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Small Bowel Obstruction

Small bowel obstruction (SBO) is a common abdominal pathology. This page examines
radiographic techniques and pathological appearances of plain film small bowel obstruction.
Before reading this page, it would be advisable to read the page on terminology and the page
on differentiating small and large bowel appearances on plain film.

Definition of Small Bowel Obstruction (SBO)

Small bowel obstruction refers to any condition where there lumen of the small bowel is
obstructed. The obstruction may be intrinsic (as with intussusception) or extrinsic (as with

abdominal adhesions). A small bowel diameter on plain film greater than 30mm is considered

Radiographic Technique
Appropriate views for an acute small bowel obstruction should start with a supine abdominal
plain film X-ray. It could be argued that all acute abdominal imaging should include an erect
AP/PA chest view to demonstrate pneumoperitoneum. There is also the possibility that the
abdominal symptoms are misleading.
No Radiological examination of the abdomen is complete without a
film taken to demonstrate the lung fields, as pulmonary consolidation
or cardiac conditions may mimic an acute abdomen
David Sutton textbook of Radiology"
Churchill Livingstone, Edinburgh, 1975

The erect abdominal plain film should be undertaken to clarify the appearances on the supine
image, or where there is a reasonable expectation of additional relevant findings (see
discussion below and here). The erect abdominal plain film should not be performed in
isolation under normal circumstances.
Where there are equivocal findings on the supine image, a repeat supine abdominal plain film
image can be very useful. It should be remembered that an abdominal image provides a
snapshot of the bowel at a particular point in time. If there is an equivocal or suspect
appearance, a repeat view taken as little as 10 minutes later will often confirm an appearance
as being pathological rather than a normal transient chance appearance.
A rarely utilised projection in the acute setting is the prone abdominal view. The advantage of
the abdominal plain film with the patient in the prone position is that the dependent and nondependent parts of the bowel are reversed. The disadvantage is that the patient is unlikely to
find the position comfortable.
The left lateral decubitus view is a suitable alternative to the erect abdominal view. A right
lateral decubitus or supine cross table lateral decubitus should also be considered in
appropriate circumstances.
A tangential view of external hernias can reveal incarcerated small bowel (see examples on
this page).

The Erect Abdominal Film in Small Bowel Obstruction

The difference between the supine abdominal plain film and the erect abdominal plain film
has plenty to do with gravity and not much else. Not to put too fine a point on it, the AP
supine abdominal plain film and the erect AP abdominal plain film are projections of the
same anatomy and are even under the same gravitational forces. The difference lies in the fact
that a contained air/fluid filled structure will have an interface that is imaged en face in the
supine projection and in profile in the erect projection.
There are, of course, other more subtle benefits of the erect plain film as follows

potential to include all of the upper abdomen (centre slightly more superiorly)

in a gasless obstruction, loops of fluid filled small bowel can be seen to drop under
the effect of gravity

possibility of demonstrating a string-of-pearls sign

others I'm sure

The Poster
I have placed a poster on the wall of the X-ray viewing area in the Emergency Department as
shown below

This is a quotation from the abdominal plain film bible by Stephen R. Baker. His book titled
The Abdominal Plain Film is out of print but second hand copies are available from
Amazon. In my opinion it's well worth the money. We have a copy in our Radiology library
but it is continuously out on loan.

The Abdominal Plain Film Spectrum

Abdominal plain films are not necessarily either normal or abnormal; this is not a dichotomyit's a continuum. If you are one of those people that likes to categorise things, you could think
of them as being;

normal -------------> probably normal ----------> suspect ------->probably abnormal-----> definitely


To summarise, the erect abdominal plain film can be very helpful in cases where the supine
findings are equivocal. Equally, its utility can range between not helpful and harmful in
patients whose diagnosis is clearly demonstrated on the supine image

The Role of CT
CT is the gold standard of diagnostic imaging in patients with acute abdominal symptoms.
Whilst a plain abdominal film can suggest a diagnosis of small bowel obstruction, CT is more
likely to reveal the cause and site of obstruction.

