Encopresis (ICD-11: 6C01) - Complete Coding and Diagnostic Guide

1. Introduction

Encopresis represents one of the most challenging elimination disorders in pediatric and psychiatric clinical practice, characterized by repeated and involuntary elimination of feces in inappropriate places. This disorder significantly affects the quality of life of children and their families, generating profound psychosocial impact that extends to the school, family, and social environments.

The condition is more common than many healthcare professionals imagine, predominantly affecting school-age children, with higher prevalence in males. Although frequently underdiagnosed due to family embarrassment in reporting the problem, encopresis represents a significant cause of consultations in pediatrics, pediatric gastroenterology, and child mental health services.

The impact on public health is considerable, not only due to direct costs associated with diagnosis and treatment, but mainly due to long-term psychological consequences. Children with encopresis frequently face bullying, social isolation, low self-esteem, and school performance problems. The family also suffers from chronic stress, conflicts related to condition management, and indirect costs related to the need for multidisciplinary follow-up.

Correct coding using the 6C01 code from ICD-11 is critical for several reasons. First, it allows appropriate epidemiological tracking of this condition, facilitating research and targeted public policies. Second, it ensures appropriate reimbursement by health systems and medical insurance. Third, it clearly differentiates encopresis from other gastrointestinal or neurological conditions that may present fecal incontinence as a secondary symptom, ensuring that the patient receives the appropriate multidisciplinary treatment that this specific condition requires.

2. Correct ICD-11 Code

Code: 6C01

Description: Encopresis

Parent category: Elimination disorders

Official definition: Encopresis is characterized by the repeated passage of feces in inappropriate places, either involuntarily or intentionally. For the diagnosis to be established, the inappropriate passage of feces must occur repeatedly, defined as at least once per month over a period of several consecutive months, in an individual who has already reached a developmental age at which fecal continence is normally expected, established as 4 years of chronological age.

Fecal incontinence may manifest in two distinct forms: it may be present from birth, representing an atypical extension of normal infantile incontinence, or it may have emerged after a period in which bowel control had been previously acquired, characterizing a regression of function.

It is essential to emphasize that encopresis should not be diagnosed when fecal loss is completely attributable to another identifiable health condition, including aganglionosis megacolon (Hirschsprung disease), spina bifida, dementia, congenital or acquired abnormalities of the intestine, acute or chronic gastrointestinal infection, or excessive use of laxatives. In these cases, coding should reflect the primary medical condition responsible for fecal incontinence.

3. When to Use This Code

The code 6C01 should be applied in specific clinical situations that meet the established diagnostic criteria. Below, we present detailed practical scenarios:

Scenario 1: Primary encopresis with associated constipation A 6-year-old child who has never achieved adequate bowel control presents with daily episodes of involuntary bowel evacuation in underclothing, usually small amounts of pasty stool. Evaluation reveals a history of chronic constipation since age 2, with hardened stool and painful bowel movements. Physical examination demonstrates palpable fecal mass in the lower abdomen and rectal examination revealing a distended rectal ampulla with impacted stool. No neurological or anatomical abnormalities are identified. This is a classic case where code 6C01 is appropriate, as the child has never established adequate fecal continence and the incontinence is not attributable to another primary medical condition.

Scenario 2: Secondary encopresis with identifiable stressor A 7-year-old boy, previously continent since age 3, began presenting with episodes of inappropriate bowel evacuation in underclothing 5 months ago, coinciding with parental separation and school change. Episodes occur 2-3 times per week, usually during school hours. The child demonstrates significant embarrassment and has avoided social activities. Complete medical evaluation ruled out organic causes. Code 6C01 is appropriate because the child had previously established bowel control and the recurrent incontinence is not explained by underlying medical condition.

Scenario 3: Encopresis with behavioral component A 5-year-old child presents with recurrent episodes of defecation in inappropriate locations (behind furniture, in room corners) for more than 8 months. Evaluation reveals that the child intentionally retains stool when in the bathroom but evacuates involuntarily in other locations. There is no significant constipation or anatomical abnormalities. Developmental history shows that the child achieved age-appropriate motor and cognitive milestones. Code 6C01 is applicable because the pattern of inappropriate elimination is recurrent and not explained by medical condition.

