Treatment of Alcoholic Liver Disease – Gastroenterology & Hepatology (2023)

G&H What are the conditions that constitute alcoholic liver disease?

TM Alcoholic liver disease has a broad clinical spectrum, from mild disease to severe, life-threatening liver injury. Alcoholic liver disease starts with fatty liver and goes on to fibrosis and cirrhosis, as well as a severe form of alcoholic liver disease known as alcoholic hepatitis. In addition, there is a very uncommon type of alcoholic liver disease known as foamy fatty change, which presents with jaundice and a high aspartate aminotransferase level. Simple fatty liver occurs in nearly all people who drink alcohol on a heavy basis, even for a relatively short period of time such as a few days. In contrast, alcohol-induced fibrosis and cirrhosis usually develop after decades of heavy drinking, as does alcoholic hepatitis. It is unclear why patients who have been drinking for decades suddenly develop alcoholic hepatitis at a certain time point, as opposed to, for example, a year or decade earlier.

G&H What are the effects of complete alcohol abstinence on alcoholic liver disease? Is cessation of alcohol sufficient for treatment?

TM Cessation of alcohol is necessary to treat alcoholic liver disease. If the patient has simple fatty liver, then cessation will allow the liver to heal and return to normal. If a patient has alcohol-induced fibrosis or cirrhosis and abstains from alcohol, damage to the liver will stop and the liver will get better, although liver scar tissue will remain. In some patients, the fibrosis seems to regress. Fibrosis regression is difficult to document and cannot be predicted in an individual patient who stops drinking. In most patients, the fibrosis remains to some degree, potentially as much as when the patient stopped drinking. For alcoholic hepatitis or foamy fatty change, stopping alcohol is necessary—and will lead to improvements in most patients—but may not be sufficient to stop the disease.

G&H How long does it take for the effects of alcohol abstinence to occur?

TM The beneficial effects of stopping alcohol start immediately, but probably are not achieved in the full sense for several weeks or longer. The exact length of time for the liver to improve is not known, and varies from patient to patient.

G&H In these patients, is there a safe threshold for resuming low alcohol consumption once their disease has improved?

(Video) Managing patients with acute alcoholic hepatitis | UCLA Digestive Diseases

TM I tell my patients who have a history of alcoholic liver disease that they cannot drink any alcohol again. I am concerned that a patient with a history of alcoholic liver disease who starts drinking small amounts of alcohol is at risk of returning to heavy alcohol use, with progression of his or her alcoholic liver disease.

G&H How effective are alcohol abstinence programs and substance abuse counseling in patients with alcoholic liver disease?

TM Alcohol treatment programs should be recommended to all patients with alcoholic liver disease. The data show that a subset of patients become abstinent. Many patients will start drinking again at some time in their lives, but participating in these programs may reduce their alcohol use or duration, or allow them to regain abstinence.

G&H How common is alcohol relapse in patients with alcoholic liver disease?

TM Alcohol relapse is fairly common. Therefore, gastroenterologists should always be aware of the possibility of relapse and question patients accordingly. It is a good idea to check their blood alcohol levels during clinic visits to assess whether they have been drinking recently.

G&H How effective are medical therapies for alcoholic liver disease?

TM Currently, there are no treatments for fatty liver, alcoholic fibrosis, or alcoholic cirrhosis other than abstinence from alcohol. The only disease for which there is specific treatment is alcoholic hepatitis. Researchers have studied corticosteroids and pentoxifylline for many years in patients with alcoholic hepatitis. Most experts recommend prednisolone at a dose of 40 mg a day for 28 or 30 days as the preferred treatment for severe alcoholic hepatitis. Some experts prefer pentoxifylline instead. The most recent data suggest that prednisolone improves survival at 1 month. However, the beneficial effects disappear by 3 to 6 months. This was especially true in the STOPAH (Steroids or Pentoxifylline for Alcoholic Hepatitis) trial.

(Video) ALCOHOLIC LIVER DISEASE | Pathogenesis | Clinical Features | Diagnosis | Treatment | Harrison

G&H When should these drugs be started for patients with alcoholic hepatitis?

