Intestinal lymphangiectasia in adults.
Identifieur interne : 002729 ( PubMed/Corpus ); précédent : 002728; suivant : 002730Intestinal lymphangiectasia in adults.
Auteurs : Hugh James Freeman ; Michael NimmoSource :
- World journal of gastrointestinal oncology [ 1948-5204 ] ; 2011.
Abstract
Intestinal lymphangiectasia in the adult may be characterized as a disorder with dilated intestinal lacteals causing loss of lymph into the lumen of the small intestine and resultant hypoproteinemia, hypogammaglobulinemia, hypoalbuminemia and reduced number of circulating lymphocytes or lymphopenia. Most often, intestinal lymphangiectasia has been recorded in children, often in neonates, usually with other congenital abnormalities but initial definition in adults including the elderly has become increasingly more common. Shared clinical features with the pediatric population such as bilateral lower limb edema, sometimes with lymphedema, pleural effusion and chylous ascites may occur but these reflect the severe end of the clinical spectrum. In some, diarrhea occurs with steatorrhea along with increased fecal loss of protein, reflected in increased fecal alpha-1-antitrypsin levels, while others may present with iron deficiency anemia, sometimes associated with occult small intestinal bleeding. Most lymphangiectasia in adults detected in recent years, however, appears to have few or no clinical features of malabsorption. Diagnosis remains dependent on endoscopic changes confirmed by small bowel biopsy showing histological evidence of intestinal lymphangiectasia. In some, video capsule endoscopy and enteroscopy have revealed more extensive changes along the length of the small intestine. A critical diagnostic element in adults with lymphangiectasia is the exclusion of entities (e.g. malignancies including lymphoma) that might lead to obstruction of the lymphatic system and "secondary" changes in the small bowel biopsy. In addition, occult infectious (e.g. Whipple's disease from Tropheryma whipplei) or inflammatory disorders (e.g. Crohn's disease) may also present with profound changes in intestinal permeability and protein-losing enteropathy that also require exclusion. Conversely, rare B-cell type lymphomas have also been described even decades following initial diagnosis of intestinal lymphangiectasia. Treatment has been historically defined to include a low fat diet with medium-chain triglyceride supplementation that leads to portal venous rather than lacteal uptake. A number of other pharmacological measures have been reported or proposed but these are largely anecdotal. Finally, rare reports of localized surgical resection of involved areas of small intestine have been described but follow-up in these cases is often limited.
DOI: 10.4251/wjgo.v3.i2.19
PubMed: 21364842
Links to Exploration step
pubmed:21364842Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Intestinal lymphangiectasia in adults.</title>
<author><name sortKey="Freeman, Hugh James" sort="Freeman, Hugh James" uniqKey="Freeman H" first="Hugh James" last="Freeman">Hugh James Freeman</name>
<affiliation><nlm:affiliation>Hugh James Freeman, Department of Medicine (Gastroenterology), University of British Columbia, Vancouver, BC, V6T 1W5, Canada.</nlm:affiliation>
</affiliation>
</author>
<author><name sortKey="Nimmo, Michael" sort="Nimmo, Michael" uniqKey="Nimmo M" first="Michael" last="Nimmo">Michael Nimmo</name>
</author>
</titleStmt>
<publicationStmt><idno type="wicri:source">PubMed</idno>
<date when="2011">2011</date>
<idno type="RBID">pubmed:21364842</idno>
<idno type="pmid">21364842</idno>
<idno type="doi">10.4251/wjgo.v3.i2.19</idno>
<idno type="wicri:Area/PubMed/Corpus">002729</idno>
<idno type="wicri:explorRef" wicri:stream="PubMed" wicri:step="Corpus" wicri:corpus="PubMed">002729</idno>
</publicationStmt>
<sourceDesc><biblStruct><analytic><title xml:lang="en">Intestinal lymphangiectasia in adults.</title>
<author><name sortKey="Freeman, Hugh James" sort="Freeman, Hugh James" uniqKey="Freeman H" first="Hugh James" last="Freeman">Hugh James Freeman</name>