Scenario 4: Encopresis with significant psychosocial impact An 8-year-old girl presents with intermittent fecal incontinence (1-2 times per week) for 6 months, resulting in school bullying and refusal to participate in extracurricular activities. The child had been continent since age 3. Medical investigation ruled out celiac disease, food intolerances, and structural abnormalities. The family reports that the child experiences significant anxiety related to using public bathrooms. Code 6C01 is appropriate considering the duration, frequency, and exclusion of organic causes.

Scenario 5: Encopresis in context of global developmental delay A 6-year-old child with mild global developmental delay (without severe intellectual disability) presents with recurrent fecal incontinence. Although having achieved other developmental milestones with delay, has not established consistent bowel control. Neurological evaluation revealed no structural abnormalities of the central nervous system or spina bifida. Code 6C01 may be used if the incontinence is disproportionate to the child's overall level of functioning and not explained by specific neurological condition.

Scenario 6: Encopresis post-treatment of chronic constipation A 7-year-old child who received treatment for severe chronic constipation continues to present with episodes of fecal incontinence 3-4 times per week, even after resolution of fecal impaction and establishment of a regular bowel movement pattern. The incontinence persists more than 4 months after adequate treatment of constipation. Code 6C01 is appropriate because the incontinence persists independent of resolution of the initial organic cause.

4. When NOT to Use This Code

It is fundamental to recognize situations where code 6C01 should not be applied, avoiding coding errors that may compromise adequate treatment and reimbursement:

Fecal incontinence secondary to neurological conditions: When fecal incontinence results directly from spina bifida, myelomeningocele, spinal cord injury, cerebral palsy, or other diagnosed neurological conditions, the primary code should reflect the underlying neurological condition, not encopresis. In these cases, incontinence is an expected consequence of the neurological pathology.

Aganglionated megacolon (Hirschsprung Disease): This congenital condition characterized by the absence of ganglion cells in the colon results in severe constipation and may cause overflow incontinence. The appropriate code should reflect the diagnosis of Hirschsprung disease, not encopresis, as there is an identifiable anatomical abnormality responsible for the incontinence.

Acute gastrointestinal infections: Diarrhea and fecal incontinence associated with acute gastroenteritis, bacterial or parasitic infections should not be coded as encopresis. These are self-limited conditions with a clear infectious cause and different specific treatment.

Adverse drug effects: Fecal incontinence resulting from the use of laxatives, magnesium supplements, antibiotics, or other medications should be coded as an adverse drug effect, not as encopresis. Resolution occurs with medication adjustment or discontinuation.

Children below 4 years of age: Fecal incontinence in children who have not yet reached the expected developmental age for bowel control (4 years) represents normal development or developmental delay, not encopresis. In these cases, observation or developmental intervention may be appropriate, but the diagnosis of encopresis is premature.

Inflammatory bowel diseases: Fecal incontinence in the context of Crohn disease, ulcerative colitis, or other inflammatory bowel diseases should be coded as part of the primary gastrointestinal condition. Treatment focuses on the underlying disease, not on the behavioral disorder.

Dementia and neurodegenerative conditions: In elderly or adult patients with dementia, Alzheimer disease, or other neurodegenerative conditions, fecal incontinence is coded as part of the dementia presentation, not as encopresis, which is primarily a pediatric diagnosis.

5. Step-by-Step Coding Process

Step 1: Assess diagnostic criteria

The first essential step involves confirming that all diagnostic criteria for encopresis are present. Begin by verifying the child's age: they must be at least 4 years of chronological age, which is the developmental age at which fecal continence is normally expected. For children with developmental delay, consider developmental age, not just chronological age.

Confirm the frequency and duration of episodes: inappropriate elimination of feces must occur at least once per month during a minimum period of several consecutive months (generally considered as 3 months or more). Carefully document the actual frequency of episodes through a bowel diary maintained by caregivers.

Perform complete medical evaluation to exclude organic causes. This includes detailed clinical history from birth, complete physical examination with emphasis on abdominal and neurological examination, and rectal examination when clinically indicated. Investigate warning signs such as rectal bleeding, weight loss, fever, persistent vomiting, or neurological symptoms that suggest organic cause.

Consider complementary tests when appropriate: abdominal radiography to evaluate fecal impaction, laboratory tests to rule out celiac disease or hypothyroidism, and specialized studies such as anorectal manometry or rectal biopsy if Hirschsprung disease is suspected.

