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Abdominal Pain William Beaumont Hospital Department of Emergency Medicine.

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1 Abdominal Pain William Beaumont Hospital Department of Emergency Medicine

2 Abdominal Pain One of the most common chief complaints Confounders making diagnosis difficult Age Corticosteroids Diabetics Recent antibiotics

3 Pitfalls Consider non-GI causes Acute MI (inferior), ectopic pregnancy, DKA, sickle cell anemia, porphyria, HSP, acute adrenal insufficiency History Location Quality Severity Onset Duration Aggravating and alleviating factors Prior symptoms

4 History Sudden onset – perforated viscusSudden onset – perforated viscus Crushing – esophageal or cardiac diseaseCrushing – esophageal or cardiac disease Burning – peptic ulcer diseaseBurning – peptic ulcer disease Colicky – biliary or renal diseaseColicky – biliary or renal disease Cramping – intestinal pathologyCramping – intestinal pathology Ripping – aneurismal ruptureRipping – aneurismal rupture

5 Physical Exam AbdomenAbdomen InspectionInspection Bowel soundsBowel sounds Tenderness (rebound, guarding)Tenderness (rebound, guarding) Extra-abdominal examExtra-abdominal exam LungLung CardiacCardiac PelvicPelvic GUGU RectalRectal

6 Labs Beta-hCGBeta-hCG WBC – poor sensitivity and specificityWBC – poor sensitivity and specificity LFTs – hepatobiliaryLFTs – hepatobiliary Lipase – pancreaticLipase – pancreatic Electrolytes – CO2Electrolytes – CO2 Lactic acidLactic acid Urinalysis – BEWAREUrinalysis – BEWARE

7 Imaging Acute Abdominal SeriesAcute Abdominal Series Free airFree air Bowel gasBowel gas KUBKUB Poor screening testPoor screening test UltrasoundUltrasound Biliary diseaseBiliary disease AAAAAA Free fluid or airFree fluid or air Pelvic pathologyPelvic pathology CTCT AppendicitisAppendicitis DiverticulitisDiverticulitis

8 Case #1 79 yo female presents with aching sharp pain in the epigastrium and right upper quadrant ½ hour after eating. Pain radiates to the back. +N, –V79 yo female presents with aching sharp pain in the epigastrium and right upper quadrant ½ hour after eating. Pain radiates to the back. +N, –V Differential diagnosis?Differential diagnosis? Testing?Testing?

9 Upper Abdominal Pain Biliary disease Hepatitis Pancreatitis PUD/gastritis/esoph agitis AAA Pneumonia (RLL)Pneumonia (RLL) PyelonephritisPyelonephritis Acute MIAcute MI AppendicitisAppendicitis Fitz-Hugh CurtisFitz-Hugh Curtis

10 Gallstone Risk Factors Female 4:1Female 4:1 FertileFertile FortyForty FatFat Family historyFamily history Others:Others: Crohns, UC, SCA, thalassemia, rapid weight loss, starvation, TPN, elevated TGs, cholesterolCrohns, UC, SCA, thalassemia, rapid weight loss, starvation, TPN, elevated TGs, cholesterol

11 Cholelithiasis History:History: RUQ/epigastric painRUQ/epigastric pain Nausea/vomiting with fatty mealsNausea/vomiting with fatty meals Similar episodes in pastSimilar episodes in past PE: RUQ tendernessPE: RUQ tenderness Labs: may be normalLabs: may be normal ECG: consider in older patientsECG: consider in older patients Imaging: test of choice = USImaging: test of choice = US

12 Cholelithiasis: Treatment Symptomatic Pain control Anti-emetics Consult general surgery 90% with recurrent symptoms 50% develop acute cholecystitis Asymptomatic Incidental finding Incidental finding 15-20% become symptomatic 15-20% become symptomatic Outpatient elective surgery if Outpatient elective surgery if Frequent, severe attacks Frequent, severe attacks Diabetic Diabetic Large calculi Large calculi

13 Acute Cholecystitis Sudden gallbladder inflammation Bacterial infection in 50-80% E. coli, Klebsiella, Enterococci History/PE: Fever, tachycardia, RUQ tenderness Murphys sign – low sensitivity Labs: Elevated WBC with left shift LFTs – large elevation CBD stone

