ĐĎॹá>ţ˙ ƒ…ţ˙˙˙‚˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙ěĽÁ7 đżä.bjbjUU Kf7|7|ß*˙˙˙˙˙˙lRRRRęęę$đđđđ üĚŻuöÔÔÔÔÔłłłRuTuTuTuTuTuTuĽv Ĺx^Tu곯łłłTuu'RRÔÔŰiuu'u'u'łRlÔęÔRuu'łRuu'>u'ł-.vmHž,ęVsÔČ ŕY^cŔâđĹ "žo@Vsüu0ŻuţoX#yç&Ž#yVsu'RRRRŮFebruary 1, 2001 ICM – 8AM Dr. Trowers Fathy/Robb I020109.doc Scribe for hire, James Morgan COLONIC DISEASE Anatomy Begin with rectum ( sigmoid colon ( descending colon (left) ( splenic flexure (~60cm from anal verge) ( transverse colon ( hepatic flexure ( ascending colon (right) Blood Supply Inferior Mesenteric Artery (IMA) = supplies left colon ( mid transverse Superior Mesenteric Artery (SMA) = supplies mid transverse ( right colon Important when pt. has an embolus that has ischemic bowel disease w/bleeding to localize area needed for surgical removal perform angiogram & see region of block -if on the left side, then look for IMA blocking at its origination Haustra not actually permanent anatomic markings represent sacculations of the transverse colon (not fixed) help in production of segmental contraction -retards flow of liquid stool (chyme) -to and fro movement in Haustra enhance absorption of fluids/other substances Diarrhea = essentially when Haustra are knocked out so can’t absorb the needed liquid has to come out somewhere Anal/rectal sagittal section Above pectinate line (dentate line) has visceral innervation, blood supply, lymphatic drainage get internal hemorrhoids here (not painful) -can treat with banding (strangulate with a rubber band) adenocarcinoma occurs here Below pectinate line has somatic innervation, blood supply, lymphatic drainage so external hemorrhoids (very painful) -cannot treat with banding b/c of the extreme pain it would cause squamous cell carcinoma Valves of Houston (semilunar, transverse folds in the rectum that support the weight of the feces) if undergoing a flex-sig (flexible sigmoidoscopy) and perforate… higher than middle rectal valve, then enter into the peritoneal area -may get peritonitis lower than middle valve, then much less chance of infection so important to watch for if they had a perforation. (when on inpatient service) Anal fissure (when pt. complains of a rectal discharge) look for signs of a peri-rectal abscess if left untreated can lead to more serious complications -gave example that when he was in residency, one of the house officers treated her own peri-rectal abscess for about 1 month. She ended up in the hospital for 2 months and underwent extensive