0:04

Patient presenting with extensive metastatic to liver,

0:08

which is very common for the small bowel

0:10

because even they, a lot of times they do, um,

0:13

CT enterography, um,

0:18

they, we can, they can't find the small bowel

0:22

primary site.

0:24

It's usually very small.

0:26

Small bowel is very hard to assess, of course,

0:28

because the extensive disease in the

0:30

liver, the liver look black.

0:31

No matter how much I decrease the intensity.

0:34

See how the parenchyma is not as black,

0:36

but actually all this is metastatic disease in the liver.

0:41

Right? And let me,

0:45

of course there's medicinal lymph nodes you can see here.

0:51

And there's also super, I remember

0:53

because I increased the intensity dramatically.

0:55

See there's here it's hot, but because which is this here,

0:59

because I, I decreased the intensity dramatically.

1:01

It just, I tweaked down.

1:03

So I go down, which is the pattern we talked about

1:06

last time, right?

1:07

GI cancers, track the,

1:11

and then goes, jumps to the lift, lift the,

1:13

it's called the black house node.

1:15

It's jump there, it's known it's a pattern.

1:17

Uh, but now what's important is

1:22

to look at here.

1:23

Here's the mr like I told you, look for them.

1:26

Here's the mesenteric. See node.

1:29

Go to the mesenteric calcified mesenteric node.

1:32

This is a, this is a typical pattern of for the, um,

1:38

med gut, which is what, which is the primary,

1:41

which is the small valve.

1:42

It's called me gut, right?

1:44

So look at your dominant enteric mass,

1:49

which is this one here, which is this one here, right?

1:53

And then look close to it.

1:55

You'll find another focus that is fusing

1:57

to a small bowel here.

1:58

Look guys, the focus fusing to the small bowel.

2:01

This is always the case.

2:04

See, I'm scrolling up

2:09

and down to show you that this is actually not

2:10

another mis enteric.

2:11

No, this is really a small l

2:15

This is the focus here and this is the ct.

2:18

If you wanna look at the cts up

2:20

and down, it's a small valve.

2:22

So here's your primary side.

2:25

This is the primary small valve in the consumer.

2:28

This is the metastatic. Um,

2:31

and I can put, uh,

2:35

here, this is a plus.

2:37

I, I don't know if you can see it, but there's a plus.

2:40

Did it go away? Yeah,

2:44

there's a plus here.

2:45

Do you see it here? Which is here.

2:49

And you can see it here in the map so I can show it here.

2:52

You see, here's the primary

2:54

and here's the, here's the me notes,

2:58

Right?

3:02

I wanna tell you that more than 99%

3:04

of the time when they send us a patient

3:07

with unknown primary, which is al almost always a al,

3:11

almost always a small bowel primary,

3:14

we can find the primary site for them.

3:16

Why is it important? Um, like you look at this case

3:20

and there's extensive metastatic disease to deliver.

3:22

This is not oleum metastatic,

3:23

like we talked about last time.

3:25

It's extensive metastatic. So why is it important?

3:29

Um, it's important because small bowel, uh, um, lesions,

3:33

eventually it will obstruct right to keep growing, growing

3:37

to till one.

3:39

At one point this small bowel is gonna obstruct.

3:43

Surgeons prefer to get in

3:45

and resected in a,

3:48

a nice quiet abdomen rather than this patient coming

3:51

to the emergency room with small bowel obstruction

3:55

and having to get in to, to an angry abdomen, messed up

4:00

with small bowel obstruction looking for a mess, right?

4:06

So this is why it's important for us to find it for them

4:09

and show them where is the primary side

4:10

so they can get in and get it out.

4:13

Uh, now, then later, this is why it's important

4:17

to find the primary side.

4:20

Um, so, so synthetic node, the static lymph node,

4:24

lymph node as I showed you, extends

4:28

liver for this patient.

4:31

Extensive, right?

4:37

Typical, um, small bowel,

4:41

like I said, synthetic is the typical plus

4:46

or minus Nia for, for the small bowel liver, of course,

4:50

always, almost always.

4:52

And as long as there is like slight disease, it's always,

4:55

almost always, um, they survive for a long time.

4:59

Uh, but unfortunately the liver meds, uh, many, many

5:02

of them have of carcinoid syndrome symptoms.

5:04

And this is what they really suffer from.