sąsaja. Uždegiminės žarnyno ligos, retos virškinamojo kanalo ligos, mikrobiotos ir kepenų transplantacija yra tik nedidelė dalis sričių, kurios yra patikėtos gydytojams gastroenterologams. Šis Lietuvos sveikatos mokslų universiteto Medicinos akademijos Medicinos fakulteto Gastroenterologijos klinikos (toliau - Gastroenterologijos klinika) kolektyvo parengtas vadovėlis yra skirtas studentams, siekiantiems susipažinti su gastroenterologijos pagrindais. Jau beveik 30 metų Gastroenterologijos klinika aktyviai dalyvauja rengiant tarptautines diagnostikos ir gydymo gaires, yra prestižinių tarptautinių mokslo projektų ir konsorciumų dalyvė, o 2020 m. klinika tapo ir asocijuota Europos retų kepenų ligų tinklo nare. Mūsų klinikos mokslinių tyrimų rezultatai yra publikuojami prestižiniuose mokslo leidiniuose: Nature, Lancet, New England Journal of Medicine, Nature Genetics ir kituose. Rengdami šį vadovėlį stengėmės perteikti visą klinikos sukauptą ilgametę pedagoginę ir klinikinę patirtį bei naujausius mokslo pasiekimus. Tikimės, kad šis vadovėlis ne tik suteiks Jums pagrindinių žinių apie gastroenterologiją, bet ir paskatins rinktis šią specialybę rezidentūros studijose. Autorių vardu prof. Juozas Kupčinskas

Introduction: Pancreatic duct anomalies are clinically significant group of conditions that are often identified incidentally during radiological investigations [1]. Although many anomalies remain asymptomatic, conditions, such as pancreas divisum and ansa pancreatica are associated with increased risk of pancreatitis [2,3]. Accurate diagnosis relies heavily on imaging techniques. Aim To investigate the frequency of pancreatic duct anomalies, their association with pancreatitis, and the diagnostic accuracy of various radiological methods. Methods and Materials A systematic review was conducted following PRISMA guidelines, analyzing 18 studies sourced from PubMed database. Keywords included "pancreatic duct anomalies," "pancreatitis," and related terms. Studies released by June 11th, 2024, that met the selection criteria, were retrieved and reviewed. Discussion Systematic review included 18 studies analyzing 5,858 patients, comprising 48% males and 52% females, with an average age ranging from 36.9 to 63.5 years. The most common pancreatic duct anomaly was pancreas divisum (4-10% prevalence in the general population, higher rates among those undergoing imaging for pancreatitis). Studies utilizing MRCP with secretin demonstrated a diagnostic sensitivity of 84.5% and specificity of 88.1% compared to ERCP. While MRCP is less invasive, ERCP was more effective for direct visualization. It was followed by ansa pancreatica (0.5- 1.2% prevalence). This anomaly was predominantly diagnosed using MRCP, with sensitivity and specificity values exceeding 80% when secretin-enhanced sequences were included. A Japanese study with 587 patients revealed a significant association with recurrent acute pancreatitis (11.1% of cases). Lastly, for annular pancreas CT and MRI were effective for visualization. In symptomatic cases, annular pancreas often causes pancreatitis. Imaging studies identified coexisting pancreas divisum in 25% of these cases. MRCP with secretin emerged as the most sensitive and non-invasive imaging modality for detecting pancreatic duct anomalies, offering enhanced ductal visualization. Conclusion MRCP with secretin offers a non-invasive, highly sensitive diagnostic option, while ERCP and EUS remain essential tools for complex or therapeutic cases.