<affiliation><nlm:affiliation>Hugh James Freeman, Department of Medicine (Gastroenterology), University of British Columbia, Vancouver, BC, V6T 1W5, Canada.</nlm:affiliation>
</affiliation>
</author>
<author><name sortKey="Nimmo, Michael" sort="Nimmo, Michael" uniqKey="Nimmo M" first="Michael" last="Nimmo">Michael Nimmo</name>
</author>
</analytic>
<series><title level="j">World journal of gastrointestinal oncology</title>
<idno type="eISSN">1948-5204</idno>
<imprint><date when="2011" type="published">2011</date>
</imprint>
</series>
</biblStruct>
</sourceDesc>
</fileDesc>
<profileDesc><textClass></textClass>
</profileDesc>
</teiHeader>
<front><div type="abstract" xml:lang="en">Intestinal lymphangiectasia in the adult may be characterized as a disorder with dilated intestinal lacteals causing loss of lymph into the lumen of the small intestine and resultant hypoproteinemia, hypogammaglobulinemia, hypoalbuminemia and reduced number of circulating lymphocytes or lymphopenia. Most often, intestinal lymphangiectasia has been recorded in children, often in neonates, usually with other congenital abnormalities but initial definition in adults including the elderly has become increasingly more common. Shared clinical features with the pediatric population such as bilateral lower limb edema, sometimes with lymphedema, pleural effusion and chylous ascites may occur but these reflect the severe end of the clinical spectrum. In some, diarrhea occurs with steatorrhea along with increased fecal loss of protein, reflected in increased fecal alpha-1-antitrypsin levels, while others may present with iron deficiency anemia, sometimes associated with occult small intestinal bleeding. Most lymphangiectasia in adults detected in recent years, however, appears to have few or no clinical features of malabsorption. Diagnosis remains dependent on endoscopic changes confirmed by small bowel biopsy showing histological evidence of intestinal lymphangiectasia. In some, video capsule endoscopy and enteroscopy have revealed more extensive changes along the length of the small intestine. A critical diagnostic element in adults with lymphangiectasia is the exclusion of entities (e.g. malignancies including lymphoma) that might lead to obstruction of the lymphatic system and "secondary" changes in the small bowel biopsy. In addition, occult infectious (e.g. Whipple's disease from Tropheryma whipplei) or inflammatory disorders (e.g. Crohn's disease) may also present with profound changes in intestinal permeability and protein-losing enteropathy that also require exclusion. Conversely, rare B-cell type lymphomas have also been described even decades following initial diagnosis of intestinal lymphangiectasia. Treatment has been historically defined to include a low fat diet with medium-chain triglyceride supplementation that leads to portal venous rather than lacteal uptake. A number of other pharmacological measures have been reported or proposed but these are largely anecdotal. Finally, rare reports of localized surgical resection of involved areas of small intestine have been described but follow-up in these cases is often limited.</div>
</front>
</TEI>
<pubmed><MedlineCitation Status="PubMed-not-MEDLINE" Owner="NLM"><PMID Version="1">21364842</PMID>
<DateCreated><Year>2011</Year>
<Month>03</Month>
<Day>02</Day>
</DateCreated>
<DateCompleted><Year>2011</Year>
<Month>07</Month>
<Day>14</Day>
</DateCompleted>
<DateRevised><Year>2017</Year>
<Month>02</Month>
<Day>20</Day>
</DateRevised>
<Article PubModel="Print"><Journal><ISSN IssnType="Electronic">1948-5204</ISSN>
<JournalIssue CitedMedium="Internet"><Volume>3</Volume>
<Issue>2</Issue>
<PubDate><Year>2011</Year>
<Month>Feb</Month>
<Day>15</Day>
</PubDate>
</JournalIssue>
<Title>World journal of gastrointestinal oncology</Title>
<ISOAbbreviation>World J Gastrointest Oncol</ISOAbbreviation>
</Journal>
<ArticleTitle>Intestinal lymphangiectasia in adults.</ArticleTitle>
<Pagination><MedlinePgn>19-23</MedlinePgn>
</Pagination>
<ELocationID EIdType="doi" ValidYN="Y">10.4251/wjgo.v3.i2.19</ELocationID>