TM Generally speaking, hepatologists recommend prednisolone or pentoxifylline when the Maddrey discriminant function score is greater than or equal to 32. Some doctors use the Model for End-Stage Liver Disease (MELD) score instead and start treatment if the patient’s MELD score is greater than or equal to 20. As mentioned above, the usual treatment duration is 28 or 30 days. I recommend adding magnesium, 1 pill a day, for many months. Magnesium may decrease intestinal permeability, an important component of reducing endotoxin absorption and exposure to the liver.

G&H Can these drugs be used for longer than1 month?

TM Pentoxifylline and prednisolone are usually used only for 1 month. There are some data (although of a relatively minimal nature) on the use of pentoxifylline for a longer duration, but most doctors do not use the drug beyond 1 month for patients with alcoholic hepatitis.

G&H Since the treatment effects are not long-lasting, can the treatment be given again?

TM The treatment is not given again unless the patient resumes alcohol consumption and returns with an exacerbation of alcoholic hepatitis.

G&H Are any new therapies being studied for alcoholic hepatitis?

(Video) 1/6/17: Alcoholic Liver Disease: A Tale of Two Maladies

TM Several new therapies have been studied in patients with alcoholic hepatitis. One is granulocyte colony-stimulating factor (GCSF). In several studies from India, the use of GCSF along with either prednisolone or pentoxifylline, depending on the study, improved short-term (2-3 months) survival. In my opinion, studies of GCSF should be performed in the United States or in the Western world to confirm its effectiveness in a Western population before the therapy can be broadly recommended. One of the potential advantages of GCSF is its reported safety.

N-acetylcysteine (NAC) has also been studied for the treatment of alcoholic hepatitis. In a meta-analysis, NAC by itself did not improve survival in alcoholic hepatitis. However, one study showed that treatment with prednisolone and NAC was better than treatment with prednisolone alone at 1 month, although the survival benefit was lost by 6 months. In my opinion, additional clinical trials of NAC are needed before it can be recommended for patients with alcoholic hepatitis.

G&H What is the role of early liver transplantation in alcoholic liver disease?

TM Patients with alcoholic cirrhosis who have been abstinent for 6 months or more are potential candidates for liver transplantation as long as they meet the other criteria for transplantation. The recidivism rate among abstinent alcoholic cirrhotic patients is roughly 10%. Alcohol use after transplantation is often minimal and does not affect organ survival; however, in a small number of patients, there is a significant return to alcohol use. Nevertheless, abstinent patients with decompensated alcoholic cirrhosis are generally considered to be suitable candidates for liver transplantation if they have fulfilled all of the standard components of the transplant evaluation process.

In contrast, transplanting patients with alcoholic hepatitis who have less than 6 months of abstinence is a difficult issue that is under study at several sites. These patients are currently being considered for transplantation
at a number of transplant centers. There have been several trials in which transplant teams evaluated patients with alcoholic hepatitis who had not been abstinent for very long and transplanted select patients, with very good survival reported at 1 and 2 years. Thus, some data do support transplanting select patients with alcoholic hepatitis with less than 6 months of alcoholic abstinence.

G&H Why is the issue of early liver transplantation more complicated in patients with alcoholic hepatitis?

TM Knowing which patients with alcoholic hepatitis are transplant candidates is difficult. In a study by Dr Philippe Mathurin and colleagues in France, the results of which were published in the New England Journal of Medicine in 2011, one of the major criteria for liver transplantation was that the alcoholic hepatitis was the patient’s first episode of decompensated alcoholic liver disease. Studies in the United States have not been as strict in requiring that the episode of alcoholic hepatitis be the patient’s first decompensation, which might explain why there was a slightly higher incidence of recidivism in at least 1 of the studies conducted in the United States.

(Video) Cirrhosis - causes, symptoms, diagnosis, treatment, pathology

Early liver transplantation of patients with alcoholic hepatitis is complicated because of perceived issues among the donor population that the donated liver may be given to a recipient who might end up drinking alcohol again. Because livers are scarce commodities, some in the transplant community feel that the organs should be reserved for the people who will take care of them the best. The ongoing uncertainty regarding the reliability of recently abstinent patients with alcoholic hepatitis to take care of their liver likely influences the decision of transplant teams across the United States to transplant patients with alcoholic hepatitis. In studies that were performed in France and the United States, roughly 1 in 10 patients with alcoholic hepatitis was a potential transplant recipient, and perhaps half of these patients ended up receiving a liver transplant.