Šios naujoviškos Mokymo priemonės tikslas - ne tik supažindinti studentus su mokymo medžiaga, bet ir teikti antrinę informaciją - apie LSMU kaip inovatyvios naujoviškos aukštosios mokyklos galimybes, mokymo proceso lankstumą, ateities aspiracijas. Peržiūrėję mokymo medžiagą studentai galės lengviau orientuotis Klinikų miestelyje, medžiaga jiems padės suprasti radiologinio ištyrimo svarbą ir galimybes. Tai pat glaustai pateikiamos diagnostikos metodų galimybės, pačios fundamentalios indikacijos, tyrimų tvarka. Mokymo priemonė trumpai ir koncentruotai informuoja studentus apie tvarką Kauno klinikose, pateikiamas savotiškas įvadas i tolimesnį Radiologijos dalyko LSMU MF III kurso studentams mokymą (Radiologijos pagrindai. Regionų anatomija MF/RAD/M-V31). Neabejotinai, ši mokymo priemonė yra svarbi ne tik ja besinaudosiantiems ir įsisavinantiems studentams, tačiau svarbi ir kaip įdomi ir naujoviška papildoma mokymosi priemonė, naudotina ir ateityje kaip naujų skaitmeninamų ir virtualizuojamų mokymo dalykų pagrindas. Rekomenduoju Medicinos fakulteto tarybai pritarti ir aprobuoti šią inovatyvią mokymo priemonę. (LSMU MA Radiologijos klinikos prof. A. Basevičius)

Colorectal cancer (CRC) is a major global health problem with a high rate of incidence and mortality. As the third most common cancer globally and the second in terms of cancer-related deaths, it substantially burdens healthcare systems and society. There were more than 1.9 million new cases of CRC in 2022 worldwide; meanwhile, in Europe, there were more than 538,000 new CRC cases. Magnetic resonance imaging (MRI) has become known as the primary diagnostic technique for the early stage of rectal cancer and is essential for precise diagnosis and treatment planning. MRI is essential for identifying tumor invasion, lymph node metastases, mesorectal fascia (MRF) involvement and extramural vascular invasion (EMVI), as well as understanding metrics such as tumor volume, tumor volume reduction rate, and magnetic resonance tumor regression grade. This thorough assessment offers a complete prognostic profile for malignancies, allowing clinicians to classify patients into low-, intermediate-, or high-risk categories. As the treatment for rectal cancer has become increasingly personalized, the role of radiologists has grown in significance. MRI is important for effective rectal cancer care, enabling a multidisciplinary approach that enhances collaboration among radiologists, surgeons, medical oncologists, radiation oncologists, and pathologists. The manifold evaluation guides treatment choices, from surgery exclusively for low-risk tumors to neoadjuvant radiation or chemoradiotherapy (CRT) for aggressive high-risk cases. The improvement of imaging techniques and reporting methodologies may significantly enhance patient outcomes and resolve the challenges presented by this widespread disease.

Background / Objective Hepatoblastoma (HB) is the most common primary malignant liver tumor for children under 5 years old. Diagnosis involves alpha-fetoprotein (AFP), imaging modalities, and histological examination. High AFP levels are found in 80-90 % of patients. Magnetic resonance imaging (MRI) is preferred as it is radiation-free and differentiates soft tissues effectively, while computer tomography (CT) has rapid scanning speed and high spatial resolution. Early detection is crucial, and imaging is indispensable. Imaging techniques play a key role in HB staging, deciding on treatment, monitoring the effectiveness of treatment, and identifying any recurrences. We aim to identify HB's MRI and CT radiological diagnostic features in pediatric patients. Methods A retrospective analysis of three pediatric patients with radiologically and histologically confirmed HB was performed. Data from physical examination and AFP levels were collected. Imaging findings from MRI and CT scans were reviewed. By analyzing MRI and CT imaging modalities, characteristic patterns of HB were identified. Results We present three pediatric cases: a ten-month-old, a two-year-old female, and a three-year-old male. Palpable abdominal masses and a heterogeneous mass in the right hepatic lobe in the US were found in all cases. Elevated AFP levels varied from 10089 to 332000 kU/l. In all cases, a diagnostic liver biopsy confirmed the epithelial type of HB. MRI detected large, heterogeneous, lobulated masses measuring 12x8x9 cm in the second case and 12x9x12 cm in the third case, accumulating contrast and displacing adjacent organs with heterogeneous hypotensive T1w, hypertensive T2w signal intensity, and DWI restriction in two cases. Hemorrhage, small cysts within the mass, and heterogeneous enhancement in postcontrast images were seen in a ten-month-old case. A chest MRI detected multiple diffuse lung metastases in a two-year-old girl. In the male case, the primary benign hepatic tumor measuring 11x10x7 cm diagnosis was later revised to HB. CT scan detected a heterogeneous nodule in the right lobe with multiple satellite tumor nodules. Also, a contrast washout was seen. Conclusions HB is often large due to rapid growth and late symptom onset. On MRI, HB appears hypointense on T1w and hyperintense on T2w images. On CT, HB appears as a hypoattenuating lesion, followed by contrast washout. Hemorrhage and necrosis contribute to heterogeneous appearance. MRI and CT define vascular anatomy and tumor invasion.