<Abstract><AbstractText>Intestinal lymphangiectasia in the adult may be characterized as a disorder with dilated intestinal lacteals causing loss of lymph into the lumen of the small intestine and resultant hypoproteinemia, hypogammaglobulinemia, hypoalbuminemia and reduced number of circulating lymphocytes or lymphopenia. Most often, intestinal lymphangiectasia has been recorded in children, often in neonates, usually with other congenital abnormalities but initial definition in adults including the elderly has become increasingly more common. Shared clinical features with the pediatric population such as bilateral lower limb edema, sometimes with lymphedema, pleural effusion and chylous ascites may occur but these reflect the severe end of the clinical spectrum. In some, diarrhea occurs with steatorrhea along with increased fecal loss of protein, reflected in increased fecal alpha-1-antitrypsin levels, while others may present with iron deficiency anemia, sometimes associated with occult small intestinal bleeding. Most lymphangiectasia in adults detected in recent years, however, appears to have few or no clinical features of malabsorption. Diagnosis remains dependent on endoscopic changes confirmed by small bowel biopsy showing histological evidence of intestinal lymphangiectasia. In some, video capsule endoscopy and enteroscopy have revealed more extensive changes along the length of the small intestine. A critical diagnostic element in adults with lymphangiectasia is the exclusion of entities (e.g. malignancies including lymphoma) that might lead to obstruction of the lymphatic system and "secondary" changes in the small bowel biopsy. In addition, occult infectious (e.g. Whipple's disease from Tropheryma whipplei) or inflammatory disorders (e.g. Crohn's disease) may also present with profound changes in intestinal permeability and protein-losing enteropathy that also require exclusion. Conversely, rare B-cell type lymphomas have also been described even decades following initial diagnosis of intestinal lymphangiectasia. Treatment has been historically defined to include a low fat diet with medium-chain triglyceride supplementation that leads to portal venous rather than lacteal uptake. A number of other pharmacological measures have been reported or proposed but these are largely anecdotal. Finally, rare reports of localized surgical resection of involved areas of small intestine have been described but follow-up in these cases is often limited.</AbstractText>
</Abstract>
<AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Freeman</LastName>
<ForeName>Hugh James</ForeName>
<Initials>HJ</Initials>
<AffiliationInfo><Affiliation>Hugh James Freeman, Department of Medicine (Gastroenterology), University of British Columbia, Vancouver, BC, V6T 1W5, Canada.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y"><LastName>Nimmo</LastName>
<ForeName>Michael</ForeName>
<Initials>M</Initials>
</Author>
</AuthorList>
<Language>eng</Language>
<PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType>
</PublicationTypeList>
</Article>
<MedlineJournalInfo><Country>China</Country>
<MedlineTA>World J Gastrointest Oncol</MedlineTA>
<NlmUniqueID>101532470</NlmUniqueID>
</MedlineJournalInfo>
<CommentsCorrectionsList><CommentsCorrections RefType="Cites"><RefSource>N Engl J Med. 1964 Apr 9;270:761-6</RefSource>
<PMID Version="1">14107315</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Arch Dis Child. 1992 Jan;67(1):134-6</RefSource>
<PMID Version="1">1739329</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Eur J Ultrasound. 1998 Aug;7(3):195-8</RefSource>
<PMID Version="1">9700215</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Leuk Lymphoma. 1993 Sep;11(1-2):147-8</RefSource>
<PMID Version="1">8220148</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Nucl Med Commun. 2001 Nov;22(11):1249-54</RefSource>
<PMID Version="1">11606892</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Dig Dis Sci. 2010 Dec;55(12):3466-72</RefSource>
<PMID Version="1">20198428</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Endoscopy. 2007 Dec;39(12):1059-63</RefSource>
