PK cK}\_rels/PK cK}\ docProps/PK cK}\ppt/PK cK}\ ppt/_rels/PK cK}\ ppt/charts/PK cK}\ppt/charts/_rels/PK cK}\ppt/embeddings/PK cK}\ ppt/media/PK cK}\ppt/slideLayouts/PK cK}\ppt/slideLayouts/_rels/PK cK}\ppt/slideMasters/PK cK}\ppt/slideMasters/_rels/PK cK}\ ppt/slides/PK cK}\ppt/slides/_rels/PK cK}\ ppt/theme/PK cK}\ppt/notesMasters/PK cK}\ppt/notesMasters/_rels/PK cK}\ppt/notesSlides/PK cK}\ppt/notesSlides/_rels/PK cK}\99[Content_Types].xml PK cK}\]] _rels/.rels PK cK}\p!docProps/app.xml 0 0 Microsoft Office PowerPoint On-screen Show (16:9) 0 30 30 0 0 false Fonts Used 2 Theme 1 Slide Titles 30 Arial Calibri Office Theme Slide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15Slide 16Slide 17Slide 18Slide 19Slide 20Slide 21Slide 22Slide 23Slide 24Slide 25Slide 26Slide 27Slide 28Slide 29Slide 30 PptxGenJS false false false 16.0000 PK cK}\docProps/core.xml Intestinal Obstruction – MBBS Teaching PptxGenJS Presentation PptxGenJS PptxGenJS 1 2026-03-29T09:27:06Z 2026-03-29T09:27:06Z PK cK}\5ͨppt/_rels/presentation.xml.rels PK cK}\Oݨ ppt/theme/theme1.xmlPK cK}\ekYYppt/presentation.xml PK cK}\Xppt/presProps.xml PK cK}\ppt/tableStyles.xml PK cK}\D >00ppt/viewProps.xml PK cK}\H7t!ppt/slideLayouts/slideLayout1.xml PK cK}\ђ77,ppt/slideLayouts/_rels/slideLayout1.xml.rels PK cK}\ MBBS SURGERY | CLINICAL SCENARIOIntestinal ObstructionA diagnostic challenge in acute surgeryCASE PRESENTATIONA 55-year-old male presents with: Abdominal pain — colicky in nature Vomiting and abdominal distension for two days No passage of stool or flatus reportedWhat is your provisional diagnosis?PK cK}\3 ppt/slides/_rels/slide1.xml.rels PK cK}\.ppt/notesSlides/notesSlide1.xml 1PK cK}\:A*ppt/notesSlides/_rels/notesSlide1.xml.rels PK cK}\qt<==ppt/slides/slide2.xml Learning ObjectivesIntestinal Obstruction | MBBS Surgery 1Understand types of intestinal obstruction clearly 2Recognise causes and pathophysiology mechanisms 3Identify clinical features and complications early 4Outline principles of management and surgeryPK cK}\2- ppt/slides/_rels/slide2.xml.rels PK cK}\ppt/notesSlides/notesSlide2.xml 2PK cK}\xշ*ppt/notesSlides/_rels/notesSlide2.xml.rels PK cK}\377ppt/slides/slide3.xml DefinitionIntestinal Obstruction | MBBS Surgery DEFINITIONIntestinal obstruction is the impaired passage of intestinal contents through the bowel AETIOLOGYMay be mechanical (dynamic) or functional (adynamic) in origin CONSEQUENCELeads to accumulation of gas and fluid proximal to the block OUTCOMEResults in bowel distension and significant systemic effectsPK cK}\W/ ppt/slides/_rels/slide3.xml.rels PK cK}\K |Őppt/notesSlides/notesSlide3.xml 3PK cK}\9 Y*ppt/notesSlides/_rels/notesSlide3.xml.rels PK cK}\}22ppt/slides/slide4.xml ClassificationIntestinal Obstruction | MBBS Surgery DYNAMIC (Mechanical)Active peristalsis is presentBowel contracts against the obstructionMay be acute or chronicMechanical block to the lumenExamples: adhesions, hernia, volvulus, intussusception ADYNAMIC (Functional)Effective peristalsis is absentNo mechanical block to lumenMotility is lost or ineffectiveIncludes paralytic ileusIncludes colonic pseudo-obstruction (Ogilvie's)PK cK}\` ppt/slides/_rels/slide4.xml.rels PK cK}\vsppt/notesSlides/notesSlide4.xml 4PK cK}\J *ppt/notesSlides/_rels/notesSlide4.xml.rels PK cK}\!C8??ppt/slides/slide5.xml Causes of Dynamic (Mechanical) ObstructionIntestinal Obstruction | MBBS Surgery INTRALUMINALFaecal impactionBezoars (food / hair)Gallstone ileusForeign bodies