# Complete evacuation did not resolve my rectal odor problem



## ileo (Jun 14, 2012)

I saw a biofeedback nurse. She took some more measurments, and said that actually I didn't have notable anismus [http://en.wikipedia.org/wiki/Anismus] Instead of biofeedback, she gave me a home anal irrigation kit. This involves gently pumping 1L into the rectum, sigmoid and descending colon. Basically its like a large volume enema. My normal bowel pattern is 2-3 movements per day, usually after each meal. This is within normal limits (anything between 3 movements per week to 3 per day is normal range)When I use this irrigation in the morning, I get complete evacuation of stool such that I don't need to go again for the rest of the day. Interestingly, I still get a small amount of mucous discharge. This to me suggests that the mucus is not related to incomplete evacuation, and perhaps is related to some physical problem like an internal hemorrhoid. Also, I still get complaints and comments about fecal odor from the public. I think that the odor is lessened, but this is hard to assess since I can't detect it myselfAlso, I recently took the hydrogen breath test, which showed bacteria in the small intestine at high levels. I know some say mucous discharge can be caused by SIBO.


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## tummyrumbles (Aug 14, 2005)

What kind of measurements exactly did the nurse take? What did she mean by not having "notable" anismus? And why would she prescribe an enema if she didn't think you had anismus? Enemas are used because evacuation is sluggish generally, which if not caused by poor diet, is more than likely animus. Is she qualified enough to make these determinations?Long term enemas aren't recommended because over time the colon relies on these. If people are still complaining, but you don't experience holding gas in, then what is causing the odour? You never experience the feeling of having to clamp your sphincter?If the odour is caused by gas, whether SIBO or stool gas, you're still back to square one. My sphincter was tested in hospital after giving birth the second time, and was told it was very strong. But my over-sensitive system goes into overdrive if it detects either gas or stool in the colon. So I've found the only thing that works is not to have digestion gas or stool gas. Sometimes I think you can carry digestion gas over from the previous day. If you wake up fluffing it's a good guess you are retaining digestion gas. The SIBO diet is pretty restrictive. One day I had no lunch, and just a ham jaffle for tea. Evacuation was pretty quick the next morning (for me) - it only took an hour I think. Probably because there just wasn't much food there. And there was no digestion gas at all the next day. But who can live on a ham jaffle all day?


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## ileo (Jun 14, 2012)

I think complete evac has helped, but it definitely has not resolved things.


tummyrumbles said:


> What kind of measurements exactly did the nurse take? What did she mean by not having "notable" anismus? And why would she prescribe an enema if she didn't think you had anismus? Enemas are used because evacuation is sluggish generally, which if not caused by poor diet, is more than likely animus. Is she qualified enough to make these determinations?Long term enemas aren't recommended because over time the colon relies on these.


Anorectal manometric measurements I guess, the same instrument used in manometry and biofeedback...measures the pressures exerted by the muscles of the anal canal. I originally had manometry done at a different hospital a while ago, who diagnosed anismus. Since then I did a lot of reading about anismus and followed the advice about correct posture, etc. Before doing any biofeedback, this new nurse took her own measurements and there was normal perineal descent, the biofeedback probe could be expelled...probably implying normal pelvic floor relaxation during attempted defecation.She said that there was not marked anismus present and to suggested to try the irrigation, although she was happy to do biofeedback. Interestingly both the biofeedback nurse and the surgeon suggested more solesta. There is some evidence for this approach, some of the patients in this study needed 3 procedures before benefit. http://www.ncbi.nlm.nih.gov/pubmed/17205492 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3155048/?tool=pubmed She also advised defecating proctogram to show any non emptying defects.


> If people are still complaining, but you don't experience holding gas in, then what is causing the odour? You never experience the feeling of having to clamp your sphincter?If the odour is caused by gas, whether SIBO or stool gas, you're still back to square one.