<PMID Version="1">18072056</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Dis Colon Rectum. 1982 Nov-Dec;25(8):813-6</RefSource>
<PMID Version="1">7172953</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Am J Obstet Gynecol. 2001 Jan;184(2):227-8</RefSource>
<PMID Version="1">11174507</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Digestion. 1994;55(1):59-64</RefSource>
<PMID Version="1">7509299</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Gastrointest Endosc Clin N Am. 2000 Oct;10(4):739-53, vii</RefSource>
<PMID Version="1">11036541</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Clin Imaging. 2003 Sep-Oct;27(5):330-2</RefSource>
<PMID Version="1">12932684</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>World J Gastroenterol. 2007 Apr 21;13(15):2263-5</RefSource>
<PMID Version="1">17465517</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Scand J Gastroenterol. 2009;44(2):252-6</RefSource>
<PMID Version="1">18855225</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>J Clin Gastroenterol. 2010 Oct;44(9):610-4</RefSource>
<PMID Version="1">20535025</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Dig Dis Sci. 2003 Aug;48(8):1506-9</RefSource>
<PMID Version="1">12924644</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Gastroenterology. 1961 Sep;41:197-207</RefSource>
<PMID Version="1">13782654</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Indian J Gastroenterol. 2007 Nov-Dec;26(6):293-5</RefSource>
<PMID Version="1">18431016</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Gastroenterology. 1981 Jan;80(1):166-8</RefSource>
<PMID Version="1">7450403</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Dig Dis Sci. 2005 Aug;50(8):1467-70</RefSource>
<PMID Version="1">16110837</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Endoscopy. 2009 Jun;41(6):510-5</RefSource>
<PMID Version="1">19533556</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Joint Bone Spine. 2008 Jan;75(1):73-5</RefSource>
<PMID Version="1">17900962</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Lymphology. 2008 Sep;41(3):111-5</RefSource>
<PMID Version="1">19013878</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Gut. 2000 Aug;47(2):296-300</RefSource>
<PMID Version="1">10896925</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Eur J Gastroenterol Hepatol. 2005 Dec;17(12):1417-9</RefSource>
<PMID Version="1">16292099</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Eur J Immunol. 1998 Dec;28(12):4275-85</RefSource>
<PMID Version="1">9862365</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>J Clin Gastroenterol. 2010 Jan;44(1):74-5</RefSource>
<PMID Version="1">19661816</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Surg Gynecol Obstet. 1980 Sep;151(3):391-5</RefSource>
<PMID Version="1">7404312</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Pediatrics. 2002 Jun;109(6):1177-80</RefSource>
<PMID Version="1">12042562</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Orphanet J Rare Dis. 2008;3:5</RefSource>
<PMID Version="1">18294365</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Nat Clin Pract Gastroenterol Hepatol. 2007 May;4(5):288-93</RefSource>
<PMID Version="1">17476211</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Endoscopy. 2005 Jun;37(6):607</RefSource>
<PMID Version="1">15933946</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Radiology. 2001 Apr;219(1):86-90</RefSource>
<PMID Version="1">11274540</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>World J Gastroenterol. 2003 Dec;9(12):2880-2</RefSource>
<PMID Version="1">14669360</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>J Clin Invest. 1972 Jun;51(6):1319-25</RefSource>
<PMID Version="1">4554185</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>J Clin Invest. 1967 Oct;46(10):1643-56</RefSource>
<PMID Version="1">4168730</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>J Pediatr Gastroenterol Nutr. 1987 Sep-Oct;6(5):803-5</RefSource>
<PMID Version="1">3694377</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Gastrointest Radiol. 1987;12(1):10-2</RefSource>