Clinical Presentation of SBO

abdominal pain

squealing bowel sounds (early obstruction)

no bowel sounds (bowel wall muscular exhaustion)

rapid onset of nausea and vomiting


abdominal rigidity

abdominal swelling

Causes of Small Bowel Obstruction






The most common cause of small bowel obstruction in the

western world is from adhesions secondary to abdominal
surgery. An adhesion is an abnormal band of tissue which
can indent/deform the small bowel causing obstruction.
It is useful for the radiographer to establish with the patient
whether they have had abdominal surgery in the past - this
may assist in interpretation of the plain film abdominal
image. Furthermore, it is helpful to ask the patient if they
have had multiple episodes of SBO from adhesions in the
Consider any abdominal wall asymmetry as a potential
hernia or other pathology. Radiographers have demonstrated
umbilical and incisional hernias only because they have
noticed the patient had an unusual abdominal wall

(Some texts will show hernias as the second most common
cause of SBO)

Treatment of SBO
The treatment of SBO will vary with the circumstances of individual cases. Insertion of a
naso-gastric tube into the patient's stomach is a common treatment. Some patients are treated
conservatively to see if the SBO will resolve spontaneously. Gastrografin has also been used
as a therapeutic agent in SBO. Surgical intervention is sometimes required.

Diagnostic Accuracy
The abdominal plain film is a blunt diagnostic tool. It has been likened to taking a patient's
temperature- an abnormal plain film appearance suggests that there is abdominal pathology
present much the same as a high temperature suggests that a patient has an infection.
The probability of a correct diagnosis by plain films varies from 55% to
80% with approximately equal likelihood of false-positive and falsenegative interpretations
Baker, S.R. The Abdominal Plain Film,
Appleton & Lange, 1990, p156

There is a good report on a study investigating the accuracy of the abdominal film in the
diagnosis of SBO here

The 3,6,9 Rule

The maximum diameter of the bowel is shown below
Maximum Normal
small bowel


large bowel




The 3,6,9 rule is a very useful guide to determining when the bowel is dilated. It can also be
useful in distinguishing between small and large bowel. For example, if the small bowel
measures 90mm in diameter it is probably not small bowel.

Geometric Magnification Issues

Geometric Magnification of Small Bowel (exaggerated)

The 3,6,9 rule

is for
The error
with an
is usually not
a problem.
Where it can
be a problem
is in morbidly
obese patients
where the
small bowel is
situated close
to the
If you perform
images PA
rather than AP
you may
small bowel
affected by
on the supine

Small Bowel Appearances Indicating SBO

small bowel dilated over 30mm

multiple air/fluid levels in small bowel

The important
finding in
SBO is a
change in
calibre of the
small bowel.
If the SBO is
the small

stretch/slit sign

string of pearls sign

coiled spring sign

proximal to
will dilate.
Small bowel
with a
greater than
30mm is
considered to
be dilated.
Small bowel
can dilate up
to around
50mm. If the
small bowel
has a diameter
of 70mm or
greater it
probably isn't
small bowel.
The stretch
sign or slit
sign in which
a slit of air
caught in a
valvulae is
of SBO.
The erect
image will
show multiple
air/fluid levels
in dilated
small bowel
in patients
with SBO.

This is an
example of
SBO at
surgery. Note
that the bowel
is dilated
proximal to
the point of
and collapsed
distal to the
point of

Can a SBO be Differentiated from an Ileus on Plain Film?

The hallmark of small bowel obstruction is the presence of gaseous loops of small bowel
which are distended over 30mm. The absorptive capacity of the small bowel is so great that
even extreme amounts of air swallowing will not distend normal small bowel.
The presence of dilated loops of small bowel is not a guarantee that the patient is obstructed.
Correlation with patient history and clinical signs can assist in arriving at a more specific
diagnosis. The difficulty in differentiating obstruction from ileus has led some radiologists to
use the blanket term "motility disorder" when describing dilated loops of bowel.
There is a very good discussion on obstruction vs ileus in paediatrics here
Note the logical process of arriving at a probable diagnosis.