INTRAMURALStrictures (Crohn's / TB)Malignancy / carcinomaCongenital atresiaIntussusception EXTRAMURALAdhesions and bandsExternal herniasVolvulusCompression by tumourPK cK}\5 ppt/slides/_rels/slide5.xml.rels PK cK}\W8ppt/notesSlides/notesSlide5.xml 5PK cK}\Qe*ppt/notesSlides/_rels/notesSlide5.xml.rels PK cK}\877ppt/slides/slide6.xml Causes of Adynamic (Functional) ObstructionIntestinal Obstruction | MBBS Surgery Paralytic IleusMost common after abdominal surgery; also peritonitis and trauma Electrolyte ImbalanceHypokalaemia is commonest; also hyponatraemia and hypomagnesaemia Peritonitis / SepsisIntra-abdominal infection inhibits bowel motility reflexly Pseudo-obstructionMimics mechanical obstruction; Ogilvie's syndrome (colonic)PK cK}\ج+ ppt/slides/_rels/slide6.xml.rels PK cK}\zppt/notesSlides/notesSlide6.xml 6PK cK}\=|*ppt/notesSlides/_rels/notesSlide6.xml.rels PK cK}\%oJJppt/slides/slide7.xml PathophysiologyIntestinal Obstruction | MBBS Surgery 1ObstructionMechanical block prevents onward passage of gas and fluid 2Proximal DilatationProximal bowel dilates; distal bowel collapses after emptying 3Peristaltic ResponseInitial peristalsis increases to overcome obstruction (colicky pain) 4Bowel FatigueBowel wall fatigues, becomes flaccid; paralysis ensuesPK cK}\F ppt/slides/_rels/slide7.xml.rels PK cK}\)lppt/notesSlides/notesSlide7.xml 7PK cK}\|g*ppt/notesSlides/_rels/notesSlide7.xml.rels PK cK}\..ppt/slides/slide8.xml Gas and Fluid ChangesIntestinal Obstruction | MBBS Surgery GAS ACCUMULATIONSwallowed air (mainly nitrogen) — 70%Bacterial fermentation — hydrogen sulphideDiffusion from blood is smallGas cannot be absorbed beyond block FLUID SEQUESTRATIONGastric, biliary, pancreatic secretions poolUp to 6–8 L of fluid lost in 24 hoursLeads to dehydration and hypovolaemiaElectrolyte imbalance worsens conditionPK cK}\6 ppt/slides/_rels/slide8.xml.rels PK cK}\iސppt/notesSlides/notesSlide8.xml 8PK cK}\pO*ppt/notesSlides/_rels/notesSlide8.xml.rels PK cK}\k<<ppt/slides/slide9.xml Strangulation — Surgical EmergencyIntestinal Obstruction | MBBS SurgeryCRITICAL: Blood supply becomes compromised — Life-threatening condition Venous obstructionVenous drainage is obstructed first → oedema and engorgement of bowel wall Arterial compromiseArterial inflow is then obstructed → ischaemia of the bowel wall NecrosisFull-thickness necrosis of bowel wall leads to bacterial translocation Perforation & SepsisPerforation causes peritonitis and septic shock — requires immediate surgeryPK cK}\>$ ppt/slides/_rels/slide9.xml.rels PK cK}\qppt/notesSlides/notesSlide9.xml 9PK cK}\1*ppt/notesSlides/_rels/notesSlide9.xml.rels PK cK}\>|77ppt/slides/slide10.xml Causes of StrangulationIntestinal Obstruction | MBBS Surgery Hernial OrificesExternal herniae — inguinal, femoral, umbilical — compress bowel at neck Adhesions & BandsPost-operative adhesions create a fixed point for bowel to kink around VolvulusTwisting of bowel on its mesentery interrupts mesenteric blood supply Closed-loopObstruction at two points raises intraluminal pressure to critical levelPK cK}\Ѳ!ppt/slides/_rels/slide10.xml.rels PK cK}\O ppt/notesSlides/notesSlide10.xml 10PK cK}\T+ppt/notesSlides/_rels/notesSlide10.xml.rels PK cK}\+&SBSBppt/slides/slide11.xml Closed-loop ObstructionIntestinal Obstruction | MBBS Surgery DefinitionBowel is obstructed at two separate points, creating an isolated segment that cannot decompress proximally or distally 1Distension confined to isolated bowel segment 2Rapid, dramatic