14 Acute Cholecystitis: Imaging KUB – stones only seen ~ 10% Air in biliary tree gangrenous CT scan – sensitivity 50% Ultrasound – sensitivity 90-95% Gallstones (absent in biliary stasis) Thickened gallbladder wall Pericholecystic fluid HIDA scan – negative scan rules out diagnosis Positive = no visualization of the GB

15 Acute Cholecystitis

16 Acute Cholecystits: Treatment Admit NPO IVF Pain control Anti-emetics Antibiotics Surgical consult

17 Hepatitis Viral Viral Hepatitis A Hepatitis A RNA, fecal-oral RNA, fecal-oral Hepatitis B Hepatitis B DNA, STD/parenteral DNA, STD/parenteral Chronic hepatitis (10%) Chronic hepatitis (10%) Hepatitis C Hepatitis C RNA, blood borne RNA, blood borne Chronic hepatitis (50%), cirrhosis (20%) Chronic hepatitis (50%), cirrhosis (20%) Hepatitis D Hepatitis D RNA, co-infects Hep B RNA, co-infects Hep B Bacterial Bacterial Alcoholic Alcoholic Immune Immune Medications Medications

18 Hepatitis: Diagnosis History:History: Malaise, low-grade fever, anorexiaMalaise, low-grade fever, anorexia Nausea/vomiting, abd pain, diarrheaNausea/vomiting, abd pain, diarrhea Jaundice (altered MS, liver failure)Jaundice (altered MS, liver failure) Labs:Labs: ALT and AST (10-100x normal)ALT and AST (10-100x normal) AST > ALT – alcoholic hepatitisAST > ALT – alcoholic hepatitis Elevated bilirubinElevated bilirubin Abnormal PTAbnormal PT Hepatitis panelHepatitis panel Tylenol levelTylenol level

19 Hepatitis: Treatment Symptomatic – IVF, electrolytes Remove toxins – ETOH, acetaminophen Admit if altered MS or coagulopathy

20 Pancreatitis Autodigestion of pancreatic tissueAutodigestion of pancreatic tissue B – BiliaryB – Biliary A – AlcoholA – Alcohol D – DrugsD – Drugs S – Scorpion biteS – Scorpion bite H – HyperTG, HyperCaH – HyperTG, HyperCa I – Idiopathic, InfectionI – Idiopathic, Infection T – TraumaT – Trauma

21 Pancreatitis: History and Physical History:History: Boring pain in LUQ or epigastriumBoring pain in LUQ or epigastrium ConstantConstant Radiates to mid-backRadiates to mid-back Nausea, vomitingNausea, vomiting PE:PE: Epigastric or LUQ tendernessEpigastric or LUQ tenderness Grey-Turner or Cullen signGrey-Turner or Cullen sign

22 Gray-Turner sign Flank ecchymosisFlank ecchymosis Intraperitoneal bleedingIntraperitoneal bleeding Hemorrhagic pancreatitisHemorrhagic pancreatitis Ruptured abdominal aortaRuptured abdominal aorta Ruptured ectopic pregnancyRuptured ectopic pregnancy

23 Cullen's Sign

24 Pancreatitis: Diagnosis Lipase – most specificLipase – most specific Ransons criteria – predicts outcomeRansons criteria – predicts outcome Acutely: >55 yo, glucose > 200, WBC >16k, ALT > 250, LDH > 350Acutely: >55 yo, glucose > 200, WBC >16k, ALT > 250, LDH > hrs: HCT decreases > 10%, BUN rises > 5, Ca 4, fluid sequestration > 6L48 hrs: HCT decreases > 10%, BUN rises > 5, Ca 4, fluid sequestration > 6L 3-4 criteria – 15% mortality3-4 criteria – 15% mortality 5-6 criteria – 40% mortality5-6 criteria – 40% mortality 7-8 criteria – 100% mortality7-8 criteria – 100% mortality

25 Pancreatitis: Imaging Plain films – sentinel loop (local ileus) Ultrasound – poor (biliary tree) CT scan with contrast

26 Pancreatitis: Treatment NPO IVF Pain control Antiemetics Antibiotics if gallstones or septic Surgical consult If gallstones, abscess, hemorrhage or pseudocyst ERCP if CBD stone