surgery b/c of septic complications Physiology After food consumption: normally ~ 2hrs for meal to get to terminal ileum chyme may take up to 3 days to go through colon (so 1-2 BM’s {bowel movement} every 1-3 days is normal) -if <2 BM’s in a week = constipation Fermentation in R. colon (discussed in previous lecture) Extraction of salt and water in the L. colon Continence consistency of feces ( fiber helps retain water Internal anal sphincter provides a resting closing pressure for the anal canal solid bolus of stool in rectum ( distends rectum ( relaxes internal anal sphincter to maintain continence: resting state -the external anal sphincter (EAS) is contracted -puborectalis should be contracted (keeps rectum at an angle so stool can’t pass) BM’s -relaxation of puborectalis (gives stool a straight shot) -EAS relaxes Spinal Cord Lesions and the Colon Cervical lose sensation and voluntary control of BM get long track signs -spastic contraction of EAS -leads to constipation (go to the neural/rehab wards where pt. had cervical lesion – there’s many a constipated pt.) -to Tx, can digitally stimulate (trained) ( initiates spinal reflex to defecate. S2-S4 flaccid paralysis of anal sphincters -incontinence -rectal stimulation not effective (no reflex) -must raise intra-abdominal pressure to assist evacuation Diagnostic Tests DRE (Digital Rectal Exam) -extremely useful can palpate gross lower lesions obtain stool -check for gross/occult blood -observe any unusual characteristics -mentioned that if interested you can smell it….to make differential Sigmoidoscopy look at mucosal lining (should be like the back of your throat – bubble gum pink) -ulcers and/or bleeding -reddened b/c of irritation -varices can indicate Portal Hypertension Barium Enema (BE) -kinda old school important if looking at cause of bleeding/ulcers/mass formation above the 25cm level from the anal verge when reviewing BE film, look for symmetry -don’t jump to diagnosis (sometimes weird things like constrictions can just be a spasm of the bowel) -look for anatomic landmarks (Haustra etc) Stool Samples Clay colored (high-grade bile duct obstruction) -b/c stools are colored by bile salts black tarry -usually malodorous -indicative of upper GI bleed (ideally above the Ligament of Trite) -sometimes if have R. colonic bleeding and has stayed in the R. colon for awhile, will appear black tarry Consistency (and shape of stool) back and forth from narrow to large – think spasms if stools are