Step 2: Verify specifiers

ICD-11 recognizes important subtypes of encopresis that should be documented. Identify whether encopresis is primary (the child never established adequate bowel control) or secondary (the child had been continent for at least 6 months before the onset of incontinence). This distinction has prognostic and therapeutic implications.

Assess whether there is associated constipation, which is present in most cases. Encopresis with constipation and overflow incontinence represents the most common subtype, where liquid or pasty feces leak around impacted fecal mass in the rectum. This subtype requires treatment of constipation as a fundamental component of the therapeutic approach.

Document severity based on frequency of episodes, impact on social and school functioning, and level of distress in the child and family. Consider mild (occasional episodes with minimal impact), moderate (frequent episodes with significant social impact), or severe (daily episodes with significant functional impairment).

Identify contributing psychosocial factors such as family stressors, school problems, history of abuse or trauma, anxiety, or other comorbid psychiatric disorders. These factors should be documented separately and may require additional codes.

Step 3: Differentiate from other codes

The most important differentiation is with code 6C00 (Enuresis), which refers to inappropriate elimination of urine, not feces. Although both are elimination disorders, they involve different physiological systems and require distinct therapeutic approaches. Some children may present with both conditions simultaneously, in which case both codes should be used.

Also differentiate from functional gastrointestinal disorders such as irritable bowel syndrome or functional diarrhea, where incontinence is secondary to bowel urgency and diarrhea, not fecal retention or primary behavioral factors. In these cases, codes from the functional gastrointestinal disorders category are more appropriate.

Exclude disruptive behavior disorders where inappropriate defecation may occur as intentional oppositional or defiant behavior without the characteristic pathophysiology of encopresis. If the behavior is part of a broader pattern of opposition and defiance, consider additional coding of oppositional defiant disorder.

Step 4: Necessary documentation

Adequate documentation is crucial to justify coding and ensure continuity of care. Record in detail the history of bowel control from birth, including age of onset of toilet training, methods used, successes and difficulties encountered.

Document the exact frequency of incontinence episodes, circumstances in which they occur (time of day, location, triggering situations), characteristics of feces (consistency, volume), and the child's response to episodes (awareness, concern, attempts to hide).

Record all physical examinations performed, including abdominal examination (presence of palpable fecal mass), perianal examination (fissures, dermatitis, sphincter tone), and neurological examination (reflexes, tone, sensation). Document results of complementary tests performed.

Include assessment of psychosocial impact: school performance, peer relationships, social activities avoided, family dynamics, caregiver stress. This information justifies the need for a multidisciplinary approach and may influence decisions about treatment intensity.

6. Complete Practical Example

Clinical Case

Lucas, 6 years and 8 months old, is brought to the appointment by his mother due to recurrent episodes of fecal soiling in his underwear. The mother reports that although Lucas was toilet trained at 3 and a half years old and remained continent until age 5, approximately 18 months ago he began having "accidents" with feces.

In the detailed history, the mother describes that Lucas experiences fecal incontinence episodes 3-4 times per week, usually in the afternoon, both at home and at school. The feces are usually pasty or liquid, in small amounts, staining his underwear. Lucas frequently denies that the episode occurred and tries to hide the soiled clothing. The mother also reports that Lucas has very voluminous and hardened bowel movements in the toilet every 4-5 days, and these evacuations are painful, causing Lucas to cry and avoid going to the bathroom.

The developmental history shows motor and cognitive milestones achieved within expected ranges. Lucas attends first grade with adequate performance, but the teacher reports that he avoids using the school bathroom and appears socially isolated. The mother mentions that 2 years ago there was parental separation and Lucas began living with his mother, visiting his father biweekly.

On physical examination, Lucas presents with adequate anthropometric development. Abdominal examination reveals a palpable fecal mass in the left lower quadrant, non-tender. Perianal examination shows mild perianal dermatitis and a small scarred anal fissure. Neurological examination is normal, with preserved reflexes, tone, and sensation. There are no vertebral column abnormalities.

The requested abdominal radiograph confirms a large amount of fecal material in the descending and sigmoid colon. Basic laboratory tests (complete blood count, thyroid function, celiac disease) are normal.

