Acute Pancreatitis Management Conference

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Acute Pancreatitis Management Conference

  1. 1. Acute Pancreatitis Management Conference LTC J. David Horwhat, MD Assistant Chief, GI WRAMC
  2. 2. Demographics <ul><li>Incidence </li></ul><ul><ul><li>17 per 100,000 </li></ul></ul><ul><li>Mortality </li></ul><ul><ul><li>2-3% overall mortality from acute pancreatitis </li></ul></ul><ul><ul><ul><li>Tertiary centers report rates of 5-15%, high of 30% </li></ul></ul></ul><ul><ul><ul><ul><li>Skew towards series with more severe pancreatitis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Interstitial pancreatitis (1%) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Necrotizing pancreatitis/organ failure (30%) </li></ul></ul></ul></ul><ul><li>Physician office visits </li></ul><ul><ul><li>911,000 per year </li></ul></ul><ul><li>Hospitalizations </li></ul><ul><ul><li>230,000 in 2002 </li></ul></ul><ul><li>Deaths </li></ul><ul><ul><li>2500 per year </li></ul></ul>
  3. 3. More Demographics <ul><li>The median age at onset depends on the etiology </li></ul><ul><ul><li>AIDS-related - 31 years </li></ul></ul><ul><ul><li>Vasculitis-related - 36 years </li></ul></ul><ul><ul><li>Alcohol-related - 39 years </li></ul></ul><ul><ul><li>Drug-induced etiology - 42 years </li></ul></ul><ul><ul><li>ERCP-related - 58 years </li></ul></ul><ul><ul><li>Trauma-related - 66 years </li></ul></ul><ul><ul><li>Biliary tract–related - 69 years </li></ul></ul>
  4. 5. Terminology of Acute Pancreatitis <ul><li>Acute interstitial pancreatitis (~80%) </li></ul><ul><li>Necrotizing pancreatitis (~20%) </li></ul><ul><ul><li>Sterile necrosis </li></ul></ul><ul><ul><li>Infected necrosis </li></ul></ul><ul><li>Pancreatic fluid collection </li></ul><ul><ul><li>Sterile </li></ul></ul><ul><ul><li>Infected </li></ul></ul><ul><li>Pancreatic pseudocyst </li></ul><ul><ul><li>Sterile </li></ul></ul><ul><ul><li>Infected </li></ul></ul><ul><li>Pancreatic abscess </li></ul><ul><ul><li>Collection of pus with little or no pancreatic necrosis </li></ul></ul><ul><li>Terms no longer used </li></ul><ul><ul><li>Hemorrhagic pancreatitis </li></ul></ul><ul><ul><li>Phlegmon </li></ul></ul>
  5. 6. Clinical Presentation <ul><li>Pain (95%) </li></ul><ul><ul><li>Acute onset </li></ul></ul><ul><ul><ul><li>Mid-abdominal or mid-epigastric </li></ul></ul></ul><ul><ul><ul><li>Radiates to the back (50%) </li></ul></ul></ul><ul><ul><li>Peak intensity in 30 minutes </li></ul></ul><ul><ul><ul><li>Lasts for several hours </li></ul></ul></ul><ul><li>Nausea and vomiting (80%) </li></ul><ul><li>Abdominal distension (75%) </li></ul><ul><li>Abdominal guarding and tenderness (50%) </li></ul><ul><li>Restlessness and agitation </li></ul>
  6. 7. Laboratory Diagnosis <ul><li>Increased amylase and/or lipase </li></ul><ul><ul><li>>3 times ULN </li></ul></ul><ul><ul><ul><li><3 ULN does not rule out diagnosis in right clinical context </li></ul></ul></ul><ul><ul><li>Amylase levels rise w/in 2 to 12h of sxs </li></ul></ul><ul><ul><ul><li>Peak w/in first 48h </li></ul></ul></ul><ul><ul><ul><li>Remain elevated 3-5d before return to baseline </li></ul></ul></ul><ul><ul><ul><li>↑ TGs interferes with assay (false negative) </li></ul></ul></ul><ul><ul><li>Lipase much more specific </li></ul></ul><ul><ul><ul><li>Causes for < 3x elevation </li></ul></ul></ul><ul><ul><ul><ul><li>Perforated ulcer, mesenteric ischemia, CRF (CrCl < 20 ml/min) </li></ul></ul></ul></ul><ul><ul><li>Height of elevation does not correlate with severity </li></ul></ul><ul><ul><li>No utility in following daily levels after the diagnosis </li></ul></ul>
