Abdominal Adhesions – Causes, Symptoms, Treatment

Abdominal adhesions are fibrous bands of fibrous tissue connections (adherence tissues) between various tissue planes or organs that span two or more intra-abdominal organs and/or the inner abdominal wall (i.e. peritoneal membrane) which typically form usually caused by inflammation, most commonly surgery, or after abdominal surgery. Adhesions may also form secondary to inflammatory conditions of the abdomen in the absence of prior abdominal surgery or as a sequela of abdominopelvic radiation. These adhesions are part of the internal healing process and inflammatory reactions. They participate in the body’s defense mechanisms against the causes of inflammation (physical, chemical, infections, etc.).

Abdominal adhesions are bands of scar-like tissue that form inside your abdomen. The bands form between two or more organs or between organs and the abdominal wall.

Normally, the surfaces of organs and your abdominal wall do not stick together when you move. However, abdominal adhesions may cause these surfaces to become adherent, or stick together.

Types of Abdominal Adhesions

There are three general types of adhesions: filmy, vascular, and cohesive,[rx] however, their pathophysiology is similar.[rx]Filmy adhesions usually do not pose problems. Vascular adhesions are problematic.

Abdominal adhesions can kink, twist, pull, or compress the intestines and other organs in the abdomen, causing symptoms and complications, such as intestinal obstruction or blockage.

Causes of Abdominal Adhesions

Abdominal surgery is the most common cause of abdominal adhesions. Adhesions caused by surgery are more likely to cause symptoms and complications than adhesions related to other causes. Symptoms and complications may start any time after surgery, even many years later.[rx]

Conditions that involve inflammation or infection in the abdomen may also cause adhesions. These conditions include Crohn’s disease, diverticular disease, endometriosis, pelvic inflammatory disease, and peritonitis.

Other causes of abdominal adhesions include long-term peritoneal dialysis to treat kidney failure and radiation therapy to treat cancer.

  • Handling of abdominal organs at the time of surgery,
  • Foreign objects left inside the abdomen at the time of surgery (for example, a piece of gauze),
  • Bleeding into the peritoneal cavity, and
  • Gynecological conditions (for example, pelvic inflammatory disease).
  • The complexity of the operation
  • The extent of peritoneal trauma
  • Previous illness (e.g., diabetes) ()
  • Poor nutritional status ()
  • Intra-abdominal placement of foreign bodies (e.g. meshes) ()
  • Excessive coagulation with tissue necrosis ()
  • Accompanying bacterial infection ()
  • Laparoscopy – Dehydration owing to high insufflation pressure and compression of capillary flow (, )
  • Laparoscopy – Dehydration owing to dry gas ()
  • Laparoscopy – Mesothelial hypoxia owing to use of CO2 ()
  • Laparotomy – Dehydration owing to light and heat ()
  • Laparotomy – Exposure to foreign material (e.g., glove powder) (, )
  • Laparotomy – Mesothelial dehydration and abrasion from use of dry abdominal drapes (, )

Symptoms of Abdominal Adhesions

In many cases, abdominal adhesions do not cause symptoms. If they do cause symptoms, chronic abdominal pain is the most common symptom.

Abdominal adhesions may cause intestinal obstruction, which can be life-threatening. If you have symptoms of intestinal obstruction, seek medical help right away.

Symptoms of intestinal obstruction may include

  • Swelling of the abdomen (abdominal distension)
  • Inability to pass gas and absent or infrequent bowel movements
  • Signs of dehydration, including dry skin, dry mouth and tongue, severe thirst, infrequent urination, fast heart rate, and low blood pressure
  • abdominal pain
  • abdominal discomfort located around the belly button (umbilicus) that is cramp-like, followed by distention of the abdomen.
  • Symptoms often are worsened by eating.
  • There may be a reduction in the amount of flatus (gas) or stool that is passed and, with prolonged obstruction, nausea and vomiting may occur.
  • When the obstruction is incomplete or intermittent, symptoms may be less severe with abdominal pain or cramping occurring only after meals.
  • Although uncommon, obstruction also may manifest primarily as nausea with or without vomiting, especially when the obstruction occurs in the proximal small intestine near the stomach.
  • bloating
  • constipation
  • not passing gas
  • nausea – vomiting

If intestinal obstruction cuts off the blood flow to the blocked part of the intestines or leads to peritonitis, you may develop additional symptoms such as a fast heart rate or fever.