Step-by-Step Coding

Analysis of diagnostic criteria:

Appropriate age: Lucas is 6 years and 8 months old, well above the minimum age of 4 years required for diagnosis. ✓
Frequency and duration: Episodes occur 3-4 times per week for approximately 18 months, far exceeding the criterion of at least once per month for several months. ✓
Inappropriate elimination: Feces are eliminated in underwear, not in the appropriate location (toilet), characterizing inappropriate elimination. ✓
Previous control: Lucas had established fecal continence between 3.5 and 5 years of age, characterizing secondary encopresis. ✓
Exclusion of organic causes: Physical examination and complementary tests ruled out neurological, anatomical, endocrinological, or inflammatory abnormalities. The constipation present is functional, not related to Hirschsprung disease or other structural pathologies. ✓

Code chosen: 6C01 - Encopresis

Complete justification:

The code 6C01 is most appropriate for Lucas because all diagnostic criteria for encopresis are present. This is secondary encopresis (with prior period of continence) with associated constipation, the most common subtype. The incontinence results from functional fecal retention with overflow, where liquid feces leak around the impacted fecal mass.

The evaluation adequately excluded organic causes that would contraindicate the use of this code. There is no evidence of Hirschsprung disease (absence of megacolon since birth, period of normal continence), neurological abnormalities (normal neurological examination, absence of signs of spina bifida), or other medical conditions that would completely explain the incontinence.

The behavioral component is evident (bathroom avoidance, denial of episodes), and contributing psychosocial factors were identified (parental separation, social difficulties at school), but these are considered contributing or precipitating factors, not alternative diagnoses.

Applicable complementary codes:

Depending on the coding system and documentation needs, additional codes may be considered:

Code for functional constipation (if the system allows dual coding to capture this important aspect)
Code for adjustment reaction if the psychosocial stressor (parental separation) requires specific intervention
Code for perianal dermatitis as a secondary complication, if specific treatment is necessary

7. Related Codes and Differentiation

Within the Same Category

6C00: Enuresis

Enuresis represents the repeated elimination of urine in inappropriate places and is the other main disorder within the category of Elimination Disorders. The fundamental differentiation is straightforward: enuresis involves urinary incontinence, while encopresis involves fecal incontinence.

When to use 6C00 vs. 6C01:

Use 6C00 when the child presents with recurrent episodes of involuntary urination in bed (nocturnal enuresis) or in clothes during the day (diurnal enuresis), after the expected age for bladder control (usually 5 years).
Use 6C01 when the child presents with recurrent episodes of involuntary defecation in inappropriate places, after the expected age for bowel control (4 years).
Both codes can be used simultaneously when the child presents with both urinary and fecal incontinence, an uncommon situation that suggests possible broader pelvic floor dysfunction or significant psychological factors.

Main differences:

Physiological system: Enuresis affects the urinary system; encopresis affects the gastrointestinal system.
Age of diagnosis: Enuresis requires a minimum age of 5 years; encopresis requires 4 years.
Temporal pattern: Enuresis frequently occurs during sleep (nocturnal enuresis); encopresis generally occurs during wakefulness.
Pathophysiology: Enuresis may involve bladder immaturity, excessive nocturnal urine production, or deep sleep; encopresis generally involves constipation and fecal retention.
Therapeutic approach: Enuresis may respond to enuresis alarm and desmopressin; encopresis requires constipation management with laxatives and behavioral intervention.

Differential Diagnoses

Functional gastrointestinal disorders: Irritable bowel syndrome, functional diarrhea, and other functional gastrointestinal disorders can cause bowel urgency and episodes of incontinence. Differentiation is based on the presence of diarrhea as the primary feature, absence of intentional or behavioral fecal retention, and a broader pattern of gastrointestinal symptoms (abdominal pain, bloating, changes in bowel habits). In these cases, the appropriate code reflects the specific functional gastrointestinal disorder.

Organic fecal incontinence: Conditions such as Hirschsprung disease, anorectal malformations, spinal cord injuries, or neuromuscular diseases cause fecal incontinence through identifiable anatomical or neurological mechanisms. Differentiation requires adequate investigation including history from birth, detailed neurological examination, and when indicated, specialized studies such as anorectal manometry or rectal biopsy. The presence of identifiable organic abnormality excludes the diagnosis of encopresis.

