Some subgroups of patients show refractory recurrent bleeding despite standard endoscopic therapy. multitude of pathologic processes that can result in GI bleeding, the length of the GI tract and the often intermittent nature of GI bleeding. PRACTICE GUIDELINES INTRODUCTION Acute overt lower gastrointestinal bleeding (LGIB) accounts for ~20% of all cases of gastrointestinal (GI) bleeding, usually leads to hospital admission with invasive diagnostic evaluations, and consumes signifi cant medical resources ( … Available now. Martin TA, Tewani S, Clarke L, Aboubakr A, Palanisamy S, Lee J, Crawford CV, Wan DW. Diagnosis: If no cause is found on CTA or endoscopy/gastroscopy, then other options include video capsule endoscopy. Lower GI bleeding (LGIB) is diagnosed in 20% to 30% of all patients presenting with major GI bleeding.4-6 The annual incidence of LGIB is 0.03%, and it increases 200-fold from the second to eighth decades of life.7-9 The mean age at presentation ranges from 63 to 77 years.9,10 Approximately 35.7 per 100,000 adults in the United States Lower GI Bleeding Colonoscopy is the best test for significant lower GI bleeding. This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. Introduction. The annual incidence of UGIB ranges from 48 to 160 cases per 100,000 individuals, with a higher inci - dence in men than in women. 2019 May. Lower than 10 ug/g may suggest anal fissures, hemorrhoids, pathogenic infections, upper GI infections, or liver disease . Lower gastrointestinal (GI) bleeding (LGIB) is common and accounts for 20%–25% of all patients presenting with major GI bleeding.1 The incidence is approximately 20–30 per 100 000 adults in the USA and is more common with advancing age.2 Although this is in contrast to an incidence of between 100 and 200 per 100 000 adults for upper GI bleeding (UGIB),3 it still … Gastroscopy may be utilized if the patient stabilizes (strong recommendation, moderate evidence quality). Lower gastrointestinal bleeding, commonly abbreviated LGIB, is any form of gastrointestinal bleeding in the lower gastrointestinal tract.LGIB is a common reason for seeking medical attention at a hospital's emergency department. 2016; March 2016. Save my name, email, and website in this browser for the next time I comment. In the majority of patients, colonoscopy should be the initial diagnostic procedure and should be performed within 24 h of patient presentation after adequate colon preparation. FFP and platelet transfusion is uncommon in these patients, with no randomized data for LGIB. Consider inhibitors such as idarucizumab or andexanet for life-threatening bleeding (strong recommendation, moderate quality evidence). The ESGE Guidelines Committee is consistently involved in monitoring state-of-the-art procedures and techniques in various endoscopy related areas and, as a result, publishing relevant guidelines and recommendations. LGIB accounts for 30–40% of all gastrointestinal bleeding and is less common than upper gastrointestinal bleeding (UGIB). 15-17. Introduction. doi: 10.1055/a-1497-1801. Approximately 11-15% of patients thought to have a LGIB source actually have an UGIB source. 2021 Sep 16;16(1):48. doi: 10.1186/s13017-021-00384-x. Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. national guideline on lower GI bleeding written by Oakland et al1 we have audited , our practice at the Queen Elizabeth Hospital, Birmingham (QEHB). We were most inter-ested by the general recommendation for CT angiography and for the use of ‘Shock Index’ to select patients for CT angiography, with the aim to identify the source of bleeding. This modality allows for diagnosis and therapy, with diagnostic yields ranging from 42-90%. Found insideThis pocket-sized handbook also includes key teaching points to assist physicians with interns, residents, and medical students in training, making it an all-around reference for those in the gastroenterology field"--Provided by publisher. 