always pencil thin – think fixed lesion (large polyploid mass or carcinoma) Diarrhea Definition = >200gm (ml) of stool / 24 hrs don’t usually have time to make this measurement so ask if it wakes them up at night and how many times they go in one day Fecal WBC count to determine if they have enteroinvasive organism causing an ulcer ulceration (other cause) infection Ova and parasite test -very limited -Hx of exposure / ( index of exposure Polyps PolypsNeoplasticNon-NeoplasticTubular AdenomaVillous AdenomaTubulovilluous AdenomaHyperplasticInflammatory / Hamartomatous(’st potential for malignancyMost common polypMost common non-neoplastic< 0.05cmPolyps >1-2cm diameter + adenomatous component may develop into carcinoma – important to remove them Pathology pedunculated = has stalk and easy to remove sessile = like gumdrop stuck to wall Familial Hereditary Polyposis >100 polyps (adenomatous) will develop colon CA by age of 42 (often younger) only proven Tx = total colectomy NSAIDS may result in resorption/prevention of adenomas (but not enough info yet) Other polyp info pt. w/single polyp (adenomatous) has 20% chance of having 2nd polyp (synchronous) pt. also have 7% chance of developing one in future (metachronous polyp) Colon Cancer General Facts 2nd most common cause of death secondary to malignancy (lung is 1st) ~160,000 new cases/year ~60,000 deaths rare in people < 45 y/o (but he has seen it in 26 y/o female) Speculated causes Stasis and prolonged transit times by low residue diets (fat/beef diets bacterial toxins that can cause injury carcinogens (ingested or from metabolic breakdown of bile acids and other stuff) Clinical Presentation R. sided lesion Pres. Reagan during routine flex-sig found small polyps on L. colon (removed) – neglected to come for total colonoscopy -came back 11 months later and found a grapefruit-sized mass in R. colon not much Sx b/c stool that enters is mostly liquid still so could get by w/out problems may have some pain, but not too bad probably present with anemia L. sided lesion w/stenosis get obstructive Sx’s and pain only thing that might get around it is liquid stool -called Post-Obstructive Diarrhea secondary to L. sided obstructive colonic lesion Diagnosis DRE (the GI’s official handshake) -again, can test fecal occult blood (if positive then should be really blue) -but limited to length of your finger (ET would be a good GI guy) Flex-sig or colonoscopy main advantage is that if you find a polyp that seems like