Abdominal trauma

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Abdominal trauma
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Abdominal trauma resulting in a right kidney contusion (open arrow) and blood surrounding the kidney (closed arrow) as seen on CT
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Abdominal trauma is an injury to the abdomen. Signs and symptoms include abdominal pain, tenderness, rigidity, and bruising of the external abdomen. Complications may include blood loss and infection.

Contents

Diagnosis may involve ultrasonography, computed tomography, and peritoneal lavage, and treatment may involve surgery. [1] It is divided into two types blunt or penetrating and may involve damage to the abdominal organs. [2] Injury to the lower chest may cause splenic or liver injuries. [3]

Signs and symptoms

The abdominal organs Gray1224.png
The abdominal organs

Signs and symptoms are not seen in early days and after some days initial pain is seen. People injured in motor vehicle collisions may present with a "seat belt sign", bruising on the abdomen along the site of the lap portion of the safety belt; this sign is associated with a high rate of injury to the abdominal organs. [4] Seatbelts may also cause abrasions and hematomas; up to 30 percent of people with such signs have associated internal injuries. [5] Early indications of abdominal trauma include nausea, vomiting, blood in the urine, and fever. [4] [6] The injury may present with abdominal pain, tenderness, [7] distension, or rigidity to the touch, and bowel sounds may be diminished or absent. Abdominal guarding is a tensing of the abdominal wall muscles to guard inflamed organs within the abdomen. Pneumoperitoneum, air or gas in the abdominal cavity, may be an indication of rupture of a hollow organ. In penetrating injuries, an evisceration (protrusion of internal organs out of a wound) may be present. [8]

Injuries associated with intra-abdominal trauma include rib fractures, vertebral fractures, pelvic fractures, and injuries to the abdominal wall. [9]

Causes

Motor vehicle collisions are a common source of blunt abdominal trauma. [5] Seat belts reduce the incidence of injuries such as head injury and chest injury, but present a threat to such abdominal organs as the pancreas and the intestines, which may be displaced or compressed against the spinal column. [5] Children are especially vulnerable to abdominal injury from seat belts, because they have softer abdominal regions and seat belts were not designed to fit them. [4] In children, bicycle mishaps are also a common cause of abdominal injury, especially when the abdomen is struck by the handlebars. [4] Sports injuries can affect abdominal organs such as the spleen and kidneys. [7] Falls and sports are also frequent mechanisms of abdominal injury in children. [4] Abdominal injury may result from child abuse and is the second leading cause of child abuse-related death, after traumatic brain injury. [6]

Gunshot wounds, which are higher energy than stab wounds, are usually more damaging than the latter. [10] Gunshot wounds that penetrate the peritoneum result in significant damage to major intra-abdominal structures in some 90 percent of cases. [10]

Pathophysiology

Abdominal trauma can be life-threatening because abdominal organs, especially those in the retroperitoneal space, can bleed profusely, and the space can hold a great deal of blood. [11] Solid abdominal organs, such as the liver and kidneys, bleed profusely when cut or torn, as do major blood vessels such as the aorta and vena cava. [11] Hollow organs such as the stomach, while not as likely to result in shock from profuse bleeding, present a serious risk of infection, [11] especially if such an injury is not treated promptly. [5] Gastrointestinal organs such as the bowel can spill their contents into the abdominal cavity. [5] Hemorrhage and systemic infection are the main causes of deaths that result from abdominal trauma. [5]

One or more of the intra-abdominal organs may be injured in abdominal trauma. The characteristics of the injury are determined in part by which organ or organs are injured.

Liver

The liver, the most vulnerable abdominal organ to all forms of injury because of its size and location (in the upper right quadrant of the abdomen), is injured in about five percent of all people admitted to a hospital for trauma. [12] Liver injuries present a serious risk for shock because the liver tissue is delicate and has a large blood supply and capacity. [11] The liver may be lacerated or contused, and a hematoma may develop. [13] It may leak bile, usually without serious consequences. [13] If severely injured, the liver may cause exsanguination (bleeding to death), requiring emergency surgery to stop the bleeding. [9]