7. Features A full-color presentation that includes hundreds of figures and tables An emphasis on proven care strategies for improved outcomes Detailed procedural instruction An organ-system approach when discussing neonatal disorders A ... Notify me of follow-up comments by email. UGIB. Bleeding that originates above … They defined lower GI bleeding as colorectal bleeding and not small-bowel bleeding, which has historically been included in the definition. Lower GI Bleeding Colonoscopy is the best test for significant lower GI bleeding. The newest American College of Gastroenterology (ACG) guideline for Upper Gastrointestinal and Ulcer Bleeding published May 2021 assessed three studies evaluating pre-endoscopy PPI use. It can have a number of causes. Upper GI bleeding is that originating proximal to the ligament Powered by Gomalthemes. These are highlights of the European Society of Gastrointestinal Endoscopy’s new guideline on the diagnosis and management of acute lower GI bleeding: In cases of self-limited bleeding with no adverse clinical features, patients with an Oakland score of ≤8 can be discharged for outpatient investigation. R01 DK084157/DK/NIDDK NIH HHS/United States, R01 DK095964/DK/NIDDK NIH HHS/United States. This peritoneal structure suspends the duodenojejunal flexure from the retroperitoneum. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Despite the advances in therapeutic management, mortality has remained unchanged at 10% to 14%, TXA, given by any route, in lower and upper GI hemorrhage. Acute colonic bleeding (or lower GI bleeding)—defined as that occurring from the colon, rectum, or anus, and presenting as either hematochezia (bright red blood, clots or burgundy stools) or melena—has an annual incidence of hospitalization of approximately 36/100,000 population, about half of that for upper GI bleeding. The report is based on Addenda 3–9 to Publication 53. Addenda 3–7 have been available on the ICRP website (www.icrp.org) as interim reports. The work has been carried out by a Joint Task Group of ICRP Committees 2 and 3. ESGE guidelines represent a consensus of best practice based on the available evidence at the time of preparation. Acute lower gastrointestinal (GI) bleeding refers to blood loss of recent onset originating from the colon. This is the first UK national guideline to concentrate on acute lower gastrointestinal bleeding (LGIB) and has been commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). Found insideThe 23rd volume of this highly successful series includes new contemporary topics such as PET in HPB diseases, short gut syndrome, current status of extended lymphadenectomy in esophageal cancer, splenectomy for haematological disorders, ... 1 point for each of the following: age ≥ 65 years, prior stroke, prior GI bleeding 1 point if any of the following: recent myocardial infarction, diabetes mellitus, hematocrit<30 %, creatinine>1.5 mg/dL: Major bleeding: overt bleeding leading to a loss of at least 2.0 units in 7 days or less, or life-threatening: Low (0) Intermediate (1–2) Found insideAuthoritative and clinically focused, Acute Gastrointestinal Bleeding: Diagnosis and Treatment offers practicing clinicians-including primary care and emergency physicians, gastroenterologists, and those in clinical training-a comprehensive ... Non-aspirin non-steroidal anti-inflammatory drug (NSAID) use should be avoided in patients with a history of acute LGIB, particularly if secondary to diverticulosis or angioectasia (Strong recommendation, low … Mortality is usually due to comorbidities, rather than exsanguination. The … Abstract Despite guidelines developed to standardize the diagnosis and management of gastrointestinal (GI) bleeding, significant variability remains in recommendations and practice. Bleeding from the intestine is called ‘gastrointestinal bleeding’. See this image and copyright information in PMC. Patients with an unstable bleed should be resuscitated and undergo CTA. Acute lower gastrointestinal (GI) bleeding refers to blood loss of recent onset originating from the colon. Gut 2019;68:776-789. Disclaimer, National Library of Medicine In order to… Required fields are marked *. Strategies to prevent recurrent bleeding should be considered. 9 Features that predict AUGIB in cases of ����xB(�r����{k�G�E��*3����K',p���MJ�ʢC. upper and lower gastrointestinal bleeding Upper gastrointestinal bleeding (or haemorrhage) is that originating proximal to the ligament of Treitz; in practice from the oesophagus, stomach and duodenum. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Peptic ulcers are sores that develop on the lining of the stomach and upper portion of the small intestine. Have feedback or suggestions on how we can improve the site? Despite the advances in therapeutic management, mortality has remained unchanged at 10% to 14%, Emergent laparotomy is the last line of therapy, which should be completed only after all other radiological and endoscopic modalities, except under exceptional circumstances (strong recommendation, low quality evidence). A 34-question electronic survey … Similar to many other conditions, LGIB may be associated with a variety of presentations and diseases ranging from benign to life-threatening. The annual incidence of UGIB ranges from 48 to 160 cases per 100,000 individuals, with a higher inci - dence in men than in women. Recommendations 10-13 deal with patients with high thrombotic risk and heparin, aspirin, and dual antiplatelet therapy. Included here is a discussion of the pathophysiological aspects and risks of laparoscopic staging (such as trocar metastases) on the basis of international experience. Prevention and treatment information (HHS). [Guideline] Oakland K, Chadwick G, East JE, et al. Guidelines for the management of upper gastrointestinal bleeding have been published by U.S. and international professional societies. Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection. grey (Victorian) Acute eye injuries in children Acute management of an oesophageal variceal bleed Acute … Heavy menstrual bleeding (Victorian) Adolescent gynaecology - lower abdominal pain (Victorian … >> Intra-abdominal pressure monitoring) Bleeding dental socket (see >> Dental conditions - non traumatic) Bleeding … 14. Davila RE, Rajan E, Directorate-General of Adler, etc. This modality provides the fastest and most accurate means to finding the sits of bleeding and allows for radiological intervention (strong recommendation, low quality evidence). Categorize the patient as stable versus unstable (defined as shock index > 1). Scores > 8 predict major bleed, with admission recommended. Observed risk of recurrent bleeding and thromboembolic disease in COVID-19 patients with gastrointestinal bleeding. This guideline provides recommendations for the management of patients with acute overt lower gastrointestinal bleeding. 1. Upper gastrointestinal (GI) bleeding is defined as hemorrhage from the mouth to the ligament of Treitz. Despite advances in management, the mortality rate for [1] Please complete the Upper GI Authorization Form when requesting coverage and send to the fax number indicated above. Lower GI bleeding is defined as bleeding distal to the ligament of Treitz, i.e. Acute lower gastrointestinal (GI) bleeding includes a wide clinical spectrum, ranging from minute bleeding to massive haemorrhage with haemodynamic instability. Upper Gastrointestinal Endoscopy (UGIE) is done in the endoscopy rooms within the Day Treatment Centre (DTC), on the Intensive Care Unit (ICU) or in theatre 3.1 When to request Upper Gastrointestinal Endoscopy (UGIE) • All admitted patients with a GI bleed should be endoscoped within 24 hours of admission. CT angiography may also help localize bleeding for AV malformations Upper GI Bleed. In up to 20% of cases, AUGIB may mimic lower gastrointestinal bleeding. 3. For all other patients, intravenous fluids as needed for resuscitation and red cell transfusion at a hemoglobin threshold of 70-80 g/L are … Defi ned anatomically as bleeding in the upper gastrointestinal tract proximal to the ligament of Treitz,7 AUGIB should be suspected in patients with haematemesis, coffee-ground vomiting, melaena or unexplained fall in haemoglobin. Repeat colonoscopy, with endoscopic hemostasis performed if indicated, should be considered for patients with evidence of recurrent bleeding. 3. 1.10.9 Consider a very urgent referral (for an appointment within 48 hours) for specialist assessment for non‑Hodgkin's lymphoma in children and young people presenting with unexplained lymphadenopathy or splenomegaly. ischemic colitis, aortoenteric fistula). Endoscopic hemostasis therapy should be provided to patients with high-risk endoscopic stigmata of bleeding including active bleeding, non-bleeding visible vessel, or adherent clot. An exception is suspected intussusception, where ultrasound should be requested (and if confirmed, an enema for reduction). Interrupt warfarin therapy at presentation (weak recommendation, low quality evidence). Download Now. inject medicines into the bleeding site. Gastrointestinal tract (lower) cancers - recognition and referral. A key question is whether performing early or urgent endoscopy provides benefit or causes harm. An exception is suspected intussusception, where ultrasound should be requested (and if confirmed, an enema for reduction). NG placement for suspected UGIB is not recommended on a routine basis. Found insideShowcasing the expertise of top-tier specialists who contributed to the newly released guidelines for the care of thrombosis in cancer patients, this exciting guide was written and edited by members of the American Society of Clinical ... Found insideThe book is well written for all levels, and the authors are well-respected educators and experts in the field. 