<PMID Version="1">3792749</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Gastrointest Endosc. 2007 Mar;65(3):522-3, discussion 523</RefSource>
<PMID Version="1">17321261</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>J Formos Med Assoc. 2009 Oct;108(10):814-8</RefSource>
<PMID Version="1">19864203</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>J Clin Endocrinol Metab. 1995 Mar;80(3):933-5</RefSource>
<PMID Version="1">7883852</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Dig Dis. 2008;26(2):134-9</RefSource>
<PMID Version="1">18431063</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>World J Gastroenterol. 2009 May 7;15(17):2078-80</RefSource>
<PMID Version="1">19418579</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>J Nephrol. 2007 Mar-Apr;20(2):246-9</RefSource>
<PMID Version="1">17514630</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Gut. 2006 Feb;55(2):196, 233</RefSource>
<PMID Version="1">16407384</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>AJR Am J Roentgenol. 2003 Jan;180(1):213-4</RefSource>
<PMID Version="1">12490507</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Clin Gastroenterol Hepatol. 2005 Aug;3(8):xxxiii</RefSource>
<PMID Version="1">16233996</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Can J Gastroenterol. 2003 Feb;17(2):111-3</RefSource>
<PMID Version="1">12605248</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Clin Investig. 1993 Jul;71(7):568-71</RefSource>
<PMID Version="1">8374252</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>J Surg Oncol. 1981;17(2):169-76</RefSource>
<PMID Version="1">7242097</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Br J Dermatol. 1964 Apr;76:153-7</RefSource>
<PMID Version="1">14140738</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>J Gastroenterol Hepatol. 2008 Jul;23(7 Pt 2):e88-95</RefSource>
<PMID Version="1">18005011</PMID>
</CommentsCorrections>
<CommentsCorrections RefType="Cites"><RefSource>Scand J Gastroenterol. 2007 Oct;42(10):1269-70</RefSource>
<PMID Version="1">17918009</PMID>
</CommentsCorrections>
</CommentsCorrectionsList>
<OtherID Source="NLM">PMC3046182</OtherID>
<KeywordList Owner="NOTNLM"><Keyword MajorTopicYN="N">Adults</Keyword>
<Keyword MajorTopicYN="N">Intestinal lymphangiectasia</Keyword>
<Keyword MajorTopicYN="N">Submucosa</Keyword>
</KeywordList>
</MedlineCitation>
<PubmedData><History><PubMedPubDate PubStatus="received"><Year>2010</Year>
<Month>07</Month>
<Day>26</Day>
</PubMedPubDate>
<PubMedPubDate PubStatus="revised"><Year>2011</Year>
<Month>01</Month>
<Day>31</Day>
</PubMedPubDate>
<PubMedPubDate PubStatus="accepted"><Year>2011</Year>
<Month>02</Month>
<Day>07</Day>
</PubMedPubDate>
<PubMedPubDate PubStatus="entrez"><Year>2011</Year>
<Month>3</Month>
<Day>3</Day>
<Hour>6</Hour>
<Minute>0</Minute>
</PubMedPubDate>
<PubMedPubDate PubStatus="pubmed"><Year>2011</Year>
<Month>3</Month>
<Day>3</Day>
<Hour>6</Hour>
<Minute>0</Minute>
</PubMedPubDate>
<PubMedPubDate PubStatus="medline"><Year>2011</Year>
<Month>3</Month>
<Day>3</Day>
<Hour>6</Hour>
<Minute>1</Minute>
</PubMedPubDate>
</History>
<PublicationStatus>ppublish</PublicationStatus>
<ArticleIdList><ArticleId IdType="pubmed">21364842</ArticleId>
<ArticleId IdType="doi">10.4251/wjgo.v3.i2.19</ArticleId>
<ArticleId IdType="pmc">PMC3046182</ArticleId>
</ArticleIdList>
</PubmedData>
</pubmed>
</record>
Pour manipuler ce document sous Unix (Dilib)
EXPLOR_STEP=$WICRI_ROOT/Wicri/Sante/explor/LymphedemaV1/Data/PubMed/Corpus
HfdSelect -h $EXPLOR_STEP/biblio.hfd -nk 002729 | SxmlIndent | more
Ou
HfdSelect -h $EXPLOR_AREA/Data/PubMed/Corpus/biblio.hfd -nk 002729 | SxmlIndent | more
Pour mettre un lien sur cette page dans le réseau Wicri
{{Explor lien |wiki= Wicri/Sante |area= LymphedemaV1 |flux= PubMed |étape= Corpus |type= RBID |clé= pubmed:21364842 |texte= Intestinal lymphangiectasia in adults. }}
Pour générer des pages wiki
HfdIndexSelect -h $EXPLOR_AREA/Data/PubMed/Corpus/RBID.i -Sk "pubmed:21364842" \ | HfdSelect -Kh $EXPLOR_AREA/Data/PubMed/Corpus/biblio.hfd \ | NlmPubMed2Wicri -a LymphedemaV1
![]() | This area was generated with Dilib version V0.6.31. | ![]() |