Spleen

Spleen is the most common cause of massive bleeding in blunt abdominal trauma to a solid organ. Spleen is the most commonly injured organ. A laceration of the spleen may be associated with hematoma. [13] Because of the spleen's ability to bleed profusely, a ruptured spleen can be life-threatening, resulting in shock. However, unlike the liver, penetrating trauma to the spleen, pancreas and kidneys do not present as much of an immediate threat of shock unless they lacerate a major blood vessel supplying the organs, such as the renal artery. [5] Fractures of the left lower ribs are associated with spleen lacerations in 20 percent of cases. [9]

Pancreas

The pancreas may be injured in abdominal trauma, for example by laceration or contusion. [4] Pancreatic injuries, most commonly caused by bicycle accidents (especially by impact with the handlebars) in children and vehicular accidents in adults, usually occur in isolation in children and accompanied by other injuries in adults. [4] Indications that the pancreas is injured include enlargement and the presence of fluid around the pancreas. [4]

Kidneys

A large hematoma (closed arrow) of the left kidney (open arrow) Kidneyhematoma.png
A large hematoma (closed arrow) of the left kidney (open arrow)

The kidneys may also be injured; they are somewhat but not completely protected by the ribs. [6] Kidney lacerations and contusions may also occur. [13] Kidney injury, a common finding in children with blunt abdominal trauma, may be associated with bloody urine. [13] Kidney lacerations may be associated with urinoma or leakage of urine into the abdomen. [4] A shattered kidney is one with multiple lacerations and an associated fragmentation of the kidney tissue. [4]

Bowel

The small intestine takes up a large part of the abdomen and is likely to be damaged in penetrating injury. [5] The bowel may be perforated. [4] Gas within the abdominal cavity seen on CT is understood to be a diagnostic sign of bowel perforation; however intra-abdominal air can also be caused by pneumothorax (air in the pleural cavity outside the lungs that has escaped from the respiratory system) or pneumomediastinum (air in the mediastinum, the center of the chest cavity). [4] The injury may not be detected on CT. [4] Bowel injury may be associated with complications such as infection, abscess, bowel obstruction, and the formation of a fistula. [4] Bowel perforation requires surgery. [4]

Diagnosis

Pneumoperitoneum, seen as an air bubble on the lower left side of the X-ray film Pneumoperitoneum X-ray.jpg
Pneumoperitoneum, seen as an air bubble on the lower left side of the X-ray film
CT scan showing the liver and a kidney CT scan showing liver and kidney.jpg
CT scan showing the liver and a kidney

Ten percent of people with polytrauma who had no signs of abdominal injury did have evidence of such injuries using radiological imaging. [1] Diagnostic techniques used include CT scanning, ultrasound, [1] and X-ray. [7] X-ray can help determine the path of a penetrating object and locate any foreign matter left in the wound, but may not be helpful in blunt trauma. [7] Diagnostic laparoscopy or exploratory laparotomy may also be performed if other diagnostic methods do not yield conclusive results. [5]

Ultrasound

Ultrasound can detect fluid such as blood or gastrointestinal contents in the abdominal cavity, [1] and it is a noninvasive procedure and relatively safe. [4] CT scanning is the preferred technique for people who are not at immediate risk of shock, but since ultrasound can be performed right in an emergency room, the latter is recommended for people who are not stable enough to move to CT scanning. [1] A normal ultrasound does not rule out all injuries. [14]

CT

People with abdominal trauma frequently need CT scans for other trauma (for example, head or chest CT); in these cases abdominal CT can be performed at the same time without wasting time in patient care. [4]

CT is able to detect 76% of hollow viscous injuries so people who have negative scans are often observed and rechecked if they deteriorate. [15] However, CT has been demonstrated to be useful in screening people with certain forms of abdominal trauma in order to avoid unnecessary laparotomies, which can significantly increase the cost and length of hospitalizations. [16] A meta-analysis of CT use in penetrating abdominal traumas demonstrated sensitivity, specificity and accuracy >= 95%, with a PPV of 85% and an NPV of 98%. [17]