All odours are gas, but this gas can also be released from liquids or solids...but I know what you mean. I asked the nurse whether many of her patients complained of odour. She said the complaints vary between patients. She suggested that if there was a pouch or something that was non emptying then stool could fester there, and that became more malodorous than normal stool. I think it is very relevant that normal rectal emptying is quoted as >95%. Incomplete evac in the presence of compromised resting anal canal pressures (i.e. internal anal sphincter compromised) could combine to create a reservoir of strong smelling stool and the poor resting tone could lead to escape of gas from this stool and a rectal odour symptom. However, I remember the immediate post op pain of the last solesta that made me feel really constipated. Normally, I would have horrendous odour from this, but no-one complained. The seal was air-tight, so no odour except when passing wind or defecating...and that would be considered normal by average people I guess.So, my latest plan is: -more solesta-however the other GI doc wants to treat the SIBO, but I should start low FODMAP and peppermint oil. I want to implement a low sulfur diet in combination with this.-defecating proctogram-a second scope which I am hoping might show any physical defects that might have been missed the first time round.-continue psyllium and irrigation in the mean time. I think both help reduce the odour. Unfortunately not enough to eliminate the jokes and laughing.-last ditch plan: antegrade continence enema...turning the appendix into a irrigation valve which is used to complete evacuate out the entire colon every other day. http://en.wikipedia.org/wiki/Malone_procedure Not really as keen on this as much anymore since the retrograde irrigation has not resolved things.Considering going to see this guy before I run out of money: http://www.obstructed-defaecation.com/Welcome.html


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## tummyrumbles (Aug 14, 2005)

I would try to narrow down as much as possible what the exact problem is before thinking about surgery.None of the web links you provided seem to describe exactly what I have, and you could have the same problem as me. Your Obstructed Defecation web link describes anismus as a failure of the puborectalis muscle sling. My problem isn't so much that the stool is there and can't get out, the problem is that it's not there and has to work its way down. So I think these are 2 separate problems. It's a really important distinction, because you don't want to be having surgery for a problem you don't have.In my case the muscles all work together OK once the stool has hit the rectum, the problem is getting all the stool in the rectum. If the problem is the puborectalis muscle sling I would feel the stool there waiting to be evacuated because it's just that the muscles aren't coordinating. I don't think this is the case. I don't actually feel the need to go most of the time I'm sitting there, so I'm not aware of any pressure. The peristalsis waves are basically weak and interrupted, and fairly sudden - like it's shooting down from higher up. So my problem isn't the puborectalis sling, but simply that the colon contractions themselves are weak and interrupted. I don't know of any surgery to correct this, it's more of a re-training your bowel thing. Doctors will operate without knowing exactly what's wrong with you. Also, the fact that there is nothing on the web that exactly describes my situation (and maybe yours) makes me suspect that doctors don't really understand the colon, even the things you can test for. In their mind such-and-such is wrong with you, but they are probably wide off the mark.The solesta procedure is probably the least invasive of the other options you have been considering. But we've discussed this before, and you know it's not designed for gas issues. At least you provide feedback on this, so thanks for that. It makes me angry when people make a huge announcement about having it done, then you never hear from them again.Do you have a relaxing sphincter? Have tests shown this? I wonder if your sphincter is a lot more relaxed than mine. You don't talk of holding your gas in, so you don't feel this pressure? If your sphincter was always partially open then you wouldn't feel any gas pressure, it would just constantly leak out, causing the odour. All odours are gas, but this gas can also be released from liquids or solids...but I know what you mean. I asked the nurse whether many of her patients complained of odour. She said the complaints vary between patients. She suggested that if there was a pouch or something that was non emptying then stool could fester there, and that became more malodorous than normal stool. I think it is very relevant that normal rectal emptying is quoted as >95%. Incomplete evac in the presence of compromised resting anal canal pressures (i.e. internal anal sphincter compromised) could combine to create a reservoir of strong smelling stool and the poor resting tone could lead to escape of gas from this stool and a rectal odour symptom. However, I remember the immediate post op pain of the last solesta that made me feel really constipated. Normally, I would have horrendous odour from this, but no-one complained. The seal was air-tight, so no odour except when passing wind or defecating...and that would be considered normal by average people I guess.So, my latest plan is: -more solesta-however the other GI doc wants to treat the SIBO, but I should start low FODMAP and peppermint oil. I want to implement a low sulfur diet in combination with this.-defecating proctogram-a second scope which I am hoping might show any physical defects that might have been missed the first time round.-continue psyllium and irrigation in the mean time. I think both help reduce the odour. Unfortunately not enough to eliminate the jokes and laughing.-last ditch plan: antegrade continence enema...turning the appendix into a irrigation valve which is used to complete evacuate out the entire colon every other day. http://en.wikipedia.org/wiki/Malone_procedure Not really as keen on this as much anymore since the retrograde irrigation has not resolved things.Considering going to see this guy before I run out of money: http://www.obstructed-defaecation.com/Welcome.html[/quote]