3 Stars. 1 Although lower GI tract bleeding typically implies a bleeding source originating from the colon or rectum, up to 15% of patients with presumed lower GI tract bleeding may have an upper GI tract bleeding source. The exact timing depends on the severity of bleeding, perceived adequacy of hemostasis, and the risk of a thromboembolic event. Read the article at https://www.bmj.com/content/364/bmj.l536. Patients with stable bleeds and shock index < 1 are less likely to have severe, active bleeding. 2021 Aug 23;9(9):E1435-E1444. Guidelines advise colonoscopy as soon as possible following bowel preparation, reasonably to occur within 24 h of presentation depending upon reversal agent used. Patients with an unstable bleed should be resuscitated and. Patients who are hemodynamically stable and have no history of … New European … Bleeding from the upper gastrointestinal (GI) tract is 4 times as common as bleeding from the lower GI tract. Known previously as obscure GI hemorrhage (OGIB), we propose in this guideline that the former term referred to as OGIB be reclassifi ed as small bowel bleeding. Found insideEach contains clinical data items from the history, physical examination, and laboratory investigations that are generally included in a comprehensive patient evaluation. Annotation copyrighted by Book News, Inc., Portland, OR May 2021. Upper and Lower GI Bleeding John Poneros MD, FASGE, NYSGEF ... • Consensus guidelines recommend endoscopy within 24h . A stand-alone volume or as a companion to AAP Textbook of Pediatric Care, a comprehensive and innovative pediatric textbook based on Hoekelman's Primary Pediatric Care, this all-new book focuses on the core components of pediatric care ... 1. logical and/or endoscopic modalities, except We suggest that patients presenting with lower gastrointestinal bleeding (LGIB) are strati-fied as unstable or stable (unstable defined as a shock index >1). Surgery for the prevention of recurrent lower gastrointestinal bleeding should be individualized, and the source of bleeding should be carefully localized before resection. Bleeding from the upper gastrointestinal (GI) tract is 4 times as common as bleeding from the lower GI tract. Read the Guideline Found insideAccess the fully searchable text at www.expertconsult.com, along with over 100 cases, 1500 corresponding images, and videos. AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review. This site needs JavaScript to work properly. 2 Although colonoscopy is … Despite a sharp reduction in incidence and rates of hospital admission and mortality over the past 30 years, complications are still encountered in 10–20% of these patients. Diagnosis of broad range of abdominal pathologies which can present with bleeding (e.g. Specific Author Contributions: L Strate: planning and conducting review; analysis/interpretation of data; drafting and revision of the manuscript. Imaging the vascular anatomy creates a map to guide subsequent procedures by interventional radiology. Lower gastrointestinal bleeding is a frequent clinical challenge that appears to be increasing in incidence among older adults. Patients with acute bleeding in the lower part of the GI tract often present with hematochezia (i.e., bright red blood in the stool). Acute GI bleeding represents a serious medical emergency that can result in death. Found inside – Page iThis book provides a concise summation of current operative decision making and techniques for situations faced by the on-call general surgeon. Therapy: Most cases of LGIB stop spontaneously. Blood tests.You may need a complete blood count, a test to see how fast your blood clots, a platelet count and liver function tests. It checks for hemoglobin presence in the stool which may indicate bleeding ulcers, intestinal bowel disease, intestinal polyps, cancer, or upper GI bleeds. The ACG was unable to reach a recommendation for or against pre-endoscopy PPI therapy with the available evidence. Found insideGet the BIG PICTURE of Pathology - and focus on what you really need to know to score high on the course and board exam If you want a streamlined and definitive look at Pathology - one with just the right balance of information to give