Behavioral disorders: In disruptive behavior disorders, inappropriate defecation may occur as intentional oppositional behavior, unrelated to constipation or bowel dysfunction. Differentiation is based on the presence of a broader pattern of challenging behavior, absence of constipation or fecal retention, and clearly intentional and provocative nature of the behavior. In these cases, the primary behavioral disorder should be coded.

8. Differences with ICD-10

In ICD-10, encopresis is coded as F98.1 - Nonorganic encopresis, within the chapter of Behavioral and Emotional Disorders that usually appear during childhood or adolescence. The transition to ICD-11 brought important conceptual and structural changes.

Main changes in ICD-11:

ICD-11 reorganized elimination disorders into their own more prominent category, better reflecting the nature of these disorders that have both physiological and behavioral components. Code 6C01 is now in a specific category of Elimination Disorders, no longer subordinated to general behavioral disorders.

The terminology was updated, removing the qualifier "nonorganic" that was present in ICD-10. This term was often confusing, as encopresis generally involves constipation, which has organic components. ICD-11 clarifies that the diagnosis should not be made when incontinence is completely attributable to another health condition, but recognizes that physiological and behavioral factors coexist in most cases.

Diagnostic criteria were more clearly specified in ICD-11, particularly regarding minimum frequency (at least once per month) and duration (several months), providing greater diagnostic consistency among different professionals and contexts.

Practical impact of these changes:

The categorical reorganization facilitates locating the appropriate code and reduces confusion about the nature of the disorder. Professionals not specialized in child psychiatry can now more easily identify the correct code when searching for elimination disorders specifically.

The removal of the term "nonorganic" reduces stigma and recognizes the multifactorial nature of encopresis. This can facilitate acceptance of the diagnosis by families and promote a more integrated approach involving pediatric gastroenterology and mental health.

For research and epidemiology purposes, the transition requires careful mapping between ICD-10 and ICD-11 codes to ensure continuity in data time series. Health systems should implement correspondence tables and provide adequate training for professionals during the transition period.

9. Frequently Asked Questions

1. How is encopresis diagnosed?

The diagnosis of encopresis is primarily clinical, based on detailed history and physical examination. The process begins with careful interview with parents and, when appropriate, with the child, exploring the frequency and circumstances of incontinence episodes, history of bowel training, bowel habits, diet, and psychosocial factors. A bowel diary maintained for 2-4 weeks provides objective information about episode frequency, evacuation pattern, and stool characteristics. Physical examination should include abdominal evaluation to identify fecal mass, perianal examination, and when indicated, digital rectal examination to assess sphincter tone and presence of fecal impaction. Complementary tests such as abdominal radiography can confirm constipation and impaction, but are not mandatory in all cases. More specialized tests are reserved for atypical cases or when there is suspicion of underlying organic cause.

2. Is treatment for encopresis available in public health systems?

Yes, treatment for encopresis is generally available in public health systems, although access may vary. Treatment involves multiple components: medical management of constipation with osmotic or stimulant laxatives (medications generally available in basic formularies), dietary guidance on increasing fiber and hydration (low-cost interventions), and behavioral intervention that can be performed by trained pediatricians, nurses, or psychologists. Follow-up can be conducted at the primary care level for uncomplicated cases, with referral to pediatric gastroenterology or child psychiatry when necessary. Most cases respond well to conservative treatment, making the approach cost-effective and accessible in different resource settings.

3. How long does treatment last?

Treatment duration varies significantly between cases, but is generally prolonged, requiring months to years of follow-up. The initial phase of fecal disimpaction, when necessary, typically lasts 1-2 weeks. After this phase, maintenance treatment with laxatives and behavioral modifications generally continues for 6-24 months. Many children require treatment for at least one year, and relapses are common if treatment is discontinued prematurely. Factors influencing duration include severity of constipation, duration of symptoms before treatment, presence of complicating psychosocial factors, and family adherence to the therapeutic plan. Gradual weaning of laxatives should be done carefully over several months after establishment of regular evacuation pattern and complete resolution of incontinence. Long-term follow-up is recommended even after discontinuation of treatment to identify relapses early.