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## ileo (Jun 14, 2012)

tummyrumbles said:


> I would try to narrow down as much as possible what the exact problem is before thinking about surgery.None of the web links you provided seem to describe exactly what I have, and you could have the same problem as me. Your Obstructed Defecation web link describes anismus as a failure of the puborectalis muscle sling. My problem isn't so much that the stool is there and can't get out, the problem is that it's not there and has to work its way down. So I think these are 2 separate problems. It's a really important distinction, because you don't want to be having surgery for a problem you don't have.


According to the Rome criteria for functional anorectal disorders, there are 3 types:i. paradoxical paradoxical contraction of the pelvic floor muscles during attempted defecationii. inadequate propulsive forces during attempted defecation (inadequate defecatory propulsion)iii. impaired relaxation with adequate propulsion...so type i. and iii. are "classical" anismus, but ii. sounds like something totally different from anismus, and more like what you describe.http://en.wikipedia.org/wiki/Anismus#Classification http://www.gastrojournal.org/article/S0016-5085(06)00516-6/abstract?referrer=http://www.ncbi.nlm.nih.gov/pubmed/16678564A more extensive classification of outlet obstruction (outlet obstruction = obstructed defecation?) from a textbook: http://en.wikipedia.org/wiki/Obstructed_defecation_syndrome#Classification It can be seen that there are many many different causes of rectal outlet obstruction other than anismus.


> In my case the muscles all work together OK once the stool has hit the rectum, the problem is getting all the stool in the rectum. If the problem is the puborectalis muscle sling I would feel the stool there waiting to be evacuated because it's just that the muscles aren't coordinating. I don't think this is the case. I don't actually feel the need to go most of the time I'm sitting there, so I'm not aware of any pressure. The peristalsis waves are basically weak and interrupted, and fairly sudden - like it's shooting down from higher up. So my problem isn't the puborectalis sling, but simply that the colon contractions themselves are weak and interrupted. I don't know of any surgery to correct this, it's more of a re-training your bowel thing.


"The two key features of obstructed defecation are:An inability to voluntarily evacuate rectal contents [5]Normal colonic transit time [5]"I am no expert, but are you describing impaired transit in the whole colon? Maybe this test would distinguish this: http://www.ncbi.nlm.nih.gov/pubmed/17357865


> Doctors will operate without knowing exactly what's wrong with you. Also, the fact that there is nothing on the web that exactly describes my situation (and maybe yours) makes me suspect that doctors don't really understand the colon, even the things you can test for. In their mind such-and-such is wrong with you, but they are probably wide off the mark.The solesta procedure is probably the least invasive of the other options you have been considering. But we've discussed this before, and you know it's not designed for gas issues. At least you provide feedback on this, so thanks for that. It makes me angry when people make a huge announcement about having it done, then you never hear from them again.


Gas continence is a function of the resting anal tone, the involuntary internal anal sphincter and the hemorroidal vascular beds, working together to provide a air tight seal. Solesta is injected above the dentate line, and below the level of the anorectal ring (the level of the junction between the rectum and the anal canal).


> Do you have a relaxing sphincter? Have tests shown this? I wonder if your sphincter is a lot more relaxed than mine. You don't talk of holding your gas in, so you don't feel this pressure? If your sphincter was always partially open then you wouldn't feel any gas pressure, it would just constantly leak out, causing the odour.