Small Bowel Obstruction- Establishing a level of


This patient has a

solitary loop of air-filled
dilated small bowel in
the left upper quadrant.
This loop of jejunum
has a coiled spring
appearance that is
associated with SBO.
Given that there is only
one proximal loop of
dilated small bowel it
would appear reasonable
to assume that the
obstruction is very
proximal. It is possible
that the obstruction is
more distal than is
suggested by this
solitary loop of dilated
small bowel. What is
difficult to appreciate is
that there may be
multiple fluid-filled
dilated loops of small
bowel which are not
clearly visualised.
There is evidence of a
collapsed large bowel
suggestive of SBO

LBO Posing as an SBO

At a cursory glance this patient

appears to have a SBO. On closer
examination, the prominent air-filled
loops of small bowel in the LUQ
(white arrow) have the features of
ileum rather than jejunum. Also, the
caecum appears unusually large and
there appears to be a sudden change in
calibre in the large bowel at the level
of the hepatic flexure(black arrow).
This was reported as a SBO. An
alternative explanation is that the
large bowel is obstructed at the level
of the black arrow. This would
account for the dilation of the caecum.
A LBO in patients with incompetent
ileocaecal valves can mimic a SBO.
The ileal loops may have been
displaced by the enlarged caecum or
they may be effaced jejunal loops.
Note that the patient has the reliably
unreliable sign of gas in the rectum!
This is a barium enema on the same
patient. Note the tight apple-core
lesion at the level of the hepatic
flexure (white arrow)
Approximately a quarter of patients

have an incompetent ileocaecal valve.

The Normal Small Bowel

One of the mantras of image interpretation is that you will not be able to recognise an
abnormal appearance if you are not able to identify a normal appearance. This is highly
relevant to the small bowel which demonstrates a highly variable normal range of

Normal Gasless Small Bowel

This patient appears to
have a gasless small
bowel. Fluid-filled loops
of small bowel are present
but are never as well
visualised as air-filled
There is debate regarding
what is a normal amount
of small bowel gas. Gas
enters the small bowel
during eating and
drinking. Some people
habitually air-swallow
while others air-swallow
at times of stress or when
they are in pain. If the
patient is air-swallowing
at a higher rate than the
small bowel can absorb
the air, it will be
visualised in the bowel.
Some texts suggest that up
to seven fluid levels in the
small bowel on an erect
abdominal film can be
normal. Most texts quote a
more conservative figure.
I have heard it said that
any air visualised in the
small bowel is abnormal. I
find this assertion hard to
Don't confuse gasless with

featureless. A featureless
abdomen can be a result
of tumour or ascites. This
patient has a gasless rather
than featureless abdomen.
Note that the renal, liver,
psoas muscles and urinary
bladder outlines are
Note that this abdominal
film is not guaranteed to
be normal. It could
represent an early gasless
small bowel obstruction.
Clinical correlation is

Normal Air-filled Small Bowel

This is an AP lumbar spine image on a
patient who presented with back pain. It
would be reasonable to assume that this
patient is unlikely to have acute abdominal
pathology (although not completely
excluded). The appearance of the small
bowel visualised in the left iliac fossa is a
result of normal air swallowing (white
arrow). The bowel diameter has been
measured at 30mm which is the upper limit
of normal. This patient is likely to be in
pain and is therefore more likely to airswallow resulting in this appearance.
The appearance has been likened to crazy
paving or the pattern on a giraffe. It appears
as an interlocking, random, tessellated

Crazy Paving Giraffe!

Minimally Dilated Small Bowel

The small
demonstrated in
this image is
(36mm). There
is evidence of
loss of the
normal random
associated with
undilated small
bowel. Instead,
the bowel is
showing signs
of a pattern
which is more
rather than
random. There
are, for
multiple loops
of small bowel
which have
may represent
an early small
obstruction or a
partial small
correlation and
an erect film
may be very
helpful in
whether the
appearance is

appearance is
not typical of
adynamic ileus
although this
cannot be

Severely Dilated Air-filled Small Bowel (Coiled Spring

The coiled spring appearance only
occurs in the dilated air-filled small
bowel. It also is most noticeable in the
jejunum where the valvulae
conniventes are closely spaced.