Immunotherapy treatment with checkpoint inhibitors (ICIs) has led to a breakthrough in the treatment of oncological diseases. Despite its clinical effectiveness, this treatment differs from others, such as cytotoxic chemotherapy, in that it causes immune-related adverse events. This type of toxicity can affect any organ or organ system of the body. We present a literature review and a rare clinical case from our clinical practice, in which a patient with metastatic clear cell renal carcinoma was treated with a single dose of dual checkpoint blockade (cytotoxic T-lymphocyte-4 (CTLA-4) and programmed death-1 (PD-1)) and simultaneously diagnosed with colitis, hepatitis, and nephritis. After early immunosuppressive treatment with the glucocorticoids, complete organ function recovery was achieved. The follow-up revealed a sustained complete response lasting more than a year.

Purpose: This study deals with an important issue of setting the role and value of computed tomography (CT) in differentiating pancreatic ductal adenocarcinoma (PDAC) and groove pancreatitis (GP). The study aimed to assess the efficacy of CT features in identifying the differences between these conditions. Material and Methods: The study was approved by the Regional Biomedical Research Ethics Committee (study protocol No. BE-2-22). 27 patients with PDAC and 33 GP patients were evaluated in this study. The presence of cystic degeneration, calcification, duct-penetrating sign, double-duct sign, cut-off of the main pancreatic duct, duodenal stenosis, and mean values measuring Hounsfield units (HU) in native scan, arterial phase and portal-venous phase were evaluated. Sensitivity, specificity, positive, and negative predictive values for native scan, arterial phase and portal venous phase CT parameters were defined using cut-off values calculated using ROC curve analysis. We accomplished logistic regression to identify the probability of PDAC vs GP. Results: Native CT scan value and cystic degeneration were identified as significant independent diagnostic criteria for the presence of PDAC over the GP. If pre-contrast CT scan value reaches the determined cut-off point and no cystic degeneration is detected, the estimated probability for the presence of PDAC was 81.5%. Conclusion: The estimated native CT value parameter and the presence of cystic degeneration may serve as independent diagnostic criteria predicting the probability of PDAC vs GP.

Purpose: To analyze dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) perfusion parameters in Pancreatic Ductal Adenocarcinoma (PDAC), and to evaluate the efficacy of this diagnostic modality in determining tumor grade. Material and Methods: We performed a single-center retrospective study in the Department of Radiology at the Hospital of Lithuanian University of Health Sciences Kaunas Clinics. Forty-four (44) patients with histologically proven PDAC underwent DCE-MRI. A DCE-MRI postprocessing software program (Tissue 4D; Siemens Magnetom Avanto, Siemens Healthineers, Erlangen, Germany) was used to obtain both a time-signal-intensity curve (TSIC) and to generate perfusion maps for the tumor, and different tumor grade. Perfusion maps of the volume transfer coefficient (Ktrans), extracellular extravascular volume fraction (Ve), rate constant (Kep), and initial area under the concentration curve in 60 s (iAUC) were generated. Results: The Ktrans value less than 0.109 was concomitant to the presence of G3 PDAC with an 83.3% sensitivity and 90% specificity (AUC = 0.994); an iAUC value less than 12.592 was concomitant to the presence of G3 PDAC with an 83.3% sensitivity and 90% specificity. If both these parameters exceed the defined cut-off point, the estimated probability of the existence of high-grade PDAC is 97.17%. Conclusion: The Ktrans and iAUC DCE-MRI perfusion parameters may be effective independent prognosticators preoperatively estimating poorly differentiated PDAC. If Ktrans and iAUC values are combined, the estimated probability of high-grade PDAC’s presence reaches 97%.