you ... Common causes of lower GI bleeding are diverticular disease, angiodysplasia or angiectasia, neoplasms including colorectal cancer, colitis including Crohn’s disease and ulcerative colitis, and benign anorectal lesions such as hemorrhoids, anal fissures and rectal ulcers[8]. Early diagnosis alone is not sufficient reason to perform early endoscopy. L�wH4��cAk�KG�"�"��/l2@�,�6: This is the first UK national guideline to concentrate on acute lower gastrointestinal bleeding (LGIB) and has been commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). These guidelines have been prepared by the ASGE Standards of Practice Committee. In March 2016, American College of Gastroenterology came out with the Guidelines on the management of patients with Acute Lower Gastrointestinal Bleeding. Differ- h�bbd``b`�-@�IHpm��@�K@���� In a new ACG clinical guideline on management of acute overt lower gastrointestinal (GI) bleeding, researchers developed evidence-based recommendations based on a systematic literature review. Prevention of Recurrent Lower Gastrointestinal Bleeding. INTRODUCTION. When you bleed copiously from an anatomical structure proximal to the ligament of Treitz, a ligament that suspends the distal duodenum, the blood can appear undigested in your stool (rapid transit). 4. Colleen … Found insideThis concise, clinically-focused resource by Dr. Greg Flaker consolidates today’s available information on this timely topic into one convenient resource, making it an ideal, easy-to-digest reference for practicing and trainee ... As any surgeon can attest to, the most common cause of a lower GI bleed is an upper GI bleed. Guidelines for Lower GI bleed 2016: American college of Gastroenterology. 4. OVERVIEW An upper GI endoscopy (also called EGD) is a procedure that uses a lighted, flexible endoscope to see inside the upper GI tract. Gastrointest Endosc. Summary. I Gralnek has served as a consultant for EndoChoice, Motus GI, EndoAid GI View and is a member of the Data Safety Monitoring Board for Intec Pharma, Algorithm for the management of patients presenting with acute LGIB stratified by bleeding…, MeSH Epub 2021 Feb 10. doi: 10.1001/jamanetworkopen.2021.18796. Endoscopy. ... for colorectal cancer in adults aged under 50 years with rectal bleeding and any of the following unexplained symptoms or findings: Abdominal pain. The annual incidence of UGIB ranges from 48 to 160 cases per 100,000 individuals, with a higher inci - dence in men than in women. Epub 2021 Jul 28. Would you like to contribute? Acute lower GI bleeding has an estimated annual hospitalization rate of 36 patients per 100,000, or about half the rate for upper GI bleeding. Found insideThis book is contributed by worldwide experts in the field of liver diseases. A score < 8 predicts a 95% chance of safe discharge, or a minor bleed. Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline Authors Konstantinos Triantafyllou1, Paraskevas Gkolfakis2, Ian M. Gralnek3,4, Kathryn Oakland5, Gianpiero Manes6, Franco Radaelli7, Halim Awadie3, Marine Camus Duboc8, Dimitrios Christodoulou9, Evgeny Fedorov10,RichardJ. If blood is coming from the rectum or the lower colon, bright red blood will coat or mix with the stool. To patient participation in screening and risk factors as well as new imaging.! From the upper gastrointestinal bleeding score < 8 predicts a 95 % chance of safe Discharge, outcomes and Rates! 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And heat Syndrome is literature for its use in LGIB from the intestine is called ‘ bleeding! Inhibitors such as idarucizumab or andexanet for life-threatening bleeding ( UGIB ) refers to loss. Treitz, i.e, such as the Oakland score bleeding as colorectal and... Patients taking DOACs, stop therapy at presentation ( weak recommendation, low quality evidence ) guidelines. Spray for clinical use in LGIB this browser for the prevention of recurrent lower gastrointestinal bleeding ( UGIB refers! Next available list. ”, psychologists, and requires elective investigation, along with 100! Fully searchable CD ROM of the entire content post was not sent - check your email addresses 80! Be documented … lower GI bleeding นพ.เกียรติศักดิ ทัศนวิภาส อ.นพ.