27 Gastritis/PUD Duodenal 80%; gastric 20% Etiology: H pylori, NSAIDS, zollinger-ellison syndrome, smoking, ETOH, FHx, male, stress H pylori – 95% duodenal; 85% gastric History: Epigastric constant, gnawing pain Food lessens – duodenal Food worsens – gastric

28 Peptic Ulcer Disease Workup:Workup: HemoglobinHemoglobin PT/PTT – if bleedingPT/PTT – if bleeding Lipase – rule out pancreatitisLipase – rule out pancreatitis Hemoccult stool – rule out GI bleedHemoccult stool – rule out GI bleed Treatment:Treatment: Antacids (GI cocktail)Antacids (GI cocktail) PPIPPI Outpatient endoscopyOutpatient endoscopy H. pylori testingH. pylori testing

29 Perforated Viscus Rare in small bowel and mid-gutRare in small bowel and mid-gut History: abrupt onset painHistory: abrupt onset pain Diagnosis: upright CXRDiagnosis: upright CXR Treatment:Treatment: IVFIVF IV antibioticsIV antibiotics NG tubeNG tube OROR

30 Questions on Upper Abdominal Pain? Lets Move On Down

31 Case #2 History: 35 y/o female c/o 1 day of periumbilical aching pain. +N,+V, +D, +F, +C, +anorexia. Today, she has crampy lower abdominal pain. No urinary sx.History: 35 y/o female c/o 1 day of periumbilical aching pain. +N,+V, +D, +F, +C, +anorexia. Today, she has crampy lower abdominal pain. No urinary sx. Exam: afebrile, bilateral lower quadrant tenderness (R > L), no rebound or guarding.Exam: afebrile, bilateral lower quadrant tenderness (R > L), no rebound or guarding. Other questions?Other questions? Differential diagnosis?Differential diagnosis? Testing?Testing?

32 Lower Abdominal Pain AppendicitisAppendicitis DiverticulitisDiverticulitis UTI/PyleonephritisUTI/Pyleonephritis Renal colicRenal colic Torsion/TOA/PIDTorsion/TOA/PID Ectopic pregnancyEctopic pregnancy

33 Appendicitis Incidence – 6%Incidence – 6% Mortality – 0.1%Mortality – 0.1% Perforation 2-6% (9% elderly)Perforation 2-6% (9% elderly) All ages – peak 10 – 30 yoAll ages – peak 10 – 30 yo Difficult diagnosis:Difficult diagnosis: Young and oldYoung and old Pregnant (RUQ)Pregnant (RUQ) ImmunocompromisedImmunocompromised

34 Appendicitis Abdominal pain (98%)Abdominal pain (98%) Periumbilical migrating to RLQ < 48 hrsPeriumbilical migrating to RLQ < 48 hrs Anorexia 70%Anorexia 70% Nausea, vomiting 67%Nausea, vomiting 67% Common misdiagnosis – gastroenteritis, UTICommon misdiagnosis – gastroenteritis, UTI

35 Appendicitis PE:PE: RLQ tenderness 95%RLQ tenderness 95% Rovsing: RLQ pain palpating LLQRovsing: RLQ pain palpating LLQ Psoas: R hip elevation, extensionPsoas: R hip elevation, extension Obturator: flexion, internal rotationObturator: flexion, internal rotation

36 Appendicitis: Diagnosis Labs:Labs: WBC > 10k – 75%WBC > 10k – 75% UA – sterile pyuriaUA – sterile pyuria Imaging:Imaging: UltrasoundUltrasound CT scanCT scan MRIMRI

37 Appendicitis: Treatment IV fluids IV fluids NPO NPO Analgesia Analgesia Antibiotics Antibiotics Surgery consult Surgery consult

38 Diverticulitis Inflammation of a diverticulum (herniation of mucosa through defects in bowel wall) Sigmoid colon is the most common site History: L > R 3% under 40 LLQ pain with BMs N/V/constipation PE: LLQ tenderness Diagnosis: clinical, CT

39 Diverticulitis: Treatment Admit if fever, abscess, elderlyAdmit if fever, abscess, elderly NPONPO IV fluidsIV fluids IV antibioticsIV antibiotics Ciprofloxacin AND metronidazoleCiprofloxacin AND metronidazole Surgical consultationSurgical consultation

40 Case #3 History: 80 y/o male c/o nausea and crampy abdominal pain x 1 day. Emesis which was bilious and is now malodorous and brown.History: 80 y/o male c/o nausea and crampy abdominal pain x 1 day. Emesis which was bilious and is now malodorous and brown. PE: Diffusely tender, distended, with hyperactive bowel sounds.PE: Diffusely tender, distended, with hyperactive bowel sounds. Differential Diagnosis?Differential Diagnosis? Workup?Workup?