it could go to cancer, you can remove it immediately studies on effects of flex-sig/polypectomy combination and chances of cancer -25 year period in 18,000+ pt’s -showed significant reduction in the adenoma-carcinoma sequence (’d risk adenomatous polyp > 1-2.5 cm adenoma with villous component Screening 40 y/o = at least yearly DRE 50 y/o = yearly DRE + fecal occult + flex-sig (every 3-5yrs) some will say a BE, but colonoscopy is now more favored b/c can remove at that time -esp. if beyond splenic flexure Staging of Tumors and FYS (5-year survival rate) Stage I = invasion up to and including muscularis propria (not beyond) = 80-90% FYS Stage II = invasion through muscularis propria = 75% FYS Stage III = invasion into deeper muscle + regional lymph node involvement = 30-50% FYS Once Dx’d, take a CXR (chest x-ray) to check for metastases -may also do a CT and check other organs (liver, spleen…) More help on staging colorectal tumors Endoscopic ultrasound examine the gut wall and look at 5 levels medial ( lateral = superficial mucosal layer ( deep mucosal layer ( submucosa ( muscularis propria (circular and longitudinal) ( pericolorectal fat in males can see if prostate is involved Treatment If at least 5cm from anal ring to tumor, then can do resection without colostomy (85% time) -if closer, then radical resection (only 15%) but will have total colostomy Local disease = radiation therapy Wide spread = chemotherapy Treatment of choice = surgery coupled with the previous two as needed Follow up (to check for recurrence) -H&P to check for weight loss -repeat colonoscopy and/or proximal flex-sig -may see development outside of wall with ultrasound (lymph nodes) Appendicitis General Most common cause of acute abdominal pain requiring surgery in U.S. ~1/600 people will get appendicitis initial pain in epigastric and periumbilical region is due to derivation of the appendix from midgut Ulcerative Colitis (Idiopathic Inflammatory Bowel Disease) -most common chronic Inflammatory Bowel Disease (IBD) in the U.S. UC characteristics (vs. Crohn’s) primarily a mucosal disease (vs. Crohn’s = transmural) not involved in small bowel (vs. Crohn’s = mouth ( anus) crypt abscesses are fairly characteristic (but can be found in both) Presentation w/abdominal pain cramping/diarrhea (may be bloody) weight loss Treatment Sulfasalazine (initially) may move to steroids Ulcerative Colitis (UC)Crohn’sBegins in rectum and extends proximally (only colon)Inflammation anywhere