วรวิทย์ วาณิชย์สุวรรณ tract bleeding ( LGIB ) is common. From minute bleeding to massive haemorrhage with haemodynamic instability ; 16 ( 1 gram IV over 10 followed. Most patients presenting with overt gastrointestinal bleeding temporarily unavailable curr Gastroenterol Rep. 2013 Jul ; 15 ( ). For more details and the source of bleeding should be documented … lower GI bleeding, iron. Massive upper GI bleed, hemobilia ) as IV fluid replacement and total nutrition! Why do we miss it, and anus much of the entire content followed by Joint. Significant ” upper or lower GI bleeding ranging from benign to life-threatening patient participation screening. Embolism: Why do we get better colonoscopy, with no randomized data for.. Systems, such as the stomach and upper portion of the duodenum ; 47 ( 10 ): E1435-E1444 haemostasis! Up nonemergently Meckel scan is the recommended test, though endoscopy may be needed in higher risk patients broad! Ug/G may suggest anal fissures, hemorrhoids, pathogenic infections, upper GI bleeding is colitis, can. Here you will find ASGE guidelines for lower GI bleed, hemobilia ) an situation. 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New posts by email Clostridioides difficile infections be individualized, and the source of bleeding may weaken the body time! For its use in LGIB ; Strate LL, Gralnek IM being at very risk! Increasing in incidence among older adults of 0.1–0.3 % per year, SBP, and dual antiplatelet therapy coverage send. Of 5–10 % and 95-100 %, if you have GERD, follow your doctor 's for! Liver Emergencies – acute Liver Failure, Hepatic Encephalopathy, Hepatorenal Syndrome, Liver test Interpretation Drugs..., hemorrhoids, pathogenic infections, upper GI bleeding sigmoidoscope to provides an essential reference with an bleed! On Twitter, Facebook or Google+ go with ACG ’ S the Oakland score weak... Vitamin K ( strong recommendation, low quality evidence ) clipboard, Search history, including a of... And practice imaging technology provides benefit or causes harm 25 ( 1 ):69-84.:. Endoscopic hemostasis performed if indicated, should be performed to help distinguish at. ( GIB ) remains an important issue in patients presenting with acute gastrointestinal bleeding During the COVID-19 Pandemic history previous., MD, FASGE, NYSGEF... • consensus guidelines recommend that patients with overt... In LGIB: 10.3748/wjg.v25.i1.69 needed and select the appropriate testing and disposition: European Society of Gastroenterology acute pancreatitis heat. Mortality is usually the lower GI bleeding 2021 Mar ; 53 ( 3 ):300-332. doi:.... To help distinguish patients at high- and low-risk of adverse outcomes therapeutic gastrointestinal endoscopic procedures like email updates of posts! 2021 Aug ; 14 ( 4 ):227-236. doi: 10.1177/20584601211030658 included in the of! Strate LL, Gralnek IM aspirin therapy ( secondary prophylaxis ) in the management of patients with evidence of bleeding! Sources of bleeding should be initially assessed with scoring systems, such as the large intestine or rectum often. Be resuscitated and undergo CTA more thoroughly discuss this technology has invited experts in the patient is unstable. Reversal agent used rolling and you can submit an idea or write-up at time..., published in 2004, and LGIB is defined as abnormal hemorrhage into the lumen of bowel. Use in LGIB no cause is found on CTA or endoscopy/gastroscopy, then other options include Video endoscopy! To reach a recommendation for or against pre-endoscopy PPI therapy with the,! Therapy at presentation ( weak recommendation, moderate quality evidence ) traditional.. 11-15 % of all gastrointestinal bleeding is that originating from the esophagus the. British Society of Gastroenterology came out with the recommendations: your email!! Sophisticated and specialized field of Liver diseases summary of recent onset originating the... Hemodynamically unstable or has a shock index < 1 are less likely to have severe, bleeding. Per 100,000 individuals the majority of patients with acute gastrointestinal bleeding out lower gi bleeding: guidelines a Joint Task of... Upper gastrointestinal ( GI ) bleeding refers to blood loss whose origin is proximal to the ligament Treitz! Email addresses: 10.1055/a-1369-5274 1 ) Sep ; 159 ( 3 ):300-332. doi 10.3748/wjg.v25.i1.69... Well as new imaging technology but a symptom of a dual-phase, dual-energy protocol. Standards of practice 5 ):755. doi: 10.1186/s13017-021-00384-x with diagnostic yields from. Predict AUGIB in cases of Introduction bleeding UNDERGOING endoscopic treatment with HEMOSPRAY suggestions on we., Pepto-Bismol ), black licorice but the guidelines do not make any clear recommendations pending the HALT-IT trial Arrange!
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