Žvinienė, Kristina

Introduction Gallstone ileus is a rare complication of gallstone disease caused by passage of a large gallstone through a biliary–enteric fistula, leading to mechanical small bowel obstruction (SBO). Because symptoms are often non-specific, diagnosis is frequently delayed [1]. This report describes a 53-year-old woman who presented with acute abdominal symptoms and was found to have gallstone ileus secondary to a cholecysto-duodenal fistula. Case Presentation A 53-year-old female arrived at Kaunas Clinics Emergency Department with severe (7 VAS) generalised abdominal pain, bloating, nausea, vomiting and inability to pass stools or gas for five days. Examination revealed a distended, diffusely tender abdomen with negative rebound tenderness. Ultrasound showed cholelithiasis and dilated intrahepatic bile ducts. Contrastenhanced CT revealed a small, non-contractile gallbladder surrounded by air and inflamed adipose tissue. A cholecysto-duodenal fistula was identified, and a 3×2×4 cm ectopic partially calcified gallstone was visualised impacted in the terminal ileum, causing mechanical SBO with dilated jejunal loops (3,2 cm) above the obstruction. The patient was admitted to the Department of Surgery for definitive treatment where operative findings confirmed CT results. Discussion Gallstone ileus accounts for 1–4% of mechanical bowel obstruction and predominantly affects elderly women [2]. Chronic cholecystitis may lead to biliary-enteric fistula formation, allowing gallstones to migrate into the bowel and lodge most commonly in the ileum [3]. Symptoms include abdominal pain, distension, vomiting and constipation [4]. CT is the diagnostic gold standard, demonstrating pneumobilia, ectopic gallstone and obstruction (Rigler's triad) as well as abnormal gallbladder (fluid accumulation within the wall, presence of air-fluid level) [5]. Treatment requires surgical removal of the obstructing stone; options include enterolithotomy alone, single-stage surgery with cholecystectomy and fistula repair, or staged repair depending on patient stability [6]. Conclusions Gallstone ileus should be considered in patients with SBO and concurrent biliary findings. Identification of characteristic CT findings, particularly Rigler’s triad and a biliary-enteric fistula, enables timely diagnosis and surgical planning, thereby reducing morbidity.

Introduction Congenital uterine malformations are the consequence of anomalous development of the uterine septum during the development of Mullerian ducts [1]. Diagnosis of these anomalies, while dependent on imaging and surgical findings, is often subjective. Nevertheless, MRI distinctly defines pelvic anatomy allowing for pinpointing other associated anomalies, particularly those of the reproductive system [2]. Case Presentation A 31–year–old female patient with a known history of endometriosis, presented with pain in the left iliac region that began with the onset of menstruation and did not subside after menstruation. Based on the clinical history and imaging findings, endometriosis was considered the primary etiology of the pain. Abdominal ultrasound (US) findings exhibited the left ovary to be non-mobile with solid mass and several enlarged follicles. Transvaginal US showed a very thin endometrium, enlarged left ovary, containing a cyst filled with hemorrhagic content. In addition, the US revealed a dense solid mass in the projection of the left ovary with a similar mass right next to the first one. No uterine duplication or cervical anomaly was identified on US or during gynecological examination. The patient underwent magnetic resonance imaging (MRI) with routine sequences and intravenous contrast enhancement. The MRI revealed that the patient had a rare congenital anomaly – uterus didelphys, presenting as two separate uterine bodies and two cervices. The patient underwent a laparoscopic surgery without any further complications and for the post–operative treatment progestin was prescribed in continuous regimen. Discussion The rarity of this developmental uterine abnormality has limited the availability of robust data regarding long-term clinical outcomes. Diagnosis of uterine didelphys is established through imaging-based evaluation, including US, MRI, and hysterosalpingography [3]. Conclusions This case report highlights that some anatomical anomalies may present as secondary findings to the main complaint – pelvic pain caused by endometriosis. These findings emphasize the importance of a holistic approach to each patient and the ability to diagnose the pathology with comprehensive imaging, especially MRI, and surgical 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

Despite advances in diagnostic tools, a reliable and standardized algorithm for accurately identifying clinically significant prostate cancer in patients prior to their first prostate biopsy has yet to be established. Traditional methods such as prostate-specific antigen testing, digital rectal examination, and systematic biopsy often suffer from limited sensitivity and specificity, leading to an increased risk of both unnecessary biopsies and missed significant cases. The aim of this study was to evaluate and compare the diagnostic value of multiparametric magnetic resonance imaging (mpMRI), urinary genetic biomarkers (PCA3 and T:E), and the PCPTRC2 risk calculator in detecting clinically significant prostate cancer. The study included men who underwent all of the mentioned diagnostic tests followed by a prostate biopsy. Findings revealed that mpMRI demonstrated high sensitivity, but low specificity. Combining all three methods yielded the highest sensitivity but significantly reduced specificity, making this combination suitable only for high-risk patients. The most effective early diagnostic approach was the combination of mpMRI and urinary biomarkers, which reduced unnecessary biopsies while maintaining detection of clinically significant cases. The study highlights the importance of a personalized and combined diagnostic strategy for the detection of clinically significant prostate cancer.