Overall, transplanting patients with alcoholic hepatitis has a relatively small effect on the use of donor livers. In most publications, less than 5% of the livers were used for patients with alcoholic hepatitis. Nevertheless, the transplantation of patients with alcoholic hepatitis who have not been abstinent for very long remains a complicated issue with no clear consensus.

G&H What research is currently underway in this area?

TM In the United States, the National Institute on Alcohol Abuse and Alcoholism is funding 4 consortia to study alcoholic hepatitis. These consortia are looking at new treatments for alcoholic hepatitis and are also performing basic science and translational research into the pathophysiology and mechanisms of liver injury in alcoholic hepatitis. The consortia have been active for 4 or 5 years and have published some preliminary findings thus far.

Dr Morgan has no relevant conflicts of interest to disclose.

Suggested Reading

Crabb DW, Bataller R, Chalasani NP, et al; NIAAA Alcoholic Hepatitis Consortia. Standard definitions and common data elements for clinical trials in patients with alcoholic hepatitis: recommendation from the NIAAA Alcoholic Hepatitis Consortia. Gastroenterology. 2016;150(4):785-790.

(Video) 6/18/2021: Optimizing Care for Patients with Alcohol-Associated Liver Disease

Mathurin P, Moreno C, Samuel D, et al. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med. 2011;365(19):1790-1800.

Thursz M, Morgan TR. Treatment of severe alcoholic hepatitis. Gastroenterology. 2016;150(8):1823-1834.

Thursz MR, Richardson P, Allison M, et al; STOPAH Trial. Prednisolone or pentoxifylline for alcoholic hepatitis. N Engl J Med. 2015;372(17):1619-1628.

FAQs

What are the treatment options for alcoholic liver disease? ›

All of the alcohol-related disorders will improve with the cessation of drinking. Treatment includes: Alcohol Withdrawal Treatment.
...
Cirrhosis of the Liver
  • Take medications, if an underlying disease is causing the cirrhosis can be treated.
  • Stop drinking alcohol.
  • Lose weight if you are overweight.
  • Eat a low-sodium diet.

What is the best treatment for liver disease? ›

Some liver problems can be treated with lifestyle modifications, such as stopping alcohol use or losing weight, typically as part of a medical program that includes careful monitoring of liver function. Other liver problems may be treated with medications or may require surgery.

What is the cornerstone in the treatment of alcoholic liver disease? ›

A cornerstone of the treatment of AUD patients with ALD is the achievement and maintenance of total alcohol abstinence.

Which is the most successful type of treatment for alcoholism? ›

A new study concludes that the Alcoholics Anonymous program is the most effective way to treat alcohol use disorder. The researchers said people who complete the organization's 12-step program have better success at abstinence as well as relationships with family members and friends.

What are five types of therapy that can be used to treat alcoholism? ›

There are many effective, evidence-based treatment therapy options for alcoholism. Most rehab facilities will utilize some or all of following treatment methods.
...
Motivational Interviewing
  • Expressing empathy.
  • Rolling with resistance.
  • Developing self-efficacy.
  • Developing discrepancy.

What is the latest treatment for liver cirrhosis? ›

In advanced cases of cirrhosis, when the liver ceases to function, a liver transplant may be the only treatment option. A liver transplant is a procedure to replace your liver with a healthy liver from a deceased donor or with part of a liver from a living donor.

Which injection is used for liver? ›

Hepatic 5mg Injection is a combination of amino acids that are used in the treatment of liver disease. It protects the liver from harmful chemical substances and improves the functioning of the liver.

Which drug is used as a liver tonic? ›

Currently, chaparral is packaged as capsules, tablets, or balms and used as a “liver tonic” and for the treatment of skin lesions.

What types of medications are used to treat patients with liver disease and cirrhosis? ›

One or more medicines may be used for cirrhosis. They may be used to control the cause and prevent more damage. They may also be used to treat symptoms and related health problems. Here are the basics about each of the medicines below.
...
Common names are:
  • Atenolol.
  • Metoprolol.
  • Nadolol.
  • Propranolol.
  • Timolol.
  • Carvedilol.

What are 3 diseases that affect the liver? ›

The most common types of liver infection are hepatitis viruses, including:
  • Hepatitis A.
  • Hepatitis B.
  • Hepatitis C.
8 Apr 2022

Which liver disease is not curable? ›

Hepatitis B.