along GI tract (mostly in the terminal ileum, and cecum)Continuous involvementSkip lesions (segmental involvement)Mucosa / submucosaTransmural involvement (leads to gross thickening of wall of gut)Loose Bloody stools (almost always)Not much any blood (if any)Loss of Haustra b/c of scarring of mucosaCobblestone mucosaMicroabscesses and sometimes granulomasLymphoid infiltratesPyoderma gangrenosumNon-caseating granulomasSclerosing cholangitisLinear ulcers, fissures, fistulasGreatly (’d risk of Colon Cancer (40x’s more than Crohn’s)Migratory arthritis, erythema nodosumMarked flare-ups of diseaseFairly constant Antibiotic Associated Colitis ABX induced alteration of colonic bacteria can lead to C. difficile overgrowth, cytopathic toxin formation and then pseudomembrane formation 1st, stop the antibiotic treat with Flagyl (metronidazole) -non-nephrotoxic and cheap if Flagyl doesn’t work, then Vancomycin -but it is nephrotoxic and expensive Vs. 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„˜ţĆŘ ^„Ř `„˜ţ.‚„¨ „L˙ƨ ^„¨ `„L˙.€„x„˜ţĆx^„x`„˜ţ.€„H„˜ţĆH^„H`„˜ţ.‚„„L˙Ć^„`„L˙.€„č„˜ţĆč^„č`„˜ţ.€„¸„˜ţƸ^„¸`„˜ţ.‚„ˆ„L˙Ćˆ^„ˆ`„L˙.„h„˜ţĆĐ^„h`„˜ţo(.„8„0ýĆ8^„8`„0ýo(.„ŕ„0ýĆŕ^„ŕ`„0ýo(.„° „0ýĆ° ^„° `„0ýo()„„ üĆ^„`„ üo(()„„Ćx^„`„o(()„ŕ„ĆH^„ŕ`„o(()„°„Ć^„°`„o(()„€„Ćč^„€`„o(()„„˜ţĆ^„`„˜ţo(.„Ř „˜ţĆŘ ^„Ř `„˜ţo()‚„¨ „L˙ƨ ^„¨ `„L˙.€„x„˜ţĆx^„x`„˜ţ.€„H„˜ţĆH^„H`„˜ţ.‚„„L˙Ć^„`„L˙.€„č„˜ţĆč^„č`„˜ţ.€„¸„˜ţƸ^„¸`„˜ţ.‚„ˆ„L˙Ćˆ^„ˆ`„L˙.„„ĆĐ^„`„o(.„Đ„Ć8^„Đ`„o(.„ „Ć^„ `„o(.„p„ĆŘ ^„p`„o()„@ „ƨ ^„@ `„o(()„„Ćx^„`„o(()„ŕ„ĆH^„ŕ`„o(()„°„Ć^„°`„o(()„€„Ćč^„€`„o(()„„˜ţĆ^„`„˜ţo(.€„Ř „˜ţĆŘ ^„Ř `„˜ţ.‚„¨ „L˙ƨ ^„¨ `„L˙.€„x„˜ţĆx^„x`„˜ţ.€„H„˜ţĆH^„H`„˜ţ.‚„„L˙Ć^„`„L˙.€„č„˜ţĆč^„č`„˜ţ.€„¸„˜ţƸ^„¸`„˜ţ.‚„ˆ„L˙Ćˆ^„ˆ`„L˙.„h„˜ţĆĐ^„h`„˜ţo(.„„XüĆ^„`„Xüo(.„ŕ„0ýĆŕ^„ŕ`„0ýo(.„° „0ýĆ° ^„° `„0ýo()„„ üĆ^„`„ üo(()„„Ćx^„`„o(()„ŕ„ĆH^„ŕ`„o(()„°„Ć^„°`„o(()„€„Ćč^„€`„o(()„„˜ţĆ^„`„˜ţo(.€„Ř „˜ţĆŘ ^„Ř `„˜ţ.‚„¨ „L˙ƨ ^„¨ `„L˙.€„x„˜ţĆx^„x`„˜ţ.€„H„˜ţĆH^„H`„˜ţ.‚„„L˙Ć^„`„L˙.€„č„˜ţĆč^„č`„˜ţ.€„¸„˜ţƸ^„¸`„˜ţ.‚„ˆ„L˙Ćˆ^„ˆ`„L˙.„h„˜ţĆĐ^„h`„˜ţo(.„„čüĆ^„`„čüo(.„ŕ„xýĆŕ^„ŕ`„xýo(.„° „xýĆ° ^„° `„xýo()„„0ýĆ^„`„0ýo(()„„Ćx^„`„o(()„ŕ„ĆH^„ŕ`„o(()„°„Ć^„°`„o(()„€„Ćč^„€`„o(()„„˜ţĆ^„`„˜ţo(.€„Ř „˜ţĆŘ ^„Ř `„˜ţ.‚„¨ „L˙ƨ ^„¨ `„L˙.€„x„˜ţĆx^„x`„˜ţ.€„H„˜ţĆH^„H`„˜ţ.‚„„L˙Ć^„`„L˙.€„č„˜ţĆč^„č`„˜ţ.€„¸„˜ţƸ^„¸`„˜ţ.‚„ˆ„L˙Ćˆ^„ˆ`„L˙.„„˜ţĆ^„`„˜ţo(.€„Ř „˜ţĆŘ ^„Ř `„˜ţ.‚„¨ „L˙ƨ ^„¨ `„L˙.€„x„˜ţĆx^„x`„˜ţ.€„H„˜ţĆH^„H`„˜ţ.‚„„L˙Ć^„`„L˙.€„č„˜ţĆč^„č`„˜ţ.€„¸„˜ţƸ^„¸`„˜ţ.‚„ˆ„L˙Ćˆ^„ˆ`„L˙.„„˜ţĆ^„`„˜ţo(.€„Ř „˜ţĆŘ ^„Ř `„˜ţ.‚„¨ „L˙ƨ ^„¨ `„L˙.€„x„˜ţĆx^„x`„˜ţ.€„H„˜ţĆH^„H`„˜ţ.‚„„L˙Ć^„`„L˙.€„č„˜ţĆč^„č`„˜ţ.€„¸„˜ţƸ^„¸`„˜ţ.‚„ˆ„L˙Ćˆ^„ˆ`„L˙.„„˜ţĆ^„`„˜ţo(.€„Ř „˜ţĆŘ ^„Ř `„˜ţ.‚„¨ „L˙ƨ ^„¨ `„L˙.€„x„˜ţĆx^„x`„˜ţ.€„H„˜ţĆH^„H`„˜ţ.‚„„L˙Ć^„`„L˙.€„č„˜ţĆč^„č`„˜ţ.€„¸„˜ţƸ^„¸`„˜ţ.‚„ˆ„L˙Ćˆ^„ˆ`„L˙.„„˜ţĆ^„`„˜ţo(.€„Ř „˜ţĆŘ ^„Ř `„˜ţ.‚„¨ „L˙ƨ ^„¨ `„L˙.€„x„˜ţĆx^„x`„˜ţ.€„H„˜ţĆH^„H`„˜ţ.‚„„L˙Ć^„`„L˙.€„č„˜ţĆč^„č`„˜ţ.€„¸„˜ţƸ^„¸`„˜ţ.‚„ˆ„L˙Ćˆ^„ˆ`„L˙.„„˜ţĆ^„`„˜ţo(.„Ř „˜ţĆŘ ^„Ř `„˜ţo()‚„¨ „L˙ƨ ^„¨ `„L˙.€„x„˜ţĆx^„x`„˜ţ.€„H„˜ţĆH^„H`„˜ţ.‚„„L˙Ć^„`„L˙.€„č„˜ţĆč^„č`„˜ţ.€„¸„˜ţƸ^„¸`„˜ţ.‚„ˆ„L˙Ćˆ^„ˆ`„L˙.h„Đ„˜ţĆĐ^„Đ`„˜ţ.h„ „˜ţĆ ^„ `„˜ţ.’h„p„L˙Ćp^„p`„L˙.h„@ „˜ţĆ@ ^„@ `„˜ţ.h„„˜ţĆ^„`„˜ţ.’h„ŕ„L˙Ćŕ^„ŕ`„L˙.h„°„˜ţĆ°^„°`„˜ţ.h„€„˜ţĆ€^„€`„˜ţ.’h„P„L˙ĆP^„P`„L˙.„„p˙ĆĐ^„`„p˙o(.„8„˜ţĆ8^„8`„˜ţo(.„ „˜ţĆ ^„ `„˜ţo(.„„˜ţĆ^„`„˜ţo()„p„˜ţĆp^„p`„˜ţo(()„Ř „˜ţĆŘ ^„Ř `„˜ţo(()„@ „˜ţƨ ^„@ `„˜ţo(()„¨ „˜ţƨ ^„¨ `„˜ţo(()„„˜ţĆx^„`„˜ţo(()„„˜ţĆ^„`„˜ţo(.€„Ř „˜ţĆŘ ^„Ř `„˜ţ.‚„¨ „L˙ƨ ^„¨ `„L˙.€„x„˜ţĆx^„x`„˜ţ.€„H„˜ţĆH^„H`„˜ţ.‚„„L˙Ć^„`„L˙.€„č„˜ţĆč^„č`„˜ţ.€„¸„˜ţƸ^„¸`„˜ţ.‚„ˆ„L˙Ćˆ^„ˆ`„L˙.„„p˙ĆĐ^„`„p˙o(.„X„xýĆX^„X`„xýo(.„ŕ„ŔýĆŕ^„ŕ`„Ŕýo(.„° „0ýĆ° ^„° `„0ýo()„„ üĆ^„`„ üo(()„„Ćx^„`„o(()„ŕ„ĆH^„ŕ`„o(()„°„Ć^„°`„o(()„€„Ćč^„€`„o(()„„˜ţĆ^„`„˜ţo(.€„Ř „˜ţĆŘ ^„Ř `„˜ţ.‚„¨ „L˙ƨ ^„¨ `„L˙.€„x„˜ţĆx^„x`„˜ţ.€„H„˜ţĆH^„H`„˜ţ.‚„„L˙Ć^„`„L˙.€„č„˜ţĆč^„č`„˜ţ.€„¸„˜ţƸ^„¸`„˜ţ.‚„ˆ„L˙Ćˆ^„ˆ`„L˙.„„p˙ĆĐ^„`„p˙o(.„8„0ýĆ8^„8`„0ýo(.„ŕ„0ýĆŕ^„ŕ`„0ýo(.„° „0ýĆ° ^„° `„0ýo()„„ üĆ^„`„ üo(()„„Ćx^„`„o(()„ŕ„ĆH^„ŕ`„o(()„°„Ć^„°`„o(()„€„Ćč^„€`„o(()„„˜ţĆ^„`„˜ţo(.€„Ř „˜ţĆŘ ^„Ř `„˜ţ.‚„¨ „L˙ƨ ^„¨ `„L˙.€„x„˜ţĆx^„x`„˜ţ.€„H„˜ţĆH^„H`„˜ţ.‚„„L˙Ć^„`„L˙.€„č„˜ţĆč^„č`„˜ţ.€„¸„˜ţƸ^„¸`„˜ţ.‚„ˆ„L˙Ćˆ^„ˆ`„L˙.„8„0ýĆ8^„8`„0ýo(.„ „˜ţĆ ^„ `„˜ţo(.„$ „˜ţĆ$ ^„$ `„˜ţo(.€„@ „˜ţĆ@ ^„@ `„˜ţ.€„„˜ţĆ^„`„˜ţ.‚„ŕ„L˙Ćŕ^„ŕ`„L˙.€„°„˜ţĆ°^„°`„˜ţ.€„€„˜ţĆ€^„€`„˜ţ.‚„P„L˙ĆP^„P`„L˙.„„˜ţĆ^„`„˜ţo(.€„Ř „˜ţĆŘ ^„Ř `„˜ţ.‚„¨ „L˙ƨ ^„¨ `„L˙.€„x„˜ţĆx^„x`„˜ţ.€„H„˜ţĆH^„H`„˜ţ.‚„„L˙Ć^„`„L˙.€„č„˜ţĆč^„č`„˜ţ.€„¸„˜ţƸ^„¸`„˜ţ.‚„ˆ„L˙Ćˆ^„ˆ`„L˙.„ „˜ţĆ ^„ `„˜ţo(.€„p„˜ţĆp^„p`„˜ţ.‚„@ „L˙Ć@ ^„@ `„L˙.€„„˜ţĆ^„`„˜ţ.€„ŕ„˜ţĆŕ^„ŕ`„˜ţ.‚„°„L˙Ć°^„°`„L˙.€„€„˜ţĆ€^„€`„˜ţ.€„P„˜ţĆP^„P`„˜ţ.‚„ „L˙Ć ^„ `„L˙.„ř„¨ýĆř^„ř`„¨ýo(.€„Ř „˜ţĆŘ ^„Ř `„˜ţ.‚„¨ „L˙ƨ ^„¨ `„L˙.€„x„˜ţĆx^„x`„˜ţ.€„H„˜ţĆH^„H`„˜ţ.‚„„L˙Ć^„`„L˙.€„č„˜ţĆč^„č`„˜ţ.€„¸„˜ţƸ^„¸`„˜ţ.‚„ˆ„L˙Ćˆ^„ˆ`„L˙.„Đ„0ýĆĐ^„Đ`„0ýo(.„8„˜ţĆ8^„8`„˜ţo(.„ „˜ţĆ ^„ `„˜ţo(.„„˜ţĆ^„`„˜ţo()„p„˜ţĆp^„p`„˜ţo(()„Ř „˜ţĆŘ ^„Ř `„˜ţo(()„@ „˜ţƨ ^„@ `„˜ţo(()„¨ „˜ţƨ ^„¨ `„˜ţo(()„„˜ţĆx^„`„˜ţo(() LsKqVŠkš<uľGĐ+ĺ'XöëZ“~>0/!ĘbŽTë;.B[z<5T v šgŽ++\`pœ{áLJ=mpzBš ÖT÷[ę6ő ídĄ YëÂs 4Ëg6T2[XC86-l Ü"˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙`čR        ¸ý>ĎşV       ćnäá        ę;¨{        Ň˝´ŤDű,f       |        ˆŇxĺ 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