Introduction & Objectives: Prostate cancer (PCa) remains a significant health concern with its high incidence and associated mortality. Conventional screening approaches, like PSA testing, often lack specificity, resulting in unnecessary biopsies and overtreatment. This study seeks to overcome these limitations by assessing the integration of novel urinary biomarkers into established risk prediction models. This study is aimed to evaluate the performance of incorporating urinary biomarkers – prostate cancer antigen 3 (PCA3) and transmembrane serine protease 2 (TMPRSS2) gene and ETS-related gene (ERG) fusion genes (T:E) – into the Prostate Cancer Prevention Trial Risk Calculator version 2 (PCPTRC2) in a Lithuanian cohort to enhance the detection of clinically significant prostate cancer (csPCa). Materials & Methods: A single-centre prospective study included 246 men scheduled for initial prostate biopsy between January 2021 and August 2024 due to elevated total PSA levels or abnormal digital rectal examination (DRE). Following ethical approval and informed consent, urinary samples were collected post-DRE and analysed for PCA3 and T:E. Each patient's risk was calculated using the basic PCPTRC2 and updated versions incorporating biomarkers. Biopsies were performed based on multiparametric magnetic resonance imaging (mpMRI) findings. Results: Of 209 biopsy samples analysed, 111 (53.1%) were diagnosed with csPCa. The AUC for PCa detection was 59.6% for the original PCPTRC2, improving to 76.2% with PCA3 and further to 79.5% when both PCA3 and T:E were included. Both updated versions demonstrated significantly higher sensitivity compared to the original (p<0.001). However, no significant differences were noted in distinguishing csPCa from non-csPCa. Conclusions: Incorporating PCA3 and T:E into PCPTRC2 substantially enhances diagnostic accuracy for detecting PCa in biopsy-naïve patients. Despite limitations, these findings underscore the potential for optimizing risk calculators in clinical practice, advocating for larger cohorts to validate these results.

Introduction & Objectives: Prostate cancer (PCa) remains a significant health concern with its high incidence and associated mortality. Conventional screening approaches, like PSA testing, often lack specificity, resulting in unnecessary biopsies and overtreatment. This study seeks to overcome these limitations by assessing the integration of novel urinary biomarkers into established risk prediction models. This study is aimed to evaluate the performance of incorporating urinary biomarkers – prostate cancer antigen 3 (PCA3) and transmembrane serine protease 2 (TMPRSS2) gene and ETS-related gene (ERG) fusion genes (T:E) – into the Prostate Cancer Prevention Trial Risk Calculator version 2 (PCPTRC2) in a Lithuanian cohort to enhance the detection of clinically significant prostate cancer (csPCa). Materials & Methods: A single-centre prospective study included 246 men scheduled for initial prostate biopsy between January 2021 and August 2024 due to elevated total PSA levels or abnormal digital rectal examination (DRE). Following ethical approval and informed consent, urinary samples were collected post-DRE and analysed for PCA3 and T:E. Each patient's risk was calculated using the basic PCPTRC2 and updated versions incorporating biomarkers. Biopsies were performed based on multiparametric magnetic resonance imaging (mpMRI) findings. Results: Of 209 biopsy samples analysed, 111 (53.1%) were diagnosed with csPCa. The AUC for PCa detection was 59.6% for the original PCPTRC2, improving to 76.2% with PCA3 and further to 79.5% when both PCA3 and T:E were included. Both updated versions demonstrated significantly higher sensitivity compared to the original (p<0.001). However, no significant differences were noted in distinguishing csPCa from non-csPCa. Conclusions: Incorporating PCA3 and T:E into PCPTRC2 substantially enhances diagnostic accuracy for detecting PCa in biopsy-naïve patients. Despite limitations, these findings underscore the potential for optimizing risk calculators in clinical practice, advocating for larger cohorts to validate these results.

Prostate cancer (PCa) remains a significant health concern due to its high incidence and associated mortality. Conventional screening approaches, like PSA testing, often lack specificity, resulting in unnecessary biopsies and overtreatment. This study seeks to overcome these limitations by assessing the integration of novel urinary biomarkers into established risk prediction models.