This type of viral hepatitis can be acute (short-term) or chronic (long-term). It's spread through bodily fluids, such as blood and semen. While hepatitis B is treatable, there's no cure for it.

What is the first-line of treatment for alcoholism? ›

Evidence-Based Answer

Acamprosate and naltrexone should be used as first-line agents for treatment of alcohol use disorder and are effective for reducing relapse rates.

Why is vitamin K given in alcoholic liver disease? ›

Vitamin K is often given to correct prolonged prothrombin times (PT) in patients with cirrhosis. However, this practice is not well defined and its effectiveness is questionable. The objective of our literature review is to determine the effectiveness of vitamin K to correct coagulopathy in cirrhosis.

Which stages of alcoholic liver disease are reversible? ›

Alcoholic fatty liver disease

Fatty liver disease is reversible. If you stop drinking alcohol for some time (months or years), your liver should return to normal.

What are the two types of addiction treatment? ›

Professionals can effectively treat addictions of all types, both physical and behavioral. Personalized treatment plans allow people suffering from addiction to ease through withdrawal and learn to live without their addictions.

What is the best form of treatment for addiction? ›

Behavioral therapy is perhaps the most commonly utilized types of treatment for addiction that is frequently used during substance rehabilitation. A general behavioral therapeutic approach has been adapted into a variety of effective techniques.

What is the first stage of treatment for addiction? ›

Detoxification is normally the first step in treatment. This involves clearing a substance from the body and limiting withdrawal reactions. In 80 percent of cases, a treatment clinic will use medications to reduce withdrawal symptoms, according to the Substance Abuse and Mental Health Services Administration (SAMHSA).

What are the 4 types of treatment? ›

Types of Treatment Methods
  • Targeted Therapies: A targeted therapy is designed to treat only the cancer cells and minimize damage to normal, healthy cells. ...
  • Chemotherapy: ...
  • Surgery: ...
  • Radiation Therapies: ...
  • Biological Therapy: ...
  • Hormonal Therapy:

What are the five stages of treatment? ›

Stage-Matched Care. Developed from the Trans-theoretical Model of Change1, the Stage of Change model includes five stages: pre-contemplation, contemplation, preparation, action, and maintenance.

What are 3 treatment options for someone who is addicted to this drug? ›

There are many options that have been successful in treating drug addiction, including:
  • behavioral counseling.
  • medication.
  • medical devices and applications used to treat withdrawal symptoms or deliver skills training.
  • evaluation and treatment for co-occurring mental health issues such as depression and anxiety.
17 Jan 2019

What is first line therapy for a patient with cirrhosis of the liver? ›

Diuretic therapy with spironolactone is typically a first-line option for patients with cirrhosis and edema. If an inadequate response is achieved with spironolactone, then furosemide or thiazide diuretics can safely be added to the regimen.

Can a liver repair from cirrhosis? ›

The liver damage done by cirrhosis generally can't be undone. But if liver cirrhosis is diagnosed early and the cause is treated, further damage can be limited and, rarely, reversed.

Why is liver cirrhosis not curable? ›

No, there is no cure for cirrhosis. The damage already done to your liver is permanent. However, depending on the underlying cause of your cirrhosis, there may be actions you can take to keep your cirrhosis from getting worse.

What are liver protective drugs? ›

Curcumin, resveratrol and thalidomide are very attractive newly discovered protective and curative compounds on experimental hepatic diseases. Their mechanism of action is associated with the ability to down-regulate NF-kappaB and to decrease pronecrotic and profibrotic cytokines.

What blood test is for liver? ›

Alanine transaminase (ALT) test.

This is an enzyme found mostly in the liver that is released into the bloodstream after acute liver cell damage. This test may be performed to assess liver function, and/or to evaluate treatment of acute liver disease, such as hepatitis.

Is liver disease curable? ›

Depending on the cause, acute liver failure can sometimes be reversed with treatment. In many situations, though, a liver transplant may be the only cure.

Which syrup is best for liver? ›

Trisoliv Syrup 200 ml is an effective and safe treatment for liver disease. The dose will be recommended by your doctor.