Gasless Small Bowel Obstruction

You could be
forgiven for
thinking that
this patient
has been
appearance is
a gasless
small bowel
and the
looking small
bowel loops
(white arrow)
are filled with
normal small
content, rather
If you
compare this
image with
the gasless
small bowel
image above
you can see
that this small
bowel is
There can be
difficulty in
an early
gasless small
from a normal
appearance of
the small
bowel in
someone who
has just eaten

a large meal.
and follow-up
imaging will
confidence in
the diagnosis.
The large
bowel is not
that it may be

String-of-Pearls Sign
The curvi-linear arrangement of air
bubbles visualised on this image is
known as the string of pearls sign.
The appearance is considered to be
diagnostic of obstruction (as opposed
to ileus) and is caused by small
bubbles of air trapped in the valvulae
of the small bowel.

Abdominal radiology [Hardcover]
James J. M.D. McCort , Robert E. M.D. Mindelzun, Robert
G. M.D. Filpi , Charles M.D. Rennell
Williams and Wilkens 1981
p 117,148,151.

The String-of-pearls
sign [is] almost
always indicative of
intestinal obstruction
and is one of the few
situations in which an

upright or decubitus
film of the abdomen
contributes crucial
information about small
bowel obstruction.
Baker, S.R. The Abdominal Plain
Appleton & Lange, 1990, p156

A similar appearance is sometimes

seen in the large bowel but can
usually be differentiated by the fact
that the gas bubbles are larger and
have flat under-surfaces
There is an excellent article on string
of pearls sign here

Slit/Stretch Sign
This patient has a small bowel
obstruction. Apart from the solitary airfilled dilated central loop of small
bowel, there is also evidence of slit sign
or stretch sign (white arrows).
Slit sign is a result of small amounts of
air caught in the valvulae of fluid-filled
bowel. The subtle fluid filled loops of
small bowel and the slit sign are highly
suggestive of small bowel obstruction.
This appearance is deserving of an erect
abdominal projection. This patient had
one of the best string of pearl signs you
will ever see!

Abdominal radiology [Hardcover]

James J. M.D. McCort , Robert E. M.D. Mindelzun, Robert G.
M.D. Filpi , Charles M.D. Rennell
Williams and Wilkens 1981
p 117,148,151.

The Large Bowel String of Pearls Sign

The large bowel has its own
version of the small bowel
string of pearls sign. Because
the plicae semilunaris of the
large bowel are larger than the
valvulae of the small bowel
the pockets of air tend to be
larger. Also, because they are
larger in the large bowel,
surface tension is unable to
make them round- instead
they tend to have a flat
underside. They look more
like a string of air-fluid levels.
One of the functions of the
large bowel is to absorb water
from the faecal content. The
faeces should not be able to
form an air/fluid level by the
time it gets to the splenic
flexure. An extensive
arrangement of these small
air/fluid levels in the large
bowel may indicate that the
patient has diarrhoea.

Multiple Air-fluid Levels

This is an erect PA
abdominal image. The
PA erect abdominal
projection has several

There is
potential for the
patient to hold
onto the erect
bucky making
them feel safer
and more secure

It is easy to
adjust the tube
and bucky
position to a PA
chest position

The anteriorly
sited small
bowel and
transverse colon
will be close the
reducing the
potential for

There are dilated loops

of small bowel and
multiple air-fluid levels.
This appearance is
characteristic of small
bowel obstruction.
Additional confidence
that the appearance is
caused by small bowel
obstruction is afforded
by the string of pearls
sign (white arrow).
The dilation of the small
bowel stimulates the
mucosa to secret fluid. A
quantity of fluid and

ingested gas in a
contained structure and
a horizontal beam are all
the necessary
requirements for an airfluid level on plain film
The appearance of
multiple air-fluid levels
on erect abdominal film
is sometimes referred to
as a step ladder sign. It
has also been suggested
that uneven levels in a
bowel loop (i.e. more
fluid on one side of the
loop than the other) is
diagnostic of SBO
rather than ileus. This is
refuted by some authors.