I think assessment of resting tone is part of the manometry. The only abnormality the reported was shortened internal sphincter. I assume resting and squeeze tonus was normal. Immediately after the first solesta, I could not just relax the muscles to let out gas, I had to contract the muscles to let it out. This to me suggests that solesta is capable of increasing gas continence. I can feel gas, so I don't think this is the issue.


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## tummyrumbles (Aug 14, 2005)

Yes, I do think I have impaired transit of the whole colon, but still can't find my condition described exactly. I don't actually have slow transit as such, because I go every morning. So the transit itself from gullet to rectum is very regular. The problem with me, and maybe most people on this board with leaky gas, is that the stool is low enough in the colon to be considered "normal transit" at least on a daily basis, but not low enough in the colon to be evacuated quickly. A series of xrays I guess would clear this up, but I don't think they do this kind of testing."Dyssynergic defecation is commonly considered to be a form of maladaptive behavior because there is no discernable neurological or anatomical defect". In other words, it's IBS. It's not a totally functional disorder, it is influenced by the mind / learned behaviour /history. So surgery won't help. You could also have this condition.Unfortunately none of the medical web sites have ever helped me, but I appreciate the links.I'm confused by your posts. Has the solesta procedure actually helped you to retain gas? I know a lot of people are thinking of having this procedure done. Yet in your opening post you said that you were still getting comments. Are you saying that even though the procedure caused constipation the gases were at least held in because of the solesta? Was this only short term then? So you have to keep having the procedure done for it to be effective? Is this a good idea if it causes constipation? Won't this just confuse the colon even more and maybe lead to compensating behaviour by the colon/sphincter?


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## ileo (Jun 14, 2012)

tummyrumbles said:


> I'm confused by your posts. Has the solesta procedure actually helped you to retain gas? I know a lot of people are thinking of having this procedure done. Yet in your opening post you said that you were still getting comments. Are you saying that even though the procedure caused constipation the gases were at least held in because of the solesta? Was this only short term then? So you have to keep having the procedure done for it to be effective? Is this a good idea if it causes constipation? Won't this just confuse the colon even more and maybe lead to compensating behaviour by the colon/sphincter?


It was short term benefits with regard gas. It only caused constipation while it was painful to go. Maybe for a few weeks. After this time, I had sudden discharge of liquid, which at the time i assumed to be an infection spontaneously draining, because I was feeling a bit sick all the time and then felt better. But, it is possible that this liquid was some of the solesta material itself, which had not yet stabilized and the body had not formed fibrous tissue around it for some reason. Possibly because I didn't know about not using enema "or any other anorectal manipulations" (wtf...) during this time. Take 2 solesta I will know about this advice.


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## tummyrumbles (Aug 14, 2005)

Yes, I should have said organic not functional disorder.Extreme behaviour, well excuse me! Those pics were sitz marker tests? Like I said, I go every day (albeit in my peculiar fashion) so mine would appear pretty normal I guess. It's just at 7.00 am most of mine would be in exactly the same place as at 8.00 and 9.00 am. I'm guessing this, I don't know. But because I go every day I suppose they're more likely lower than higher in the colon. It takes quite a series of contractions to get them out.Medicine can't help me. I do what I do because it works. I can work, socialise to a certain extent, and pretend I'm normal for a while. Put it this way. A typical leaky gasser sits for a long longer than I do being miserable.What's the point of all these tests if there's no resolution at the end of it. Doctors will never understand IBS because they deal in science. What happens to me is a physical process which is very real, and works like clockwork in its own strange way, but a lot of the dysfunction involves my personal history and a whole lot of other murky stuff. There's no surgery for these things.


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## ileo (Jun 14, 2012)

tummyrumbles said:


> Medicine can't help me. I do what I do because it works. I can work, socialise to a certain extent, and pretend I'm normal for a while. Put it this way. A typical leaky gasser sits for a long longer than I do being miserable.What's the point of all these tests if there's no resolution at the end of it. Doctors will never understand IBS because they deal in science. What happens to me is a physical process which is very real, and works like clockwork in its own strange way, but a lot of the dysfunction involves my personal history and a whole lot of other murky stuff. There's no surgery for these things.