41 Differential Diagnosis Small bowel obstructionSmall bowel obstruction Large bowel obstructionLarge bowel obstruction Sigmoid volvulusSigmoid volvulus Cecal volvulusCecal volvulus HerniaHernia Mesenteric ischemiaMesenteric ischemia GI BleedGI Bleed

42 Small Bowel Obstruction Etiology Adhesions (>50%) Incarcerated hernia Neoplasms Adynamic ileus – non mechanical Abd trauma (post op), infection, hypokalemia, opiates, MI, scleroderma, hypothyroidism Rare: intusseception, bezoar, Crohns disease, abscess, radiation enteritis

43 Large Bowel Obstruction Etiology Tumor Left obstruct Right bleeding Diverticulitis Volvulus Fecal impaction Foreign body

44 Bowel obstruction Pathophysiology: 3 rd spacing bowel wall ischemia perforates, peritonitis sepsis shockPathophysiology: 3 rd spacing bowel wall ischemia perforates, peritonitis sepsis shock History: crampy, colicky diffuse abdominal pain, vomiting (feculent), no flatus or BMHistory: crampy, colicky diffuse abdominal pain, vomiting (feculent), no flatus or BM PE: abdominal distension, high pitched BS, diffuse tendernessPE: abdominal distension, high pitched BS, diffuse tenderness Diagnosis: AAS shows air fluid levels with dilated bowelDiagnosis: AAS shows air fluid levels with dilated bowel SB > 3cm; LB > 10cmSB > 3cm; LB > 10cm

45 SBO: Imaging

46 SBO: Treatment IV fluids! Correct electrolyte abnormalities NPO NG tube Broad spectrum antibiotics if peritonitis Surgery consult

47 Sigmoid Volvulus History:History: Elderly, bedridden, psychiatric ptsElderly, bedridden, psychiatric pts Crampy lower abdominal pain, vomiting, dehydration, obstipationCrampy lower abdominal pain, vomiting, dehydration, obstipation Prior h/o constipationPrior h/o constipation PE:PE: Diffuse abdominal tendernessDiffuse abdominal tenderness DistensionDistension

48 Sigmoid Volvulus

49 Sigmoid Volvulus: Imaging and Treatment AAS: dilated loop of colon on leftAAS: dilated loop of colon on left Barium enema: birds beakBarium enema: birds beak WBC > 20k: suggests strangulationWBC > 20k: suggests strangulation CT scanCT scan TreatmentTreatment IVFIVF Surgical consultSurgical consult Antibiotics if suspect perforationAntibiotics if suspect perforation

50 Cecal volvulus Most common in year olds No underlying chronic constipation History: Severe, colicky abd pain Vomiting PE: Diffusely tender abdomen Distension

51 Cecal Volvulus KUB: KUB: Coffee bean – large dilated loop colon in midabdomen Coffee bean – large dilated loop colon in midabdomen Empty distal bowel Empty distal bowel Treatment: Treatment: Surgery Surgery Mortality –10-15% if bowel viable; 30-40% if gangrene Mortality –10-15% if bowel viable; 30-40% if gangrene

52 Hernias Inguinal (most common) 75% Indirect 50% vs. direct 25% Men > women High risk incarceration in kids Femoral 5% - women > men Incisional 10% Umbilical – newborns, women > men Incarcerated – unable to reduce Strangulated – incarcerated with vascular compromise

53 Hernias Clinical presentations:Clinical presentations: Most are asymptomaticMost are asymptomatic Leads to SBO sxsLeads to SBO sxs Peritonitis and shock – if strangulationPeritonitis and shock – if strangulation TreatmentTreatment Reduce if non-tender – trendelenberg, sedation, warm compressesReduce if non-tender – trendelenberg, sedation, warm compresses Do not reduce if possible dead bowelDo not reduce if possible dead bowel Admit via OR if strangulationAdmit via OR if strangulation