rise in intraluminal pressure 3Very high risk of ischaemia and early perforation 4Sigmoid volvulus is the classic examplePK cK}\;!ppt/slides/_rels/slide11.xml.rels PK cK}\s6ӑ ppt/notesSlides/notesSlide11.xml 11PK cK}\O+ppt/notesSlides/_rels/notesSlide11.xml.rels PK cK}\ h_88ppt/slides/slide12.xml AdhesionsIntestinal Obstruction | MBBS Surgery Post-operative adhesions are the COMMONEST cause of small bowel obstruction worldwide MechanismPeritoneal damage triggers fibrin deposition → organised fibrous bands TypeFlimsy vascular bands or dense avascular fibrous adhesions LocationPredominantly involve the lower small bowel (ileum) TimeMay form within weeks; can cause obstruction decades after surgeryPK cK}\c!ppt/slides/_rels/slide12.xml.rels PK cK}\*)@ ppt/notesSlides/notesSlide12.xml 12PK cK}\Fb+ppt/notesSlides/_rels/notesSlide12.xml.rels PK cK}\9_J_Jppt/slides/slide13.xml Prevention of Adhesions — Operative PrinciplesIntestinal Obstruction | MBBS Surgery 1Handle tissues with extreme gentleness — meticulous surgical technique 2Minimise contact with gauze swabs and foreign materials 3Irrigate peritoneal cavity copiously with warm saline 4Cover raw peritoneal surfaces; close peritoneum where possible 5Use laparoscopy where feasible — significantly reduces adhesion formationPK cK}\x!ppt/slides/_rels/slide13.xml.rels PK cK}\Ї ppt/notesSlides/notesSlide13.xml 13PK cK}\yv+ppt/notesSlides/_rels/notesSlide13.xml.rels PK cK}\@99ppt/slides/slide14.xml IntussusceptionIntestinal Obstruction | MBBS Surgery DefinitionTelescoping of a proximal segment of bowel (intussusceptum) into the adjacent distal segment (intussuscipiens) ChildrenMost common in infants 3 months – 2 yearsIleocaecal region most common siteUsually idiopathic — hypertrophied Peyer's patchesPresents with episodic crying, redcurrant jelly stool AdultsLess common; always has a lead pointLead point: polyp, tumour, Meckel's diverticulumPresents as subacute / chronic obstructionRequires surgical resectionPK cK}\O!ppt/slides/_rels/slide14.xml.rels PK cK}\0 ppt/notesSlides/notesSlide14.xml 14PK cK}\?ݤ+ppt/notesSlides/_rels/notesSlide14.xml.rels PK cK}\w@k6k6ppt/slides/slide15.xml VolvulusIntestinal Obstruction | MBBS Surgery Twisting of a loop of bowel around the axis of its mesentery — causes obstruction AND vascular compromise Sigmoid VolvulusCommonest type (75%) worldwideElderly, constipated, institutionalised patientsCoffee-bean sign on AXRInitial treatment: sigmoidoscopic decompression Caecal VolvulusLess common (25%)Younger patientsAssociated with incomplete peritoneal fixationRequires surgical fixation (caecopexy) or resectionPK cK}\*R!ppt/slides/_rels/slide15.xml.rels PK cK}\Qz ppt/notesSlides/notesSlide15.xml 15PK cK}\$Q+ppt/notesSlides/_rels/notesSlide15.xml.rels PK cK}\ԛDDppt/slides/slide16.xml Cardinal Features of Intestinal ObstructionIntestinal Obstruction | MBBS Surgery PAINColicky abdominal painPeristaltic waves against obstruction; becomes constant with distension VOMITINGLevel-dependent onsetEarly and severe (proximal); late and feculent (distal) DISTENSIONVisible abdominal swellingMore marked with distal obstruction; visible peristalsis may be seen CONSTIPATIONAbsolute (complete block)No passage of stool or flatus — a cardinal diagnostic featurePK cK}\ !ppt/slides/_rels/slide16.xml.rels PK cK}\  ppt/notesSlides/notesSlide16.xml 16PK cK}\ y+ppt/notesSlides/_rels/notesSlide16.xml.rels PK cK}\3^ppt/slides/slide17.xml Small Bowel vs Large Bowel