Peritoneal lavage

Diagnostic peritoneal lavage is a controversial technique but can be used to detect injury to abdominal organs: a catheter is placed in the peritoneal cavity, and if fluid is present, it is aspirated and examined for blood or evidence of organ rupture. [1] If this does not reveal evidence of injury, sterile saline is infused into the cavity and evacuated and examined for blood or other material. [1] While peritoneal lavage is an accurate way to test for bleeding, it carries a risk of injuring the abdominal organs, may be difficult to perform, and may lead to unnecessary surgery; thus it has largely been replaced by ultrasound in Europe and North America. [1]

Classification

Abdominal trauma is divided into blunt and penetrating types. While penetrating abdominal trauma (PAT) is usually diagnosed based on clinical signs, diagnosis of blunt abdominal trauma is more likely to be delayed or altogether missed because clinical signs are less obvious. [1] Blunt injuries predominate in rural areas, while penetrating ones are more frequent in urban settings. [5] Penetrating trauma is further subdivided into stab wounds and gunshot wounds, which require different methods of treatment. [7]

Treatment

Abdominal trauma requires urgent medical attention and sometimes requires hospitalization. The initial treatment involves stabilizing the person enough to ensure adequate airway, breathing, and circulation, and identifying other injuries. [7] Surgery may be needed to repair injured organs. Surgical exploration may be necessary for people with penetrating injuries and signs of peritonitis or shock. [5] Laparotomy is often performed in blunt abdominal trauma, and is urgently required if an abdominal injury causes a large, potentially deadly bleed. [1] [5] The main goal is to stop any sources of bleeding before moving onto any definitive find and repair any injuries that are found. [18] Due to the time sensitive nature, this procedure also emphasizes expedience in terms of gaining access and controlling the bleeding, thus favoring a long midline incision. [19] Intra-abdominal injuries are also frequently successfully treated nonoperatively as there is little benefit shown if there is no known active bleeding or potential for infection. [7] [4] [20] The use of CT scanning allows care providers to use less surgery because they can identify injuries that can be managed conservatively and rule out other injuries that would need surgery. [7] Depending on the injuries, a person may or may not need intensive care. [4]

For injuries that penetrate the peritoneal cavity (penetrating abdominal trauma), prophylactic (preventative) antibiotics are often administered with the goal of reducing the risk of sepsis and septic complications, including septicaemia, abscesses in the abdomen, and wound infections. [21] [22] The effectiveness of the use of antibiotics prophylactically for penetrating abdominal trauma has not been well studied and there is no strong evidence to support one particular antibiotic type or dose over another. [22] The length of time that these antibiotics should be used for is also not clear. [22]

Prognosis

If abdominal injury is not diagnosed promptly, a worse outcome is associated. [1] Delayed treatment is associated with an especially high morbidity and mortality if perforation of the gastrointestinal tract is involved. [13]

Epidemiology

In the United Kingdom, abdominal trauma due to road traffic accidents and assaults are most common. This situation is reversed in South Africa and United States where firearms related trauma are the most common. [23]

Most deaths resulting from abdominal trauma are preventable; [5] abdominal trauma is one of the most common causes of preventable, trauma-related deaths. [7]

Related Research Articles

The term abdominal surgery broadly covers surgical procedures that involve opening the abdomen (laparotomy). Surgery of each abdominal organ is dealt with separately in connection with the description of that organ Diseases affecting the abdominal cavity are dealt with generally under their own names.

<span class="mw-page-title-main">Abdominal cavity</span> Body cavity in the abdominal area

The abdominal cavity is a large body cavity in humans and many other animals that contain organs. It is a part of the abdominopelvic cavity. It is located below the thoracic cavity, and above the pelvic cavity. Its dome-shaped roof is the thoracic diaphragm, a thin sheet of muscle under the lungs, and its floor is the pelvic inlet, opening into the pelvis.

<span class="mw-page-title-main">Peritonitis</span> Medical condition

Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One part or the entire abdomen may be tender. Complications may include shock and acute respiratory distress syndrome.

A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy.

<span class="mw-page-title-main">Injury in humans</span> Physiological wound caused by an external source

An injury is any physiological damage to living tissue caused by immediate physical stress. Injuries to humans can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, or overexertion. Injuries can occur in any part of the body, and different symptoms are associated with different injuries.