This is defeatist. What you are saying to my ears when you say doctors will never understand IBS is that you are not willing to research your own condition. Current knowledge of the physiology of the lower GI tract is vast. I don't pretend to understand it, but neither do I say that experts and researches in that field don't understand anything either. Also I should remind you that were it not for medicine you and I would have had a good chance of childhood death from smallpox.Your personal history and murky stuff is very much within the realms of medicine if it is impacting your health* The "surgery" would be things like therapy and biofeedback I'm guessing. *Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity [world health organisation].Not really sure why I defend medicine since I have 5 year history of being fobbed off and even laughed at without solving my only complaint about odour. You would think it would be easy after all. It is their general failure to understand how it destroys your life that bothers me the most. Nevertheless I still have every faith that I will find successful management, but I long ago realized I need to take responsibility for this myself.


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## AIRPLANE (Mar 15, 2004)

tummyrumbles said:


> Yes, I do think I have impaired transit of the whole colon, but still can't find my condition described exactly. I don't actually have slow transit as such, because I go every morning. So the transit itself from gullet to rectum is very regular. The problem with me, and maybe most people on this board with leaky gas, is that the stool is low enough in the colon to be considered "normal transit" at least on a daily basis, but not low enough in the colon to be evacuated quickly. A series of xrays I guess would clear this up, but I don't think they do this kind of testing."Dys


Tummyrumbles,I was wondering if you had had any transit testing done. I've had my issues for 28 years and never had any kind of transit test until this year. I don't think that the transit test that I had done is widely available. It was one where I ate a radioactive breakfast and then had to return to have pictures taken for 3 days.While it didn't provide a concrete solution, it at least did show that there were some problem areas in my colon where things had a difficult time getting through. My stomach emptying was normal, actually even a bit above normal as far as emptying time went, but then it was somewhat slow in the small bowel and also slow in the large bowel. There seemed to be problem areas in the right ascending colon and in the sigmoid and rectal area.I have incomplete evacuation and even when the rectum does feel empty there is usually more to come- sometimes shortly after or a couple or more hours later- sometimes as often as 3-6 times a day but not always. It feels like there is some kind of a hump in my left rectal area that I have to try and get things around. I was once told that I had a small rectocele that shouldn't be an issue and most doctors and physical therapists tell me that they can't detect one even though a defecography test supposedly showed it a few years ago but then I suppose it could be something else. It is usually when I eat a bit more freely on an evening when I don't have to go anywhere the next day that I seem to have the multiple, increasingly urgent bms.I usually tend to the D side but I do alternate a lot. The doctor who ordered the test theorized that my D was really constipation but my body was trying to force it through which is why I often have D. Certainly possible but who knows. Anyway, she recommended biofeedback for tight muscles at their clinic but I couldn't do it because my insurance wouldn't cover it (this was recommended to me a few years ago and I wasn't able to do it for the same reason.) And the cost is way too high to pay for it myself and its success rate isn't that great according to what I've read from other patients who went through with it. I've also been told that I have adhesions by physical therapists but doctors refuse to consider that possibility as a factor in my motility issues.I'm going to a new physical therapist who will be working on adhesions, maybe checking to see if I have tight muscles, and also my tailbone apparently is out of whack even though I had it x-rayed on the advice of my massage therapist and it came back negative. She said that my anal sphincter was very tight yet I do tend to leak gas and/or just general rectal odors. She told me that if I did have tight muscles that they can cause burning and irritation- it sounds like actual friction- which I know always means odor when I have it, regardless of how well I have or haven't emptied my rectum and/or colon. I also wonder about sometimes having bile in my stool when things are loose which only adds to the problem- both odor and irritation-wise. I also get bad odor from the left vaginal area when it gets irritated which has been a problem for me ever since I had a hysterectomy 14 years ago. Irritation + burning + stinging = odor for me. I frequently have to use ointments in both the vagina and rectum to try and calm things down as much as possible.