In general, any of the following may be seen in association with/due to intra-abdominal adhesions:

  • Chronic (persistent or intermittent) bloating.
  • Abdominal cramping and borborygmi.
  • Altered bowel habits, including constipation or frequent loose stools (e.g. from the development of small intestinal bacterial overgrowth).
  • Nausea with or without early satiety.
  • Bowel obstruction, which may be transient, partial, or complete (and may cause the aforementioned symptoms).
  • Female infertility and dyspareunia.
  • Rectal bleeding and dyschezia (i.e. painful defecation) during menses, which typically indicate colorectal involvement of endometriosis .

Diagnosis of Abdominal Adhesions

Doctors use medical history, physical exams, blood tests, imaging tests, and, in some cases, surgery to diagnose abdominal adhesions.

No tests are available to detect adhesions. Doctors usually find them during surgery to diagnose other problems.

Some adhesions go away by themselves. If they partly block your intestines, a diet low in fiber can allow food to move easily through the affected area. If you have a complete intestinal obstruction, it is life-threatening. You should get immediate medical attention and may need surgery.

Medical history

A doctor will ask about your symptoms and your medical history, including your history of abdominal surgery or other conditions that may cause abdominal adhesions. A doctor will also ask about your history of other diseases and disorders that may cause symptoms similar to those of abdominal adhesions.

Physical exam

During a physical exam, the doctor may tap on your abdomen to check for tenderness or pain and use a stethoscope to listen to sounds in your abdomen.

Blood tests

A health care professional will take blood samples and send the samples to a lab. Although blood tests can’t be used to diagnose abdominal adhesions, doctors may order blood tests to rule out other health problems that could be causing your symptoms. If you have signs of an intestinal obstruction, blood tests can help doctors find out how severe the obstruction is.

Imaging tests

Imaging tests most often cannot show abdominal adhesions. However, doctors can use imaging tests to diagnose intestinal obstruction caused by abdominal adhesions. Doctors may also use imaging tests to rule out other problems that may be causing your symptoms.

Imaging tests may include

  • x-rays  – which use a small amount of radiation to create pictures of the inside of the body. X-rays with water-soluble contrast medium, a special liquid that makes the digestive tract more visible on x-rays. If adhesions are causing intestinal obstruction, this imaging test can help doctors find out if you need surgery. The water-soluble contrast medium may also help relieve the obstruction. lower GI series, which uses x-rays to view your large intestine.
  • computerized tomography (CT) – which uses a combination of x-rays and computer technology to create images. A CT scan may help doctors diagnose intestinal obstruction and find the location, cause, and severity of the obstruction.

Doctors can use imaging tests to diagnose intestinal obstruction caused by abdominal adhesions or rule out other problems.

Treatment of Abdominal Adhesions

Non-surgical treatments for adhesions

Alternatives to surgery include:

  • exercise
  • physical therapy
  • lifestyle changes
  • soft tissue mobilisation (Wasserman et al 2019)