<span class="mw-page-title-main">Gastrointestinal perforation</span> Medical condition

Gastrointestinal perforation, also known as gastrointestinal rupture, is a hole in the wall of the gastrointestinal tract. The gastrointestinal tract is composed of hollow digestive organs leading from the mouth to the anus. Symptoms of gastrointestinal perforation commonly include severe abdominal pain, nausea, and vomiting. Complications include a painful inflammation of the inner lining of the abdominal wall and sepsis.

<span class="mw-page-title-main">Splenic injury</span> Injury to the spleen

A splenic injury, which includes a ruptured spleen, is any injury to the spleen. The rupture of a normal spleen can be caused by trauma, such as a traffic collision.

<span class="mw-page-title-main">Pneumoperitoneum</span> Medical condition

Pneumoperitoneum is pneumatosis in the peritoneal cavity, a potential space within the abdominal cavity. The most common cause is a perforated abdominal organ, generally from a perforated peptic ulcer, although any part of the bowel may perforate from a benign ulcer, tumor or abdominal trauma. A perforated appendix seldom causes a pneumoperitoneum.

<span class="mw-page-title-main">Blunt trauma</span> Trauma to the body without penetration of the skin

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, describes a physical trauma due to a forceful impact without penetration of the body's surface. Blunt trauma stands in contrast with penetrating trauma, which occurs when an object pierces the skin, enters body tissue, and creates an open wound. Blunt trauma occurs due to direct physical trauma or impactful force to a body part. Such incidents often occur with road traffic collisions, assaults, and sports-related injuries, and are notably common among the elderly who experience falls.

<span class="mw-page-title-main">Focused assessment with sonography for trauma</span> Fluid accumulation screening

Focused assessment with sonography in trauma is a rapid bedside ultrasound examination performed by surgeons, emergency physicians, and paramedics as a screening test for blood around the heart or abdominal organs (hemoperitoneum) after trauma. There is also the extended FAST (eFAST) which includes some additional ultrasound views to assess for pneumothorax.

Hemoperitoneum is the presence of blood in the peritoneal cavity. The blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs. Hemoperitoneum is generally classified as a surgical emergency; in most cases, urgent laparotomy is needed to identify and control the source of the bleeding. In selected cases, careful observation may be permissible. The abdominal cavity is highly distensible and may easily hold greater than five liters of blood, or more than the entire circulating blood volume for an average-sized individual. Therefore, large-scale or rapid blood loss into the abdomen will reliably induce hemorrhagic shock and, if untreated, may rapidly lead to death.

<span class="mw-page-title-main">Blunt splenic trauma</span>

Blunt splenic trauma occurs when a significant impact to the spleen from some outside source damages or ruptures the spleen. Treatment varies depending on severity, but often consists of embolism or splenectomy.

<span class="mw-page-title-main">Gunshot wound</span> Injury caused by a bullet

A gunshot wound (GSW) is a penetrating injury caused by a projectile from a gun. Damage may include bleeding, bone fractures, organ damage, wound infection, loss of the ability to move part of the body, and in severe cases, death. Damage depends on the part of the body hit, the path the bullet follows through the body, and the type and speed of the bullet. Long-term complications can include bowel obstruction, failure to thrive, neurogenic bladder and paralysis, recurrent cardiorespiratory distress and pneumothorax, hypoxic brain injury leading to early dementia, amputations, chronic pain and pain with light touch (hyperalgesia), deep venous thrombosis with pulmonary embolus, limb swelling and debility, and lead poisoning.

<span class="mw-page-title-main">Penetrating trauma</span> Type of injury

Penetrating trauma is an open wound injury that occurs when an object pierces the skin and enters a tissue of the body, creating a deep but relatively narrow entry wound. In contrast, a blunt or non-penetrating trauma may have some deep damage, but the overlying skin is not necessarily broken and the wound is still closed to the outside environment. The penetrating object may remain in the tissues, come back out the path it entered, or pass through the full thickness of the tissues and exit from another area.

Abdominal guarding is the tensing of the abdominal wall muscles to guard inflamed organs within the abdomen from the pain of pressure upon them. The tensing is detected when the abdominal wall is pressed. Abdominal guarding is also known as 'défense musculaire'.