ObstructionIntestinal Obstruction | MBBS Surgery Feature Small Bowel Obstruction Large Bowel Obstruction Pain Severe, central, colicky Milder, peripheral, colicky Vomiting Early, frequent, bilious / feculent Late; may be absent initially Distension Mild to moderate, central Marked, peripheral (flanks) Constipation Present; may pass initial stool Absolute — early feature X-ray pattern Valvulae conniventes; central loops Haustra; peripheral loops Common cause Adhesions, hernia Colorectal carcinoma, volvulus PK cK}\檋!ppt/slides/_rels/slide17.xml.rels PK cK}\r. ppt/notesSlides/notesSlide17.xml 17PK cK}\BI+ppt/notesSlides/_rels/notesSlide17.xml.rels PK cK}\/KKppt/slides/slide18.xml Pain CharacteristicsIntestinal Obstruction | MBBS Surgery 1Early — ColickyPeristaltic contractions against the obstruction produce intermittent cramping pain at 3–5 minute intervals 2IntermediateBowel distension stretches the visceral peritoneum — pain becomes more constant and diffuse 3Late — ConstantBowel fatigue; pain becomes continuous; colicky character lost 4StrangulationSevere, continuous, localised pain with guarding — ischaemia and peritoneal involvement; surgical emergencyPK cK}\Yh!ppt/slides/_rels/slide18.xml.rels PK cK}\ ppt/notesSlides/notesSlide18.xml 18PK cK}\N+ppt/notesSlides/_rels/notesSlide18.xml.rels PK cK}\C!22ppt/slides/slide19.xml Vomiting in Intestinal ObstructionIntestinal Obstruction | MBBS Surgery PROXIMAL OBSTRUCTIONVomiting is EARLY and FREQUENTLarge volume bilious vomitRapid dehydration and electrolyte lossPain and distension may be mildGastric outlet / duodenum: projectile, non-bilious DISTAL OBSTRUCTIONVomiting is LATE or ABSENTSmall volume initially, then feculentDistension is the dominant featureFaeculent vomit indicates stagnant stool in proximal bowelClassic in left colonic obstructionPK cK}\~!ppt/slides/_rels/slide19.xml.rels PK cK}\0[ ppt/notesSlides/notesSlide19.xml 19PK cK}\i+ppt/notesSlides/_rels/notesSlide19.xml.rels PK cK}\& :3:3ppt/slides/slide20.xml Distension and ConstipationIntestinal Obstruction | MBBS Surgery DISTENSIONDepends on SITE and DURATION of obstructionDistal obstruction: marked generalised distensionProximal obstruction: mild distensionVisible peristalsis — ladder pattern in thin patientsFree gas under diaphragm suggests perforation CONSTIPATIONAbsolute constipation = no stool or flatusKey diagnostic feature of complete obstructionPartial obstruction may still pass flatusRectal examination essential — empty rectum suggests true obstructionLoaded rectum suggests constipation, not obstructionPK cK}\g_!ppt/slides/_rels/slide20.xml.rels PK cK}\7 ppt/notesSlides/notesSlide20.xml 20PK cK}\SB+ppt/notesSlides/_rels/notesSlide20.xml.rels PK cK}\/A/Appt/slides/slide21.xml Dehydration — Assessment and EffectsIntestinal Obstruction | MBBS Surgery Fluid loss occurs via vomiting, nasogastric output AND third-space sequestration within the obstructed bowel SymptomsThirst, weakness, reduced urine output, oliguria SignsDry tongue, sunken eyes, reduced skin turgor, tachycardia Blood testsRaised urea and creatinine; raised haematocrit; electrolyte disturbance ElectrolytesLow Na+, K+, Cl−; metabolic alkalosis (vomiting) or acidosis (ischaemia) SeverityHypovolaemic shock with hypotension indicates severe depletionPK cK}\z!ppt/slides/_rels/slide21.xml.rels PK cK}\89| ppt/notesSlides/notesSlide21.xml 21PK cK}\HΩ+ppt/notesSlides/_rels/notesSlide21.xml.rels PK cK}\#Ib>>ppt/slides/slide22.xml Clinical Signs of StrangulationIntestinal