54 Mesenteric Ischemia EtiologyEtiology 50% arterial emboli50% arterial emboli 20% non-occlusive disease (CHF, sepsis, shock)20% non-occlusive disease (CHF, sepsis, shock) 15% arterial thrombi15% arterial thrombi 5% venous occlusion5% venous occlusion Mortality rates 70-90% - delayed diagnosisMortality rates 70-90% - delayed diagnosis

55 Mesenteric Ischemia Pathophysiology: impaired blood supply from SMA, IMA, celiac trunk adynamic ileus mucosal infarction & 3 rd spacing bacterial invasion sepsis shockPathophysiology: impaired blood supply from SMA, IMA, celiac trunk adynamic ileus mucosal infarction & 3 rd spacing bacterial invasion sepsis shock History:History: Acute, severe, colicky, poorly localized painAcute, severe, colicky, poorly localized pain Postprandial painPostprandial pain Nausea, vomiting and diarrheaNausea, vomiting and diarrhea

56 Mesenteric Ischemia: Diagnosis Pain out of proportion to exam! Heme positive stools (>50%) May present as LGIB Peritonitis and shock Late findings WBC > 15k Metabolic acidosis Lactic acid – high sensitivity, not specific

57 Mesenteric Ischemia: Diagnosis CT scan Bowel wall edema/gas, +/- mesenteric thrombus Normal CT does NOT rule out Plain films – late findings Portal venous gas Pneumatosis intestinalis Treatment: IVF NG tube IV antibiotics IR consult for angiography Surgical consult

58 GI hemorrhage: Upper GIB vs. Lower GIB History:History: Hematemesis seen in 50% UGIBHematemesis seen in 50% UGIB MelenaMelena 70% UGIB70% UGIB 30% LGIB30% LGIB Hematochezia – LGIB vs. rapid UGIBHematochezia – LGIB vs. rapid UGIB Ask about:Ask about: NSAID, ASA, ETOH, Plavix, warfarinNSAID, ASA, ETOH, Plavix, warfarin Night sweats, weight loss, bowel changes malignancyNight sweats, weight loss, bowel changes malignancy Iron, bismuth – guaiac negative, black stoolsIron, bismuth – guaiac negative, black stools

59 GI hemorrhage Consider with chief complaints: Weakness SOB Dizzy Abdominal pain PE: orthostatics, abdomen, rectal Conjunctival pallor Cool, clammy skin Spider angiomata, palmer erythema, jaundice, bruises liver disease

60 GIB: Diagnosis Hemoccult – iodide, methylene blue and red meat cause false pos Labs: CBC (Hg < 8) PT T & S Increased BUN (blood, hypovolemia) ECG – rule out silent MI (anemia) NG tube – rule out UGI bleed

61 Upper GI Hemorrhage: Etiology PUD 60%PUD 60% Gastritis/esophagitis 15%Gastritis/esophagitis 15% Varices – portal HTN, liver diseaseVarices – portal HTN, liver disease Mallory-WeissMallory-Weiss Aortoenteric fistula – H/o AAA repairAortoenteric fistula – H/o AAA repair Other: Stress ulcers, malignancy, AVM, ENT bleeds, hemoptysisOther: Stress ulcers, malignancy, AVM, ENT bleeds, hemoptysis

62 Lower GI Hemorrhage: Etiology Hemorrhoids – most common overallHemorrhoids – most common overall Diverticulosis – most common severe cause LGIBDiverticulosis – most common severe cause LGIB AngiodysplasiaAngiodysplasia Polyps/cancerPolyps/cancer Rectal diseaseRectal disease IBDIBD

63 GIB: Treatment Unstable:Unstable: IV x 2, O2, monitorIV x 2, O2, monitor Blood products – FFP, pRBCs, plateletsBlood products – FFP, pRBCs, platelets NG tube with lavage if upper GIB suspectedNG tube with lavage if upper GIB suspected Upper GI bleed GI for endoscopyUpper GI bleed GI for endoscopy Lower GI bleed GI and/or surgery consultsLower GI bleed GI and/or surgery consults Tagged red blood cell study – need 0.1 – 0.2 ml/min of hemorrhageTagged red blood cell study – need 0.1 – 0.2 ml/min of hemorrhage