Tangential Views of External Hernias

This patient
with a history
with small
The patient
also reported
that a lump
had appeared
on her
undertaken a
plain film in
the supine

position. This
position may
be preferable
to the erect
shown below.
advantage of
the supine
position is
that there may
be a greater
chance of air
entering the
because it is
the least
part of the
bowel in the
small bowel
in an external
hernia may be
difficult to
An aluminium
filter covering
the herniated
bowel is very
useful when
hernias in a
Also, DR is
better than
CR, and CR is
better than

This patient
presented to
with a similar
history. The
has performed
an erect
revealing an
small bowel
and an
air/fluid level.
The herniated
contents may
not appear to
contain bowel
if the bowel is

The Gas in the Rectum "Conspiracy"

The presence of gas in the rectum is widely considered a useful indicator to exclude bowel
obstruction. The reasoning is that if the bowel is obstructed, there should be no passage of gas
to the rectum. This sign is unreliable. The bowel is often partially obstructed, allowing the
passage of bowel contents past the level of the partial obstruction. More importantly, the large
bowel produces its own gas through fermentation processes. Even in cases of complete
obstruction, gas in the rectum may persist for several days. A lack of gas in the rectum is
worthy of consideration, but is not a reliable sign of bowel obstruction. Equally, gas in the
rectum does not exclude bowel obstruction. A collapsed large bowel is arguably a more
reliable sign of bowel obstruction.

Limited Gastrografin Follow-through

The limited gastrografin follow-through has become a popular examination in recent years.
The objective is simply to establish if orally administered gastrografin is propelled
throughout the small bowel to the large bowel. An added benefit of gastrografin is that it is a

hyperosmolar water-soluble contrast medium. Its hyperosmolar properties can have a

therapeutic as well as diagnostic benefit.
One of the difficulties with
the limited gastrografin
follow through examination
in patients with suspected
SBO is that it can be selfdefeating. That is to say, the
aim of the study is to
examine the gastrografin as
it passes through the
bowel...and the indication
for the examination that
there is something causing
stasis of bowel contents.
It is not uncommon for the
gastrografin to become so
dilute that it is barely
detectable. It is possible to
add a small quantity of
barium (say 10 mls) to the
gastrografin as a trace
contrast medium. The
barium tends to leave a trail
of where it has been. The
argument against this is that
the barium will become an
irritant if it enters the
peritoneal cavity through a
bowel perforation. The
counter argument is "... not
as much as the bowel
The limited gastrografin
follow through is a popular
study with the surgeons. The
expectation is that if the
gastrografin makes it to the
caecum, surgical treatment
of the SBO will probably
not be required or not
required urgently.

Generalised Adynamic Ileus

The bowel could reasonably
be said to be a very sensitive
organ. It has a propensity to
stop functioning with little
provocation. Amongst the
possible causes are
abdominal inflammation,
causes and trauma.
Abdominal surgery
commonly results in
generalised adynamic ileus
in which the bowel is
temporarily non-functioning.
This typically manifests on
day 4 post-op. In response,
the patients are often referred
for abdominal plain film
imaging to rule out bowel
The appearance of
generalised adynamic ileus is
quite characteristic. The large
and small bowel are
extensively airfilled but not
dilated. I have heard this
described as the large and
small bowel "looking the

Case 1

This 70
year old
to the
nt with
l pain and
n. She
reported a
history of
There is
e of small
The large
very little
and is

l plain
which is
monic of

Further Reading
Unless I am mistaken, this is the best
textbook ever written on the abdominal plain
film. It is well referenced and written in a
readable style. It is out of print.
I have an older version of this book which I
purchased second hand through Amazon. It
was well worth the money!
I have also added the follwoing text onto my
Abdominal radiology [Hardcover]
James J. M.D. McCort , Robert E. M.D.
Mindelzun, Robert G. M.D. Filpi , Charles
M.D. Rennell
Williams and Wilkens 1981

Small bowel obstruction is a common pathology. A knowledge of the patterns of normal
small bowel and small bowel obstruction will assist in the interpretation of plain film
findings. Importantly, correlation with clinical findings, patient history, and other test results
can give an equivocal appearance additional meaning. Finally, the radiographer's knowledge
of normal and pathological appearance will allow him/her to make an informed decision as to
when supplementary views are justified and what views would be most suitable.