Is Liv 52 syrup good for liver? ›

This product is used to aid the recovery of patients suffering from liver disorders. It is also used to strengthen the liver for children who are suffering from either liver-related or digestive tract-related ailments. Liv 52 is also used to ensure the healthy functioning of the liver and spleen.

Can liver damage reversed? ›

If you have fatty liver disease, the damage may be reversed if you abstain from alcohol for a period of time (this could be months or years). After this point, it's usually safe to start drinking again if you stick to the NHS guidelines on alcohol units. However, it's important to check with your doctor first.

Which antibiotic is best for liver cirrhosis? ›

Fluoroquinolones (norfloxacin and ciprofloxacin), third-generation cephalosporins (G3) (ceftriaxone and cefotaxime) and trimethoprim–sulfamethoxazole (SXT) are recommended for preventing infections in patients with cirrhosis or liver failure.

What drugs should be avoided in liver disease? ›

The 10 Worst Medications for Your Liver
  • 1) Acetaminophen (Tylenol) ...
  • 2) Amoxicillin/clavulanate (Augmentin) ...
  • 4) Amiodarone (Cordarone, Pacerone) ...
  • 5) Allopurinol (Zyloprim) ...
  • 8) Azathioprine (Imuran) ...
  • 9) Methotrexate. ...
  • 10) Risperidone (Risperdal) and quetiapine (Seroquel)
10 Feb 2019

What drugs should be avoided with cirrhosis? ›

ACE inhibitors and nonsteroidal anti-inflammatory drugs counteract the enhanced activity of the renin-angiotensin system in advanced liver disease, thereby generating a high risk of excessive hypotension or acute renal failure, respectively. These drugs are best avoided in patients with cirrhosis.

What are 2 types of liver problems caused by alcohol? ›

drinking a large amount of alcohol in a short amount of time (binge drinking) can cause fatty liver disease and, less commonly, alcoholic hepatitis. drinking more than the recommended limits of alcohol over many years can cause hepatitis and cirrhosis, the more serious types of ARLD.

What are 4 diseases alcohol can cause for the liver? ›

With continued drinking, alcoholic liver disease can proceed to liver inflammation (i.e., steatohepatitis), fibrosis, cirrhosis, and even liver cancer (i.e., hepatocellular carcinoma).

Which stage of liver damage is not reversible? ›

Stage 3: Cirrhosis

Cirrhosis refers to severe, irreversible scarring of the liver.

How long does liver disease take to heal? ›

Healing can begin as early as a few days to weeks after you stop drinking, but if the damage is severe, healing can take several months. In some cases, “if the damage to the liver has been long-term, it may not be reversible,” warns Dr. Stein.

What are signs that cirrhosis of the liver is getting worse? ›

If cirrhosis gets worse, some of the symptoms and complications include: yellowing of the skin and whites of the eyes (jaundice) vomiting blood. itchy skin.

How do you treat alcoholism? ›

There is no such thing as a small stroke…
  1. Drink fluids. ...
  2. Get some carbohydrates into your system. ...
  3. Avoid darker-colored alcoholic beverages. ...
  4. Take a pain reliever, but not Tylenol. ...
  5. Drink coffee or tea. ...
  6. B vitamins and zinc.

What are the treatment options available for individuals who suffer from alcohol? ›

Two main components of professionally led treatment

Treatment can include one-on-one, family, or group sessions. Medications. A primary care clinician or a board-certified addiction doctor can prescribe non-addicting medications. These can help people stop drinking and avoid relapse.

What is the most important treatment option for alcohol related liver disease? ›

Alcohol Withdrawal Treatment

The most crucial step for beginning treatment for alcoholic liver disorder (ALD is to quit drinking completely. Unfortunately, because the body has become dependent on alcohol, the sudden cessation of alcohol may cause painful withdrawal symptoms.

What is the cornerstone treatment of alcoholic liver disease? ›

While pharmacologic options for ALD are limited, avoidance of alcohol remains the cornerstone of treatment for all patients with ALD because alcohol use is an important risk factor for disease progression. For patients with alcohol-associated cirrhosis, abstinence decreases the risk of liver-related complications.

Why is thiamine given in liver disease? ›

Vitamin B

Thiamine deficiency is common in many forms of cirrhosis particularly alcoholic liver disease where it is caused by inadequate dietary intake, decreased hepatic storage, and impairment of intestinal thiamine absorption by ethanol.