<span class="mw-page-title-main">Abdominopelvic cavity</span>

The abdominopelvic cavity is a body cavity that consists of the abdominal cavity and the pelvic cavity. The upper portion is the abdominal cavity, and it contains the stomach, liver, pancreas, spleen, gallbladder, kidneys, small intestine, and most of the large intestine. The lower portion is the pelvic cavity, and it contains the urinary bladder, the rest of the large intestine, and the internal reproductive organs.

<span class="mw-page-title-main">Diaphragmatic rupture</span> Tear in the thoracic diaphragm

Diaphragmatic rupture is a tear of the diaphragm, the muscle across the bottom of the ribcage that plays a crucial role in breathing. Most commonly, acquired diaphragmatic tears result from physical trauma. Diaphragmatic rupture can result from blunt or penetrating trauma and occurs in about 0.5% of all people with trauma.

An exploratory laparotomy is a general surgical operation where the abdomen is opened and the abdominal organs are examined for injury or disease. It is the standard of care in various blunt and penetrating trauma situations in which there may be life-threatening internal injuries. It is also used in certain diagnostic situations, in which the operation is undertaken in search of a unifying cause for multiple signs and symptoms of disease, and in the staging of some cancers.

<span class="mw-page-title-main">Stab wound</span> Medical condition

A stab wound is a specific form of penetrating trauma to the skin that results from a knife or a similar pointed object. While stab wounds are typically known to be caused by knives, they can also occur from a variety of implements, including broken bottles and ice picks. Most stabbings occur because of intentional violence or through self-infliction. The treatment is dependent on many different variables such as the anatomical location and the severity of the injury. Even though stab wounds are inflicted at a much greater rate than gunshot wounds, they account for less than 10% of all penetrating trauma deaths.

<span class="mw-page-title-main">Liver injury</span> Form of trauma sustained to the liver

A liver injury, also known as liver laceration, is some form of trauma sustained to the liver. This can occur through either a blunt force such as a car accident, or a penetrating foreign object such as a knife. Liver injuries constitute 5% of all traumas, making it the most common abdominal injury. Generally nonoperative management and observation is all that is required for a full recovery.