  7. 8. Lab studies <ul><li>Other causes for  amylase </li></ul><ul><ul><li>SBO </li></ul></ul><ul><ul><li>mesenteric ischemia </li></ul></ul><ul><ul><li>tubo-ovarian disease </li></ul></ul><ul><ul><li>renal insufficiency </li></ul></ul><ul><ul><li>macroamylasemia </li></ul></ul><ul><ul><li>brain injury/brain trauma </li></ul></ul><ul><li>LTFs </li></ul><ul><ul><li>ALT > 3x ULN = 95% PPV for biliary etiology </li></ul></ul><ul><li>Calcium </li></ul><ul><ul><li> Ca as a cause </li></ul></ul><ul><ul><li> Ca as a complication </li></ul></ul><ul><ul><ul><li>saponification of fats in retroperitoneum </li></ul></ul></ul><ul><li>TG </li></ul><ul><ul><li>Can be falsely low during an attack </li></ul></ul>
  8. 9. Differential Diagnosis <ul><li>Mesenteric ischemia </li></ul><ul><li>Perforated peptic ulcer </li></ul><ul><li>Intestinal obstruction </li></ul><ul><li>Biliary colic </li></ul><ul><li>Inferior wall MI </li></ul><ul><li>Ectopic pregnancy </li></ul>
  9. 10. Causes OBSTRUCTION -GB Stones : 30 to 75% *ALT > 3x ULN = 95% PPV -Tumors TOXINS - EtOH : ~30% -Scorpion bites Tityus trinitatis & T. serrulatus -Insecticides METABOLIC -  TG ~ 4% -> 1000 mg/dl -  PTH < 0.5% TRAUMA -Surgery -Post-ERCP -MVAs etc . INFECTION -Viral -HIV/EBV/Coxsackie/Mumps -CMV/Varicella/Hep A&C -Parasitic -Ascariasis, clonorchiasis -Bacterial -Mycoplasma, C. jejuni, TB -MAI, Leptospirosis, Legionella VASCULAR -Ischemia -Embolic -Vasculitis <ul><li>MISC </li></ul><ul><li>-Hereditary </li></ul><ul><li>-Cystic Fibrosis </li></ul><ul><li>- Idiopathic : 10 to 30% </li></ul><ul><li>- 70% microlithiasis </li></ul><ul><li>P. divisum </li></ul><ul><li>Annular pancreas </li></ul><ul><li>SOD </li></ul><ul><li>-Crohn’s Dz </li></ul><ul><li>-Post Perf DU </li></ul>Drugs -Imuran -Estrogens -TCN -Flagyl -Thiazides -Lasix -DDI -Sulfa drugs -Depakote -Pentamidine 80%
  10. 11. Management questions <ul><li>When should patients admitted with AP be monitored in an ICU or step-down unit? </li></ul><ul><li>When do I order a CT scan? </li></ul><ul><li>Should patients with SAP receive prophylactic abx? </li></ul><ul><li>What is the optimal mode and timing of nutritional support for the patient with SAP? </li></ul><ul><li>Under what circumstances should patients with gallstone pancreatitis undergo interventions to clear the bile duct? </li></ul><ul><li>What are the indications for surgery in AP; optimal timing for intervention, and roles for less invasive approaches including percutaneous drainage and laparoscopy? </li></ul>
  11. 12. Tityus trinitatus Tityus serrulatus
  12. 13. When Do I Transfer to the Unit ? <ul><li>Severe pancreatitis </li></ul><ul><li>Multi-organ failure </li></ul><ul><ul><li>Pulmonary </li></ul></ul><ul><ul><li>Renal </li></ul></ul><ul><li>Consider it if you are placing the patient on antibiotics and/or ordering a CT to evaluate non-improvement </li></ul>