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## AIRPLANE (Mar 15, 2004)

ileococcygeus said:


> Not really sure why I defend medicine since I have 5 year history of being fobbed off and even laughed at without solving my only complaint about odour. You would think it would be easy after all. It is their general failure to understand how it destroys your life that bothers me the most. Nevertheless I still have every faith that I will find successful management, but I long ago realized I need to take responsibility for this myself.


So true, ileococcygeus! That's what is the worst thing about this- even worse than trying to function with it is going to a doctor for help but then being treated like you are just an over-sensitive whiner who is just imagining all those hurtful comments and reactions. It doesn't count as a 'real' medical problem and if you even try to describe what happens in public due to it they immediately give you psychological labels because you can't 'prove' that what you are describing is true. I've often thought about asking these insensitive 'professionals' if I should have brought an attorney with me for defense- 'I swear to tell the whole truth, nothing but the truth'. And the over-simplified statement 'but EVERYBODY passes gas' that they so often like to spout is about as dismissive as it can get. Going for help, having to pay for it and instead getting these kinds of attitudes should be illegal.


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## tummyrumbles (Aug 14, 2005)

No Airplane, I’ve never had any testing like that. I think I know why I have my problems. My maternal grandmother had bad gas issues and my father took a long time to go. So I may have inherited a weakness there. Maybe because of this even when I was young I just never learned to go properly. I know I ignored the urge to go a lot when I was younger and I think that tells the colon not to try so hard with contractions next time. Maybe it just gets steadily worse like that. I really don’t think anything physical can be done about this, in terms of doctors. I only sought help once or twice. They just looked at me like I was insane, and I thought – well that’s helpful.I was told my anal sphincter was very tight as well immediately after childbirth, so I think it’s a sensitivity thing more than a physical thing. If my colon senses either gas or stool it seems to upset the sphincter. I have the D symptoms too, but then I have a whole pot of tea at breakfast to help move things along. I also have a pot of tea at night too. These are my only addictions and I’m not giving them up, but maybe they make things a bit too fluid. Isn’t it funny how you have tests and the doctors still aren’t sure what they mean. I just can’t be bothered with it. I’m used to having to spend a long time to go and works pretty well if I work part-time. Working full time hours from 9 to 5 is hard, because I have to get up super early and I’m just too tired for things to work well.That’s interesting about the tight muscles causing burning. I remember when I had day-long LG I’d get this hot, burning sensation down there. I suppose if you clench down hard while trying to hold gas in that could cause friction.


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## tummyrumbles (Aug 14, 2005)

Ileococcygeus, I think the colon has its own brain, independent of us. If a leaky gasser became concussed and amnesic I don’t think their bowel evacuation would suddenly start working normally. Even without our input I think the colon has its own memories and pattern of behaviour although I don’t suppose this could ever be proved one way or the other. I’m pretty sure biofeedback is designed for people with pelvic floor issues. I don’t think this is my problem and I’m not sure this is all that effective anyway even for someone with this condition.In terms of management you just do whatever works. I'd rather not have leaky gas than have it.


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## ileo (Jun 14, 2012)

tummyrumbles said:


> Ileococcygeus, I think the colon has its own brain, independent of us. If a leaky gasser became concussed and amnesic I don't think their bowel evacuation would suddenly start working normally. Even without our input I think the colon has its own memories and pattern of behaviour although I don't suppose this could ever be proved one way or the other. I'm pretty sure biofeedback is designed for people with pelvic floor issues. I don't think this is my problem and I'm not sure this is all that effective anyway even for someone with this condition.In terms of management you just do whatever works. I'd rather not have leaky gas than have it.


Yes, the enteric nervous system. The colon also has its own "pacemaker" of sorts. Like the heart. However it is subject to higher controls.I do not hold with all this talk. The gut is first and foremost a tube for chemical reactions, which is subject to the laws of physics. It is not some mysterious abyss. At least try to access the current scientific understanding before making claims otherwise.I was using biofeedback as an example of something that was not surgery. And stop using the made up term "leaky gas" already.


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