References

  1. 1 2 3 4 5 6 7 8 9 10 11 Jansen JO, Yule SR, Loudon MA (April 2008). "Investigation of blunt abdominal trauma". BMJ. 336 (7650): 938–42. doi:10.1136/bmj.39534.686192.80. PMC   2335258 . PMID   18436949.
  2. ↑ Fitzgerald, J.E.F.; Larvin, Mike (2009). "Chapter 15: Management of Abdominal Trauma". In Baker, Qassim; Aldoori, Munther (eds.). Clinical Surgery: A Practical Guide. CRC Press. pp. 192–204. ISBN   9781444109627.
  3. ↑ Wyatt, Jonathon; Illingworth, RN; Graham, CA; Clancy, MJ; Robertson, CE (2006). Oxford Handbook of Emergency Medicine. Oxford University Press. p. 346. ISBN   978-0-19-920607-0.
  4. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Bixby SD, Callahan MJ, Taylor GA (January 2008). "Imaging in pediatric blunt abdominal trauma". Semin Roentgenol. 43 (1): 72–82. doi:10.1053/j.ro.2007.08.009. PMID   18053830.
  5. 1 2 3 4 5 6 7 8 9 10 11 12 13 Hemmila MR, Wahl WL (2005). "Management of the Injured Patient". In Doherty GM (ed.). Current Surgical Diagnosis and Treatment. McGraw-Hill Medical. pp. 227–8. ISBN   978-0-07-142315-1. Archived from the original on 2017-11-06. Retrieved 2008-06-21.
  6. 1 2 3 Lichtenstein R, Suggs AH (2006). "Child abuse/assault". In Olshaker JS, Jackson MC, Smock WS (eds.). Forensic Emergency Medicine: Mechanisms and Clinical Management (Board Review Series). Hagerstown, MD: Lippincott Williams & Wilkins. pp. 157–9. ISBN   978-0-7817-9274-5. Archived from the original on 2017-11-06. Retrieved 2008-06-21.
  7. 1 2 3 4 5 6 7 8 9 Yeo A (2004). "Abdominal trauma". In Chih HN, Ooi LL (eds.). Acute Surgical Management. World Scientific Publishing Company. pp. 327–33. ISBN   978-981-238-681-6 . Retrieved 2008-06-21.
  8. ↑ Chih, p.343
  9. 1 2 3 Hemmila, p. 231
  10. 1 2 Chih, pp. 346–348
  11. 1 2 3 4 Blank-Reid C (September 2006). "A historical review of penetrating abdominal trauma". Crit Care Nurs Clin North Am. 18 (3): 387–401. doi:10.1016/j.ccell.2006.05.007. PMID   16962459.
  12. ↑ Fabian TC, Bee TK (2004). "Liver and biliary trauma". In Moore EJ, Feliciano DV, Mattox KL (eds.). Trauma. New York: McGraw-Hill, Medical Pub. Division. p. 637. ISBN   978-0-07-137069-1. Archived from the original on 2017-11-06. Retrieved 2008-06-21.
  13. 1 2 3 4 5 6 Visrutaratna P, Na-Chiangmai W (April 2008). "Computed tomography of blunt abdominal trauma in children" (PDF). Singapore Med J. 49 (4): 352–8, quiz 359. PMID   18418531. Archived (PDF) from the original on 2008-09-07.
  14. ↑ Stengel, D; Leisterer, J; Ferrada, P; Ekkernkamp, A; Mutze, S; Hoenning, A (12 December 2018). "Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma". The Cochrane Database of Systematic Reviews. 12 (12): CD012669. doi:10.1002/14651858.CD012669.pub2. PMC   6517180 . PMID   30548249.
  15. ↑ Amal Mattu; Deepi Goyal; Barrett, Jeffrey W.; Joshua Broder; DeAngelis, Michael; Peter Deblieux; Gus M. Garmel; Richard Harrigan; David Karras; Anita L'Italien; David Manthey (2007). Emergency medicine: avoiding the pitfalls and improving the outcomes . Malden, Mass: Blackwell Pub./BMJ Books. pp.  61. ISBN   978-1-4051-4166-6.
  16. ↑ Demetriades D, Velmahos G, Cornell E 3rd, et al. Selective nonoperative management of gunshot wounds of the anterior abdomen. Arch Surg 1997; 132:178–183
  17. ↑ Goodman CS, Hur JY, Adajar MA, Coulam CH., How well does CT predict the need for laparotomy in hemodynamically stable patients with penetrating abdominal injury? A review and meta-analysis., AJR Am J Roentgenol. 2009 Aug;193(2):432-7.
  18. ↑ Moore. 2012. p. 517.
  19. ↑ Moore. 2012. p. 516.
  20. ↑ Oyo-Ita, Angela; Chinnock, Paul; Ikpeme, Ikpeme A. (2015-11-13). "Surgical versus non-surgical management of abdominal injury". The Cochrane Database of Systematic Reviews (11): CD007383. doi:10.1002/14651858.CD007383.pub3. ISSN   1469-493X. PMC   11179156 . PMID   26568111.
  21. ↑ Brand, Martin; Grieve, Andrew (2019-12-12). "Prophylactic antibiotics for penetrating abdominal trauma". The Cochrane Database of Systematic Reviews. 12 (12): CD007370. doi:10.1002/14651858.CD007370.pub4. ISSN   1469-493X. PMC   6907398 . PMID   31830316.
  22. 1 2 3 Herrod, Philip J.; Boyd-Carson, Hannah; Doleman, Brett; Blackwell, James; Williams, John P.; Bhalla, Ashish; Nelson, Richard L.; Tou, Samson; Lund, Jon N. (2019-12-12). "Prophylactic antibiotics for penetrating abdominal trauma: duration of use and antibiotic choice". The Cochrane Database of Systematic Reviews. 12 (12): CD010808. doi:10.1002/14651858.CD010808.pub2. ISSN   1469-493X. PMC   6953295 . PMID   31830315.
  23. ↑ Garner, Jeff (June 2005). "Blunt and penetrating trauma to the abdomen". Surgery (Oxford). 23 (6): 223–228. doi:10.1383/surg.23.6.223.66552.

Bibliography

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