  13. 14. Determining severity <ul><li>Clinical criteria </li></ul><ul><ul><ul><li>early development/persistence of organ dysfnx </li></ul></ul></ul><ul><ul><li>Ranson criteria </li></ul></ul><ul><ul><li>Atlanta criteria </li></ul></ul><ul><ul><li>POP score </li></ul></ul><ul><li>Clinical assessment </li></ul><ul><ul><ul><li>frequent VS, fluid status/UOP, pulse oximetry </li></ul></ul></ul><ul><li>Radiographic criteria </li></ul><ul><ul><li>CT severity index </li></ul></ul><ul><ul><ul><li>necrosis may not be evident until 48-72h </li></ul></ul></ul>
  14. 15. Ranson Criteria <ul><li>Admission </li></ul><ul><ul><li>Age > 55 years </li></ul></ul><ul><ul><li>White blood cells > 16,000/mm 3 </li></ul></ul><ul><ul><li>Glucose > 200 mg/dL </li></ul></ul><ul><ul><li>LDH > 350 IU/L </li></ul></ul><ul><ul><li>AST > 250 U/L </li></ul></ul><ul><li>During Initial 48 Hours </li></ul><ul><ul><li>Hct decrease of > 10 mg/dL </li></ul></ul><ul><ul><li>BUN increase of > 5 mg/dL </li></ul></ul><ul><ul><li>Base deficit > 4 mEq/L </li></ul></ul><ul><ul><li>Fluid sequestration > 6 L </li></ul></ul><ul><ul><li>Ca++ < 8 mg/dL </li></ul></ul><ul><ul><li>Pa O 2 < 60 mm Hg </li></ul></ul><ul><li>Directly related to fluid resuscitation </li></ul><ul><li>Independent predictors of mortality </li></ul>** Caveat ** Valid at 48h after onset of symptoms and not at any other time during the disease
  15. 16. Ranson et al. Radiology, 1990;174:331 † Sn 73%, Sp 77% * > 7 d in ICU MORTALITY † MORBIDITY *
  16. 17. Pancreatitis Outcome Prediction (POP) Score <ul><li>Data collected within 24hr of ICU admission </li></ul><ul><li>2,462 patients from 159 ICUs in the UK </li></ul><ul><li>Logistic regression model with area under the ROC curve of 0.838 </li></ul><ul><li>(needs prospective validation) </li></ul>
  17. 18. Pancreatitis Outcome Prediction Score
  18. 19. TAP? CRP? Hct? <ul><li>Trypsinogen activation peptide </li></ul><ul><li>CRP </li></ul><ul><ul><li>Latency of 24-48hr </li></ul></ul><ul><ul><ul><li> not useful for EARLY determination </li></ul></ul></ul><ul><li>Hematocrit </li></ul><ul><ul><li>Admission Hct ≥50% </li></ul></ul><ul><ul><ul><li>significant predictor of severe pancreatitis, necrosis, LOS, need for ICU </li></ul></ul></ul><ul><ul><ul><li>LR 7.5 for severe AP </li></ul></ul></ul>
  19. 20. Famous people who have had pancreatitis <ul><li>Alexander the Great </li></ul><ul><li>Ludwig von Beethoven </li></ul><ul><li>Dizzie Gillespie </li></ul><ul><li>Maximilian Schell </li></ul><ul><li>Matthew Perry </li></ul><ul><li>John Ashcroft </li></ul>
  20. 22. Acute Pancreatitis INTERSTITIAL (Edematous) 80% NECROTIZING 20% INFECTED NECROSIS 70% INFLAMMATORY MASS STERILE NECROSIS 30% HEALING CHRONIC PSEUDOCYST PANCREATIC ABSCESS
  21. 23. Severe Pancreatitis Atlanta criteria <ul><li>Organ Failure </li></ul><ul><ul><li>i.e. systolic blood pressure <90 mm Hg, PaO 2 <60 mm Hg, serum creatinine >2 mg/dL, >500 mL/24 h GI bleeding OR </li></ul></ul><ul><li>Local Complications </li></ul><ul><ul><li>Necrosis </li></ul></ul><ul><ul><li>Abscess </li></ul></ul><ul><ul><li>Pseudocyst OR </li></ul></ul><ul><li>Unfavorable Early Prognostic Signs </li></ul><ul><ul><li> 3 Ranson's signs OR </li></ul></ul><ul><ul><li> 8 APACHE-II points </li></ul></ul>