Median arcuate ligament syndrome (MALS) is a compressed celiac artery syndrome, also known as Dunbar syndrome. MALS is a clinically rare syndrome and is usually a diagnosis of exclusion. Diagnosis is a difficult task. Surgery is the treatment of choice, and laparoscopic surgery has promising results.

Introduction Adrenal tumors (AT) are commonly discovered incidentally on cross-sectional abdominal imaging performed for reasons unrelated to an adrenal mass (AM). AT affect around 4–10% of the general population, with the highest incidence occurring in the seventh decade of life1,2. In any patient with a newly discovered AM, determining whether it is malignant and whether it is hormonally active are equally important to guide optimal management3. All patients found to have an AT should undergo a detailed clinical, biochemical and radiological evaluation to select those requiring surgical management2. Modern image techniques play a central role in the diagnosis of AT. Unenhanced computed tomography (CT) attenuation is the preferred method for evaluating primary AT, as it helps differentiate between malignant and benign tumors4. CT radiographic characteristics of malignant AM include a tumor size > 4 cm, irregular margins, heterogeneous enhancement, and lesions exhibiting < 40% relative percentage washout (RPW) or < 60% absolute percentage washout (APW) of intravenous contrast5. AT can affect the synthesis of hormones produced by the adrenal glands (i.e. cortisol, aldosterone, and androgens) leading to hyperadrenalism from excess hormones or hypoadrenalism if non-functional6. In either case, the presence of an AT can significantly affect the levels of adrenal hormones, leading to various health symptoms. Aim To evaluate the distribution of different AT types, hormonal profiles, and radiological data of patients diagnosed with AT. Methods We retrospectively analyzed the medical documentation from database of the Hospital of LUHS KK of 80 patients (40 female, 40 male) who were diagnosed with AT in 2017-2018 using CT. Formal Bioethical Permit from regional legal body was obtained. Clinical and laboratory data, including hormone levels (DHEAS, testosterone, aldosterone, ACTH, cortisol, renin, metanephrine, normetanephrine), were recorded. CT features (tumor size, contrast enhancement) and hormone levels were analyzed, with statistical significance set at p<0.05 using "IBM SPSS Statistics 29.0." Results The most frequently occurring AT (42.5%) was adenoma, whereas aldosteronoma was the least common (3.8%). Analyzing the distribution of the AT types and blood hormone concentrations, it was found that the percent increase in metanephrine and noretanephrine was significantly higher in pheochromocytoma than in other tumors. There was a statistically significant difference in tumor sizes between adenomas and pheochromocytomas, with pheochromocytomas being notably larger. Additionally, pheochromocytomas showed significantly greater contrast enhancement compared to all other AT. Conclusions The most common AT type was adenoma. Pheochromocytomas showed significantly higher metanephrine and normetanephrine levels, larger tumor sizes, and greater contrast enhancement compared to other AT.

Introduction Median arcuate ligament syndrome (MALS) is a celiac artery compression syndrome. It is a rare phenomenon caused by compression of the celiac trunk by median arcuate ligament. Fibers insert inferiorly and cross anteriorly to the celiac trunk with the compression of the artery. [1] Laparoscopic median arcuate ligament release and transection of the celiac plexus is the "gold" standard for treating MALS. [3] Case Presentation A 40-year-old female with no comorbidities presented to her primary physician complaining of chronic abdominal pain, appetite loss, pain after eating, decline in weight about 5 years. The symptoms have caused her to reduce her food intake and skip meals entirely. Also reported nausea, vomiting after eating during abdominal pain episode. The patient was referred to general surgery in outpatient clinic for further evaluation and management. Abdomen CT with intravenous contrast was performed and found short segment stenosis of the coeliac trunk with a characteristic hooked appearance, post-stenotic dilatation, and the thickening of the median arcuate ligament. The abdomen/pelvis CTA was done and found 50% celiac artery stenosis. Due to inadequate symptom control, laparoscopic median arcuate ligament release was performed in one month after the first visit to general surgeon. After the surgery all symptoms subsided. Discussion It is calculated that the incidence of MALS has been estimated to be about 2/100,000 patients per year. [3] There are no uniform diagnostic criteria for MALS, but the diagnosis requires ruling out other etiologies. Complications of MALS includes gastroparesis and pancreatic duodenal aneurysm, etc. [2] Celiac artery decompression is indicated only for symptomatic patients with confirmed celiac artery compression on inspiratory and expiratory vascular imaging studies. [1] If symptoms persist even after laparoscopic ligament release, revascularization of the celiac artery by either endovascular stenting or bypass can be considered as secondary options. [4] Conclusions MALS is a rare and incompletely understood syndrome. We presented a case report of MALS. This case highlights the importance differential diagnosis for patients with chronic abdominal pain, weight loss. Laparoscopic median arcuate ligament release and transection of the celiac plexus is an effective treatment for MALS.