How long can a liver survive alcoholism? ›

The life expectancy of a person with alcoholic liver disease reduces dramatically as the condition progresses. On average, 1 in 3 people with the most advanced stage of liver disease and cirrhosis are still alive after 2 years. When the body can compensate and manage cirrhosis, the typical lifespan is 6–12 years.

Can your liver recover from 10 years of drinking? ›

Even after years of heavy alcohol use, the liver has a remarkable regenerative capacity and, following alcohol removal, can recover a significant portion of its original mass and function.

Are any of the forms of alcoholic liver disease reversible? ›

It's generally not reversible, but stopping drinking alcohol immediately can prevent further damage and significantly increase your life expectancy. A person who has alcohol-related cirrhosis and doesn't stop drinking has a less than 50% chance of living for at least 5 more years.

Can you recover from alcoholic liver disease? ›

While cirrhosis scars from excessive drinking are irreversible, quitting alcohol and leading a healthier lifestyle can help your liver heal from fatty liver disease and alcoholic hepatitis. The liver is the organ that metabolizes alcohol. The average liver can process the equivalent of about one small drink an hour.

How long does it take to heal the liver from alcohol abuse? ›

Severe drinking may require three months to a year to fully regenerate the liver to its original capacity and functionality. Over time, the liver can heal itself from damages caused by alcoholic fatty liver disease and hepatitis. Unfortunately, when it comes to the scars of cirrhosis, these damages are irreversible.

What is the most advanced type of alcoholic liver disease? ›

Alcoholic cirrhosis is an advanced stage of alcoholic liver disease that causes your liver to become stiff, swollen, and barely able to do its job.

What are the 3 stages of alcoholic liver disease? ›

Alcoholic liver disease is defined by three stages of liver damage following chronic heavy alcohol consumption: fatty liver, alcoholic hepatitis, and fibrosis/cirrhosis (Figure 5).

How do you test for alcoholic liver disease? ›

How is alcoholic liver disease diagnosed?
  1. Blood tests. Including liver function tests, which show whether the liver is working the way it should.
  2. Liver biopsy. This involves removing small tissue samples from the liver with a needle or during surgery. ...
  3. Ultrasound. ...
  4. CT scan. ...
  5. MRI.

What is the final stage of liver damage from drinking? ›

Cirrhosis is the final stage of alcohol-related liver disease. It usually happens after many years of heavy drinking.

Is liver damage from alcohol permanent? ›

Alcohol may cause swelling and inflammation in your liver, or something called hepatitis. Over time, this can lead to scarring and cirrhosis of the liver, which is the final phase of alcoholic liver disease. The damage caused by cirrhosis is unfortunately irreversible.

What are 4 warning signs of damaged liver? ›

If signs and symptoms of liver disease do occur, they may include:
  • Skin and eyes that appear yellowish (jaundice)
  • Abdominal pain and swelling.
  • Swelling in the legs and ankles.
  • Itchy skin.
  • Dark urine color.
  • Pale stool color.
  • Chronic fatigue.
  • Nausea or vomiting.
8 Apr 2022

How do I know if my liver is recovering? ›

You will experience physical signs your liver is healing, such as healthier-looking skin and eyes, increased energy levels, and reduced stomach pain and swelling. Other signs your liver is healing include: Improved amino-acid regulation – Your liver processes proteins and amino acids that your body cannot store.

Videos

1. GASTROENTEROLOGY & HEPATOLOGY | ALCOHOLIC LIVER DISEASE AND NON ALCOHOLIC FATTY LIVER DISEASE | PHA
(Planetary Health Academia)
2. "Alcoholic liver disease" - Professor Ewan Forrest
(SHAAP)
3. "Alcoholic Liver Disease: Focus on Alcoholic Hepatitis" by Stanley Martin Cohen, MD
(UH Medicine)
4. ISG Master Class XVI : Dr Kaushal Madan : Stepwise Management of Alcoholic Hepatitis
(Indian Society of Gastroenterology)
5. Dr. Wing-Kin Syn - SLUCare Gastroenterology & Hepatology
(SLUCare)
6. Liver Cirrhosis (Clinical essentials) - Dr. Kiran Peddi MRCP(UK), FRCP(London), CCT(Gastro)
(Dr.G Bhanu Prakash Animated Medical Videos)
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