  22. 24. Organ Failure <ul><li>Cardiovascular </li></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>Septic physiology </li></ul></ul><ul><ul><ul><li> HR, CO and  SVR </li></ul></ul></ul><ul><li>Respiratory </li></ul><ul><ul><li>Hypoxemia </li></ul></ul><ul><ul><li>Pleural effusions </li></ul></ul><ul><li>Renal </li></ul><ul><ul><li>ATN </li></ul></ul><ul><ul><li>Oliguria </li></ul></ul><ul><li>Hematologic </li></ul><ul><ul><li>DIC </li></ul></ul><ul><ul><li>Thrombocytosis </li></ul></ul><ul><li>Hepatic </li></ul><ul><ul><li>Encephalopathy </li></ul></ul><ul><ul><li> T bili (3 mg/dl) </li></ul></ul><ul><ul><li> AST/ALT 2X nl </li></ul></ul><ul><li>GI </li></ul><ul><ul><li>Stress ulcer </li></ul></ul><ul><ul><li>Acalculous cholecystitis </li></ul></ul>
  23. 25. When Do I Order A CT? <ul><li>If the patient has….. </li></ul><ul><ul><li>Signs of severe acute pancreatitis </li></ul></ul><ul><ul><li>No signs of clinical improvement after several days </li></ul></ul><ul><ul><li>Diagnostic dilemma </li></ul></ul><ul><ul><li>Infection suspected </li></ul></ul><ul><ul><ul><li>T > 101 o F </li></ul></ul></ul><ul><ul><ul><li>Positive blood cultures </li></ul></ul></ul><ul><li>What kind of CT? </li></ul><ul><ul><li>Dynamic with rapid bolus IV contrast </li></ul></ul><ul><li>What are you looking for? </li></ul><ul><ul><li>Necrosis: Lack of enhancement with contrast </li></ul></ul><ul><ul><li>Fluid Collections </li></ul></ul><ul><ul><li>Alternate diagnosis </li></ul></ul>
  24. 26. CT Findings <ul><li>Pancreas </li></ul><ul><ul><li>Pancreatic enlargement </li></ul></ul><ul><ul><li>Decreased density due to edema </li></ul></ul><ul><ul><li>Intrapancreatic fluid collections </li></ul></ul><ul><ul><li>Blurring of gland margins due to inflammation </li></ul></ul><ul><li>Peripancreatic </li></ul><ul><ul><li>Fluid collections and stranding densities </li></ul></ul><ul><ul><li>Thickening of retroperitoneal fat </li></ul></ul>* It may take up to 72h for inflammatory changes to become apparent on CT *
  25. 27. CT Findings Tail Indistinct Intraperitoneal fluid PANC LIVER
  26. 28. CT Findings Severe Pancreatitis Peripancreatic edema and inflammation Unenhancing Necrosis PANC LIVER GB
  27. 29. Normal Pancreas
  28. 30. POINTS Grade of Acute Pancreatitis A = Normal pancreas 0 B = Pancreatic enlargement 1 C = Pancreatic/peripancreatic inflammation 2 D = Single peripancreatic fluid collection 3 E = Multiple fluid collections 4 Grade E = 50% chance of developing an infection and 15% chance of death Degree of Necrosis No necrosis 0 Necrosis of one third of pancreas 2 Necrosis of one half of pancreas 4 Necrosis of more than one half 6 CT Severity Index = Grade + Degree of necrosis
  29. 31. * > 7 days in the ICU CT Severity Index = Grade of Panc. + Degree of Necrosis per Balthazar MORTALITY MORBIDITY*
  30. 32. Cullen’s sign
  31. 33. Management Mild-Moderate <ul><li>NPO with IVF (crystalloid) </li></ul><ul><ul><li>Colloid (blood if Hct <25, albumin if serum alb <2) </li></ul></ul><ul><li>Closely follow I/Os, UOP </li></ul><ul><ul><li>UOP 0.5cc/kg body wt per hr in absence of renal failure </li></ul></ul><ul><li>Generous narcotics </li></ul><ul><ul><li>PCA </li></ul></ul><ul><ul><ul><li>MSO4 OK </li></ul></ul></ul><ul><ul><ul><ul><li>no evidence in humans of worsening Ac Panc d/t sphincter of Oddi </li></ul></ul></ul></ul><ul><ul><li>Scheduled not PRN </li></ul></ul><ul><li>NGT decompression </li></ul><ul><ul><li>if frequent emesis or evidence of ileus on plain films </li></ul></ul><ul><li>Start clear liquids when pain/anorexia resolve </li></ul><ul><li>DO NOT follow amylase and lipase levels </li></ul>