64 GIB: Treatment Colonscopy – ligate or sclerose diverticulosis, AVM bleedsColonscopy – ligate or sclerose diverticulosis, AVM bleeds EGD – band ligation or sclerose varicesEGD – band ligation or sclerose varices Octreotide – varices, PUDOctreotide – varices, PUD Vasopressin – varicesVasopressin – varices Sengstaken-Blakemore tube – varicesSengstaken-Blakemore tube – varices

65 GIB: Surgical Indications Hemodynamically unstable Unresponsive to endoscopy, IV fluids, and correction of coagulopathy Transfused > 5units in 4-6 hrs Mortality 23% if emergent surgery

66 GIB: Disposition Admit Any UGIB Any hemodynamic instability Significant LGIB Observation LGIB with stable vital signs and HgB Discharge home Hemorrhoid bleed, rectal negative with normal HgB

67 Case #4 70 y/o male with HTN, DM c/o acute onset right flank pain. Pain is sharp and crampy, radiates to the groin. He is pale, diaphoretic. Abdomen is soft, diffusely tender, no rebound or guarding. What are you thinking and what are you going to do?

68 Differential Diagnosis Renal colic Renal colic Mesenteric ischemia Mesenteric ischemia PUD with perforation PUD with perforation GI bleed GI bleed Diverticulitis Diverticulitis Cholecystitis Cholecystitis Pancreatitis Pancreatitis Low back pain Low back pain

69 AAA 4 male: 1 female4 male: 1 female Peak incidence 70 yoPeak incidence 70 yo 98% infrarenal (50% involve iliacs)98% infrarenal (50% involve iliacs) 33% of cases initially misdiagnosed33% of cases initially misdiagnosed Renal colic, low back painRenal colic, low back pain Risk factors: HTN*, smoking, COPD, diabetes, hyperlipidemia, connective tissue disease (Marfans, Ehlers-danlos)Risk factors: HTN*, smoking, COPD, diabetes, hyperlipidemia, connective tissue disease (Marfans, Ehlers-danlos)

70 AAA: Pathophysiology Atherosclerosis causes loss of elastin and collagen in aortic wall Atherosclerosis causes loss of elastin and collagen in aortic wall Normal aorta diameter = 2 cm Normal aorta diameter = 2 cm Uncommon to rupture if < 5 cm Uncommon to rupture if < 5 cm Elective repair Elective repair 30% of aneurysms >5 cm rupture within 5 years 30% of aneurysms >5 cm rupture within 5 years

71 AAA History:History: Sudden onset severe constant mid-abdomen or back painSudden onset severe constant mid-abdomen or back pain Pain may radiate to the thigh or testesPain may radiate to the thigh or testes Back/flank pain – retroperitoneal ureteral irritationBack/flank pain – retroperitoneal ureteral irritation PE:PE: Pulsatile mass 50-90%Pulsatile mass 50-90% Abdominal distension due to RP or IP bloodAbdominal distension due to RP or IP blood Abdominal bruit 3-8%Abdominal bruit 3-8% Blue toe syndrome 5% due to emboliBlue toe syndrome 5% due to emboli

72 AAA: Diagnosis ECG Plain films R/o free air or SBO Calcified aorta US Helpful to diagnosis Does not delineate rupture or leaking aneurysm CTCT Evaluates size, leakage and extentEvaluates size, leakage and extent AngiographyAngiography May miss AAA if mural thrombusMay miss AAA if mural thrombus

73 AAA

74 AAA: Treatment Asymptomatic patient Incidental finding <4 cm – repeat US Q6 months >4 cm – elective repair Symptomatic patient CT to confirm diagnosis (if stable) 2 large bore IVs T&C pRBC - ~8 units Admit via OR (vascular surgery consult)

75 AAA: Mortality Elective repair – 4%Elective repair – 4% Post rupture – 45%Post rupture – 45% Normal BP – 20%Normal BP – 20% Hypotensive, responds to volume – 40%Hypotensive, responds to volume – 40% Hypotensive, incomplete response 60%Hypotensive, incomplete response 60% Hypotensive, no urinary output – 80%Hypotensive, no urinary output – 80%

76 The End Any Questions?


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