Medications

  • Medication is often the first treatment choice for acute pain and forms part of the treatment for chronic pain
  • If you don’t need emergency surgery, doctors may try to treat the obstruction without surgery. Health care professionals will give you intravenous (IV) fluids and insert a tube through your nose and into your stomach to remove the contents of your digestive tract above the obstruction. In some cases, the obstruction may go away. If the obstruction does not go away, surgeons will perform surgery to release the adhesions, relieving the intestinal obstruction.
  • Patients undergo either laparoscopic or open surgery and the adhesions are cut by scalpel or electrical current (lysis). The problem is that adhesions have a tendency to reform, and some individuals have a propensity to form adhesions.
  • Laparoscopic surgery results in fewer adhesions and, theoretically, is a better option; however, whether the adhesions are lysed at laparoscopic or open surgery, the inflammation caused by the process of cutting can result in recurrent adhesions.
  • Seprafilm procedure – Adhesions due to open surgery can be prevented by the use of a product called Seprafilm. Seprafilm is a waxed paper-like film that is placed inside of the abdomen over the intestines. The film covers the intestine and keeps them from sticking to the incision. The incision heals normally with scarring, but the film prevents the scar tissue from spreading to the adjacent tissues to form adhesions. After several days, the film dissolves spontaneously.
  • Seprafilm should be carefully placed because it can slow down the healing (scarring) process. For example, if the film is wrapped around an incision in a hollow organ such as the intestine, the incision may not heal, and a leak from the organ may occur.

Surgery

In some cases, doctors may recommend surgery to look inside the abdomen and check for adhesions or other problems that may be causing symptoms. Surgeons may check for abdominal adhesions with laparoscopic or open surgery.

  • Open adhesiolysis – As adhesions are likely to form after certain surgical procedures, open adhesiolysis may not be worthwhile, except to remedy serious problems such as bowel obstruction. In around 70 per cent of cases, the operation to remove the original adhesions will cause more adhesions to develop. Discuss the risks, benefits and alternatives to surgery thoroughly with your doctor before you make a decision.

In some cases, surgeons may be able to treat the problem during the procedure.

Can abdominal adhesions be prevented?

When performing abdominal surgery, surgeons take steps to lower the chance that patients will develop abdominal adhesions and related complications after surgery. For example, surgeons may

  • recommend laparoscopic surgery, if possible, instead of open surgery.
  • handle tissues gently to prevent damage.
  • take steps to keep foreign materials out of the abdomen, such as using powder-free gloves and lint-free tools.
  • cover damaged tissues inside the abdomen with a special film-like barrier at the end of surgery. The barrier keeps tissues separated while they heal, and then the barrier is absorbed by the body.

What are the complications of abdominal adhesions?

Abdominal adhesions can cause intestinal obstruction and female infertility.

Intestinal obstruction

Intestinal obstruction is the partial or complete blockage of the movement of food, fluids, air, or stool through the intestines. Abdominal adhesions are the most common cause of obstruction of the small intestine.  Intestinal obstruction may lead to

  • lack of blood flow to the blocked part of the intestine and death of the blood-starved intestinal tissues
  • peritonitis, an infection of the lining of the abdominal cavity

Intestinal obstruction can be life-threatening. People with symptoms of a complete blockage—which include abdominal pain and passing no fluids, stool, or gas—should seek medical attention right away.

Female infertility

In women, abdominal adhesions in the pelvis or inside the uterus can compress or block parts of the reproductive system and cause infertility.

Practical tips: general strategies for reduction of adhesions

  • Preference for tissue-sparing and micro-invasive surgical techniques
  • Minimization of operating time and of heat and light
  • Avoidance of peritoneal trauma by superfluous contact and coagulation
  • Limited placement of intra-abdominal foreign bodies such as patches, meshes, and suture material
  • Use of moistened abdominal drapes and swabs and occasional application of the saline solution to minimize dehydration of mesothelial surfaces
  • Irrigation of the abdominal cavity to remove residual intra-abdominal blood depots
  • Reduction of infection risk by ensuring sterile working conditions and giving antibiotics as required
  • Laparotomy: preferential use of latex- and powder-free gloves
  • Laparoscopy: use of humidified gases at an appropriately low insufflation pressure
  • High-risk patients: use of barrier techniques or peritoneal instillations after appropriate explanation

References