  32. 34. When Do I Start Antibiotics? <ul><li>Acute pancreatitis is c/b infection ~ 10% </li></ul><ul><ul><ul><li>30-50% of those with necrosis get infection </li></ul></ul></ul><ul><li>Prophylactic antibiotics </li></ul><ul><ul><li>Controversial </li></ul></ul><ul><ul><ul><li>No benefit in mild EtOH pancreatitis </li></ul></ul></ul><ul><ul><ul><li>Imipenem or meropenem in necrotizing pancreatitis </li></ul></ul></ul><ul><ul><ul><li>Selective gut decontamination may be beneficial </li></ul></ul></ul><ul><ul><ul><li>Abx do not appear to promote fungal infection </li></ul></ul></ul><ul><li>General recommendations for use: </li></ul><ul><ul><li>Biliary pancreatitis with signs of cholangitis </li></ul></ul><ul><ul><li>> 30% necrosis on CT scan </li></ul></ul>
  33. 35. Antibiotics - EBM <ul><li>Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. </li></ul><ul><li>Cochrane Database of Systematic Reviews. 3, 2005 </li></ul>Despite variations in drug agent, case mix, duration of treatment and methodological quality (especially the lack of double blinded studies), there was strong evidence that intravenous antibiotic prophylactic therapy for 10 to 14 days decreased the risk of super-infection of necrotic tissue and mortality in patients with severe acute pancreatitis with proven pancreatic necrosis at CT
  34. 37. A final word on antibiotics <ul><li>Do not use empirically early in mild pancreatitis </li></ul><ul><li>Fever early in the disease process is almost universally secondary to the inflammatory response and NOT an infectious process </li></ul>
  35. 38. When can he eat ? Nutritional issues in AP <ul><li>TPN vs. enteral feeding </li></ul><ul><ul><li>Not TPN per meta-analysis but …* </li></ul></ul><ul><ul><li>NJ not NG </li></ul></ul><ul><li>Early initiation of enteral nutrition in severe AP </li></ul><ul><ul><ul><li>tube feed if anticipate NPO > 1 week </li></ul></ul></ul><ul><ul><ul><li>may be unnecessary for mild AP </li></ul></ul></ul><ul><ul><li>Reduce microbial translocation </li></ul></ul><ul><ul><li>Enhance gut mucosal blood flow </li></ul></ul><ul><ul><li>Promote gut mucosal surface immunity </li></ul></ul>Reduce incidence of infected necrosis * 6 older studies, relationship b/w glycemic control and infectious risk may confound vs. TPN
  36. 39. Nutrition <ul><li>Mild pancreatitis </li></ul><ul><ul><li>Calories from IVF (D5W) are sufficient </li></ul></ul><ul><ul><li>No benefit from additional nutritional support </li></ul></ul><ul><ul><li>Oral intake advancing to low fat diet once pain/anorexia resolve </li></ul></ul><ul><li>Moderate/Severe </li></ul><ul><ul><li>Begin nutritional support as early as possible </li></ul></ul><ul><ul><ul><li>NJ tube preferred </li></ul></ul></ul><ul><ul><li>TPN only if : </li></ul></ul><ul><ul><ul><li>Can’t maintain adequate jejunal access </li></ul></ul></ul><ul><ul><ul><li>Unable to meet caloric demands enterally </li></ul></ul></ul>
  37. 41. When Do I Consult GI ? <ul><li>Evidence of biliary pancreatitis </li></ul><ul><ul><li>Elevated LFTs + pancreatitis </li></ul></ul><ul><ul><ul><li>No matter what the US shows </li></ul></ul></ul><ul><li>Severe pancreatitis </li></ul><ul><li>Recurrent unexplained pancreatitis </li></ul><ul><li>Rule out infected necrosis </li></ul><ul><ul><ul><li>EUS FNA sampling of fluid collections </li></ul></ul></ul><ul><li>Endoscopic treatment of necrosis/abscess </li></ul>