Obstruction | MBBS SurgerySTRANGULATION MUST BE DETECTED EARLY — OPERATE WITHOUT DELAY Pain character changeColicky pain becomes constant and severe — hallmark of ischaemia Localised tendernessTenderness localised to one area; voluntary and involuntary guarding PyrexiaFever indicates bowel ischaemia and bacterial translocation / peritonitis TachycardiaEarly sign of shock; raised CRP and WCC support diagnosis ShockHypotension and cold peripheries — advanced ischaemia; requires resuscitation and urgent surgeryPK cK}\dV!ppt/slides/_rels/slide22.xml.rels PK cK}\cQc ppt/notesSlides/notesSlide22.xml 22PK cK}\aeZ+ppt/notesSlides/_rels/notesSlide22.xml.rels PK cK}\ )022ppt/slides/slide23.xml Examination FindingsIntestinal Obstruction | MBBS Surgery INSPECTION & PALPATIONAbdominal distension (peripheral or central)Visible peristalsis in thin patientsLocalised tenderness = strangulationGuarding and rigidity = peritonitisCheck ALL hernial orifices routinely PERCUSSION & AUSCULTATIONTympanitic (resonant) due to gasHigh-pitched tinkling bowel sounds — earlyRushes coinciding with colic — earlyAbsent bowel sounds — late (ileus)Rectal examination always essentialPK cK}\A!ppt/slides/_rels/slide23.xml.rels PK cK}\] ppt/notesSlides/notesSlide23.xml 23PK cK}\ ~t+ppt/notesSlides/_rels/notesSlide23.xml.rels PK cK}\XtW@@ppt/slides/slide24.xml Imaging — Plain Abdominal X-ray (AXR)Intestinal Obstruction | MBBS Surgery Small Bowel PatternCentral location of loopsValvulae conniventes cross entire width — "stack of coins"Dilated loops > 3 cm diameterMultiple fluid levels Large Bowel PatternPeripheral position of loopsHaustral markings — do NOT cross full widthDilated loops > 6 cm (caecum > 9 cm)Paucity of gas distal to obstruction General / Other SignsMultiple air-fluid levels (erect AXR)Coffee-bean sign — sigmoid volvulusFree gas under diaphragm = perforationPneumatosis — bowel wall ischaemiaPK cK}\Y!ppt/slides/_rels/slide24.xml.rels PK cK}\`z ppt/notesSlides/notesSlide24.xml 24PK cK}\8+ppt/notesSlides/_rels/notesSlide24.xml.rels PK cK}\v>>ppt/slides/slide25.xml CT Scan — The Investigation of ChoiceIntestinal Obstruction | MBBS Surgery CT abdomen and pelvis with contrast is the MOST ACCURATE imaging modality for intestinal obstruction Level of obstructionPrecisely identifies the transition point between dilated and collapsed bowel AetiologyIdentifies cause — adhesive band, hernia, volvulus, neoplasm ComplicationsDetects ischaemia (poor enhancement), pneumatosis, free fluid, and perforation Surgical planningGuides decision for surgery, approach, and extent of resectionPK cK}\̜|g!ppt/slides/_rels/slide25.xml.rels PK cK}\Y ppt/notesSlides/notesSlide25.xml 25PK cK}\#+ppt/notesSlides/_rels/notesSlide25.xml.rels PK cK}\[[ppt/slides/slide26.xml Initial Management — The Drip and Suck RegimeIntestinal Obstruction | MBBS Surgery 1IV Access & BloodsInsert large-bore IV cannula; FBC, U&E, LFT, coagulation, group & save; blood cultures if pyrexial 2Fluid ResuscitationHartmann's or 0.9% saline bolus; correct dehydration; target urine output > 0.5 mL/kg/hr 3Nasogastric DecompressionWide-bore NG tube; free drainage + 2-hourly aspiration; relieves vomiting and reduces distension 4Electrolyte CorrectionMonitor and correct K+, Na+; replace losses; daily U&E monitoring 5Catheterise & MonitorUrinary catheter for strict fluid balance; hourly urine output; continuous monitoring of vitalsPK cK}\5b?!ppt/slides/_rels/slide26.xml.rels PK cK}\Aʑ ppt/notesSlides/notesSlide26.xml 26PK cK}\${+ppt/notesSlides/_rels/notesSlide26.xml.rels PK cK}\v<v<ppt/slides/slide27.xml Indications for SurgeryIntestinal Obstruction | MBBS SurgeryAny suspicion of strangulation = IMMEDIATE operation — do not delay for further investigationsURGENT / EMERGENCY INDICATIONS StrangulationAbsolute indication; bowel ischaemia cannot be treated conservatively Closed-loopRapidly rising intraluminal pressure; very high perforation risk Obstructed herniaAny hernia with obstruction must be treated operatively urgently Large bowel obstructionMost large bowel obstruction requires surgery (exception: volvulus deflation, stenting)NON-URGENT INDICATIONSPK cK}\PG!ppt/slides/_rels/slide27.xml.rels PK cK}\W  ppt/notesSlides/notesSlide27.xml 27PK cK}\e+ppt/notesSlides/_rels/notesSlide27.xml.rels PK cK}\ KKppt/slides/slide28.xml Surgical PrinciplesIntestinal Obstruction | MBBS Surgery 1Relieve the ObstructionIdentify and divide the causative adhesion, reduce the hernia, or untwist the volvulus 2Assess Bowel ViabilityInspect colour, peristalsis, and arterial pulsation; warm packs for 5–10 min to assess recovery 3Resect Non-viable BowelFrankly necrotic bowel must be resected; primary anastomosis or stoma depending on contamination 4Prevent RecurrenceDivide only the causative adhesion; avoid iatrogenic damage; consider laparoscopy for adhesiolysisPK cK}\ [R]!ppt/slides/_rels/slide28.xml.rels PK cK}\\ ppt/notesSlides/notesSlide28.xml 28PK cK}\i+ppt/notesSlides/_rels/notesSlide28.xml.rels PK cK}\ _r{I{Ippt/slides/slide29.xml Management of Adhesive Small Bowel ObstructionIntestinal Obstruction | MBBS Surgery Admit + Drip and Suck IV fluids + Electrolytes Review at 24–72 hours RESOLVINGContinue conservativeResume oral intake graduallyDischarge; follow up NOT RESOLVINGUrgent laparoscopy or laparotomyDivide causative adhesion onlyAvoid extensive adhesiolysisDeterioration at ANY time = Immediate surgerySigns of resolution: decreasing NG output, return of flatusPK cK}\->w!ppt/slides/_rels/slide29.xml.rels PK cK}\zx ppt/notesSlides/notesSlide29.xml 29PK cK}\(Lk+ppt/notesSlides/_rels/notesSlide29.xml.rels PK cK}\M4@@ppt/slides/slide30.xml SUMMARYKey TakeawaysCausesAdhesions = commonest cause worldwide; adhesions, hernias, malignancy are the big threeFeaturesPain, Vomiting, Distension, Absolute Constipation — the four cardinal featuresEmergencyStrangulation = surgical emergency; continuous pain + guarding = operate immediatelyImagingCT abdomen is investigation of choice; AXR for initial assessmentManagementDrip and suck for 24–72 hours; operate for strangulation, failure, or closed-loop obstructionQuestions & DiscussionPK cK}\*!ppt/slides/_rels/slide30.xml.rels PK cK}\ q) ppt/notesSlides/notesSlide30.xml 30PK cK}\+ppt/notesSlides/_rels/notesSlide30.xml.rels PK cK}\K !ppt/slideMasters/slideMaster1.xml PK cK}\N),ppt/slideMasters/_rels/slideMaster1.xml.rels PK cK}\6TT!ppt/notesMasters/notesMaster1.xml 7/23/19Click to edit Master text stylesSecond levelThird levelFourth levelFifth level‹#›PK cK}\s **,ppt/notesMasters/_rels/notesMaster1.xml.rels PK cK}\_rels/PK cK}\ $docProps/PK cK}\Kppt/PK cK}\ mppt/_rels/PK cK}\ ppt/charts/PK cK}\ppt/charts/_rels/PK cK}\ppt/embeddings/PK cK}\ ppt/media/PK cK}\Bppt/slideLayouts/PK cK}\qppt/slideLayouts/_rels/PK cK}\ppt/slideMasters/PK cK}\ppt/slideMasters/_rels/PK cK}\  ppt/slides/PK cK}\3ppt/slides/_rels/PK cK}\ bppt/theme/PK cK}\ppt/notesMasters/PK 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