4. Can this code be used in medical certificates?

Yes, code 6C01 can be used in medical certificates when clinically appropriate and necessary to justify school absences or special needs. However, privacy and stigma considerations should be carefully evaluated. For communication with schools, it is often preferable to use descriptive language such as "chronic medical condition under treatment" instead of specifying encopresis, unless details are necessary to implement specific accommodations (such as facilitated bathroom access, permission to change clothes, exemption from certain activities). When the code is necessary for reimbursement or official documentation purposes, it should be included, but professionals should be aware of the potential psychological impact on the child and family. In some situations, it may be appropriate to discuss with the family how they prefer the condition to be described in documents that may be seen by third parties.

5. Is encopresis considered a psychiatric or gastrointestinal disorder?

Encopresis is best understood as a disorder with both gastrointestinal and behavioral/psychological components, not being purely one or the other. In ICD-11, it is classified as an elimination disorder, recognizing this multifactorial nature. Most cases involve functional constipation (gastrointestinal component) associated with behavioral factors such as toilet avoidance, intentional fecal retention, or difficulties in bowel training. Psychological factors such as anxiety, family stressors, or emotional problems frequently contribute, but are rarely the sole cause. This multifactorial nature explains why the most effective treatment is multidisciplinary, combining medical management of constipation with behavioral interventions. The integrated approach between pediatric gastroenterology and mental health generally produces better results than treatment focused exclusively on one aspect.

6. Do children with encopresis have higher risk of other psychological problems?

Yes, there is significant association between encopresis and other psychological problems, although the direction of causality is not always clear. Children with encopresis present elevated rates of anxiety disorders, depression, attention-deficit/hyperactivity disorder (ADHD), and disruptive behavior disorders. These associations may reflect different relationships: psychological problems may predispose to encopresis (for example, anxiety leading to toilet avoidance), encopresis may cause secondary psychological problems (low self-esteem, social isolation resulting from embarrassment), or common underlying factors may predispose to both. Regardless of causal direction, the presence of psychiatric comorbidities complicates treatment and worsens prognosis, emphasizing the importance of comprehensive psychological evaluation in all children with encopresis. Treatment of psychiatric comorbidities is often necessary for successful resolution of encopresis.

7. Is there a difference in treatment between primary and secondary encopresis?

Although general treatment principles are similar, there are some important differences. Primary encopresis (when the child never established adequate bowel control) often requires more intensive and prolonged approach, with greater emphasis on structured behavioral training and establishment of routines. There may be need for more detailed evaluation to exclude subtle developmental or neurological abnormalities. Secondary encopresis (with previous period of continence) is often associated with identifiable stressful events and may respond better when these stressors are addressed. Investigation of precipitating psychosocial factors is particularly important in secondary encopresis. Psychological interventions focused on stress or anxiety management may be more central in treatment of secondary encopresis. However, in both types, management of constipation (when present) and establishment of regular bowel habits are fundamental components of treatment.

8. What are the signs that encopresis may have organic cause and requires more thorough investigation?

Various warning signs suggest possible organic cause and need for specialized investigation. These include: symptom onset from birth or first weeks of life (suggests congenital condition such as Hirschsprung disease), delayed meconium passage beyond 48 hours after birth, presence of neurological abnormalities on examination (changes in reflexes, tone, or sensation), visible anatomical abnormalities of the perianal region or spine, constitutional symptoms such as fever, weight loss, or significant rectal bleeding, severe abdominal distension or vomiting, and lack of response to adequately implemented conventional treatment. Children with these characteristics require evaluation by a pediatric gastroenterologist and possibly specialized studies such as anorectal manometry, colonic transit studies, or rectal biopsy to exclude organic causes before confirming the diagnosis of functional encopresis.

Conclusion

Encopresis represents a complex elimination disorder that requires multifaceted understanding for appropriate diagnosis and coding. The ICD-11 code 6C01 should be applied when specific criteria are met, particularly recurrent inappropriate fecal elimination in a child at least 4 years of age, after careful exclusion of organic causes. Accurate coding is essential not only for administrative and epidemiological purposes, but fundamentally to ensure that affected children receive the appropriate multidisciplinary approach that this condition requires. Recognition of the multifactorial nature of encopresis, involving gastrointestinal, behavioral, and psychosocial components, should guide both diagnostic evaluation and therapeutic planning, optimizing outcomes and minimizing the impact of this challenging condition on the lives of children and their families.

External References

This article was prepared based on reliable scientific sources:

References verified on 2026-02-03

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