  38. 42. Biliary pancreatitis <ul><li>Q: When should I suspect it ? </li></ul><ul><ul><li>A: Always </li></ul></ul><ul><li>Q: How do I evaluate for it ? </li></ul><ul><ul><li>A: (E)US and LFTs </li></ul></ul><ul><li>Q: When is ERCP indicated ? </li></ul><ul><ul><li>A: 3 studies looked at emergency (within 24-72h) ERC with ES vs standard therapy in biliary AP </li></ul></ul>
  39. 43. Fan Neoptolemus Fölsch Meta-analysis <ul><li>Emergency ERC (with ES & stone extraction when stones present) </li></ul><ul><ul><li>benefits severe AP but not mild </li></ul></ul>
  40. 44. Management of Pancreatic Complications <ul><li>Acute fluid collections </li></ul><ul><ul><li>Occur early, seen not felt </li></ul></ul><ul><ul><li>No defined wall  usually resolve spontaneously </li></ul></ul><ul><ul><li>NO routine percutaneous or operative drainage </li></ul></ul><ul><ul><ul><li>may infect otherwise sterile tissue </li></ul></ul></ul><ul><li>Infected pancreatic necrosis </li></ul><ul><li>Pancreatic abscess </li></ul><ul><li>Pseudocysts </li></ul>
  41. 45. Grey-Turner’s sign
  42. 46. Management of Pancreatic Complications <ul><li>Infected necrosis </li></ul><ul><ul><li>Organisms on gram stain after aspirate </li></ul></ul><ul><ul><li>Surgical drainage </li></ul></ul><ul><ul><li>Trans-gastric drainage </li></ul></ul><ul><ul><li>Try to delay necrosectomy 2-3wk for demarcation of necrosis </li></ul></ul><ul><li>Pancreatic abscess </li></ul><ul><ul><li>CT or EUS guided drainage </li></ul></ul><ul><ul><ul><li>Walled collection of pus </li></ul></ul></ul><ul><ul><ul><li>Similar to management of pseudocyst </li></ul></ul></ul>
  43. 48. Pseudocysts <ul><li>Collection of pancreatic fluid enclosed by non-epithelialized wall of granulation tissue </li></ul><ul><li>Complicates 5-10% cases of AP </li></ul><ul><li>~ 4 weeks after insult </li></ul><ul><li>25-50% resolve spontaneously </li></ul>
  44. 49. Complications of Pseudocyst <ul><li>Infection - 14% </li></ul><ul><li>Rupture - 6.8% </li></ul><ul><li>Hemorrhage - 6.5% </li></ul><ul><li>Common bile duct obstruction - 6.3% </li></ul><ul><li>GI obstruction - 2.6% </li></ul>
  45. 50. Pseudocyst Management <ul><li>Old thought </li></ul><ul><ul><li>Pseudocysts > 5 cm that have been present > 6 weeks must be drained </li></ul></ul><ul><li>Current practice </li></ul><ul><ul><li>Asymptomatic pseudocysts , regardless of size, do not require treatment </li></ul></ul>
  46. 51. Pseudocyst Drainage Techniques <ul><li>Endoscopic </li></ul><ul><li>Surgical </li></ul><ul><li>Radiologic </li></ul>Liver PC PC Stom
  47. 52. Endoscopic Pseudocyst Management <ul><li>Pseudocyst classification </li></ul><ul><ul><li>Communicating </li></ul></ul><ul><ul><li>Non-communicating </li></ul></ul>
  48. 53. Endoscopic Pseudocyst Management
  49. 54. Percutaneous Pseudocyst Drainage Open Cystgastrostomy
  50. 55. Laparoscopic Cyst Gastrostomy
  51. 56. Closing Points <ul><li>4 out of 5 patients have mild uneventful pancreatitis </li></ul><ul><li>If the patient is not getting considerably better in 36-48 hrs, start thinking about that “5th patient” </li></ul><ul><li>A CT is that 5th patient’s friend </li></ul><ul><li>If you are thinking about antibiotics, you should be thinking about a CT and a few consults </li></ul><ul><li>The pancreas is mean organ….respect it </li></ul>
  52. 57. Questions?

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