....back to the applied radiography home page here

Latest page update: made by M.J.Fuller , Sep 11 2011, 4:58 AM EDT (about this
update - complete history)
Keyword tags: 3 3 6 9 rule 369 rule 6 9 rule adhesions adynamic ileus air-fluid
levels air-swallow bowel coiled spring crazy paving dependent dilated external
hernia gasless SBO gastrografin giraffe hernia hyperosmolar ileus incisional
hernia intussusception non-dependent obstruction pneumoperitoneum radiography
M.J.Fuller SBO slit sign small bowel stretch sign string of pearls succus entericus tessellated
umbilical hernia
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erect abdominal


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Nov 23 2008, 9:40 PM EST by

Thread started: Nov 23 2008, 9:40 PM EST Watch

thank's as posting it..

that's so great for learning..
the abdominal x ray are so good and with explanations..
really help me in the process of learning..
intestinal obstruction..
23 out of 26 found this valuable. Do you?


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Erect Abdominal

Oct 27 2008, 10:01 PM EDT by


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Nutcracker Fracture of the Cuboid

Top 20 Practical Tips for Radiography in the Operating Theatre

Soft Tissue Signs- The Wrist

Soft Tissue Signs- The Elbow

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Knee: non-trauma soft tissue signs and artifacts

Soft Tissue Signs- Knee Trauma

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Oblique Lumbar Spine Technique

Oblique Cervical Spine Technique

Hyaline Membrane Disease (syn RDS) and BPD

Imaging Nail Gun Injuries

Ankle Trauma 3

Ankle Trauma 2

Ankle Trauma 1 (ST)

Knee Dislocations and Subluxations

Cervical Myelography

T-tube Cholangiogram

Trigeminal Nerve Block

Wrist Arthrogram

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Normal Paediatric Elbow Anatomy

Normal Paediatric Wrist Anatomy

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Imaging Fractures of the Acromion

Snow Globe Effect

Common Abdominal Pathologies and Normal Anatomical Variants

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Dextracardia in the Resus Room

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Functional Views of the Wrist

Elbow Supracondylar Fracture- Cases

Triquetral Fractures

Carpal Bone Fractures

What Constitutes a True Lateral Wrist Position?

Fracture Types and Mechanisms of Injury

Subluxation of the distal radioulnar joint

Neck of Femur Fractures- Cases

Neck of Femur Fractures

The Binocular Cone

Using the Lead Snake to Reduce Scatter Radiation

Soft Tissue Signs- Shoulder

Lateral Lumbar Spine Breathing Technique

Lateral Chest X-ray Digital Double-Dipping

AP Thoracic Spine Breathing Technique

Radiography in the Round

Pelvic Calcifications

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Imaging Vertebral Body Wedge Fractures

Pneumoperitoneum- Radiographic Techniques

Chest Trauma1

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Left Upper Lobe Collapse

Right Lower Lobe Collapse

Right Upper Lobe Collapse

Patterns of Consolidation

Knee Trauma 1E

Ankle Trauma 5

Ankle Trauma 4

The Abdominal Plain Film- Gasless vs Featureless

Large Bowel Obstruction

The Abdominal Plain Film- Differentiating Large and Small Bowel

Imaging Tibial Plateau Fractures

Lateral Knee Radiography

Transthoracic Lateral Shoulder

Breathing Exposure Techniques in Radiography

Interstitial vs Alveolar Lung Patterns

Toxic Megacolon


Lunate and Perilunate Dislocations

Facial Bone Radiography

Pneumothorax Self-test

Imaging Calcaneal Fractures

Multi-lobar Collapse


Cardiac Calcifications

CR vs DR Image Quality

Radiographic Terminology

Abdominal Plain Film Anatomy

The Patella- Normal Anatomical Variants

The SI Projection of the Trauma Shoulder



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