Bands of scar tissue that join two parts of tissue together that would otherwise not be physiologically joined together constitute adhesions. These abnormal connections have a plastic wrap appearance. They appear like thin sheets or thicker fibrous bands.
Adhesions develop when the repair mechanisms of the body are triggered by events such as trauma, infection, radiation, or surgery. They may occur anywhere in the body. However, they are most commonly found in the heart, pelvis, and gastrointestinal tract.
Typically, cells responsible for repairing organ damage do not distinguish between one organ and another or between different parts of the same organ. Hence, any contact between the part of the organ damaged with another organ or another part of itself may result in the formation of scar tissue at the interface. This is an inevitable part of the healing processes within the body.
Adhesions are intrinsically painless; the pain that occurs in association with adhesions is a secondary complication due to the problems that the adhesions may create. For example, pain may result from an adhesion tugging on a nerve or causing obstruction within the intestines, which can lead to pain in the pelvis and the restriction of the movement of food, fluid, and stool through the bowels.
In addition to pain and obstruction, adhesions may also cause complications such as female infertility.
Complications
Abdominal surgery is one of the most frequent causes of adhesions. Almost everyone who undergoes an abdominal surgery may develop adhesions. These connective bands of scar tissue tend to become larger and tighter as time passes and consequently may cause problems several years after a surgery was performed.
Tissue incisions, contact of internal tissues with non-biological agents like gauze and the dehydration of internal organs during surgery are just some of the reasons why adhesions may develop after an abdominal surgery.
Intestinal obstruction leads to the build up of food, fluid, and gas in the intestines, which can cause rupture of the intestines once the pressure has built up enough to do so. The leakage of harmful intestinal contents into the abdominal cavity, if left untreated, can be fatal.
Female infertility occurs when abdominal adhesions inside or in the vicinity of the fallopian tubes block eggs from reaching the uterus. These women are at an increased risk for an ectopic pregnancy, which is a pregnancy where the fetus attempts to grow outside of the womb.
This is a potentially life-threatening condition for the pregnant woman if hemorrhage arises.
Abdominal adhesions may also occur in up to 10% of people who never may have had any surgical operations done. The formation of adhesions after surgery typically begins within a few days after the procedure, but their symptoms may not occur for several months or, as alluded to earlier, many years later. Adhesions, ironically, are treated surgically where applicable, but they commonly recur, because surgery causes them in the first place.
An intrinsic property of adhesions is that they are painless and the pain that occurs in connection with adhesions tends to be due to secondary complications. Adhesions, which are bands of scar tissue connecting two parts of tissue that would otherwise not be connected together, develop in response to injury.
This injury may be due to infection, trauma, surgery, or radiation. Adhesions are most frequently found in the pelvis, gastrointestinal tract. and the heart. However, they may occur anywhere else in the body that underwent damage of some sort and requires repair.
Clinical Presentation
Under normal circumstances, the passage of food, fluid, stool, and gases through the intestines happens freely. In the presence of adhesions, this free passage is disturbed due to the tethering of intestinal loops to each other, other abnormal organs and/ or the abdominal wall.
This obstruction results in symptoms such as abdominal distention and colicky pain that is often worsened with food intake. Furthermore, there is a reduction in stool and/ or flatulence and constitutional symptoms such as nausea and vomiting may occur.
Typical adhesions may show no clinical signs and as a result tend to go unnoticed and undiagnosed. Hepatic adhesions typically cause pain when the patient inhales and exhales deeply, while lesions of the intestinal loops tend to cause more pain with exercise or stretching.
Symptoms that require seeking immediate medical attention include the inability to pass intestinal gas or have a bowel movement, progressive distention of the abdomen accompanied by loud bowel sounds, and severe cramping or abdominal pain.
Pathophysiology
In the natural process of healing, fibrin is deposited onto the tissue that is damaged and it behaves like a glue to seal off the injury. Additionally, the fibrin builds a naïve adhesion onto which the mature one builds to connect adjacent tissues to each other.
Fibrin deposition may be physiologically controlled by enzymes that limit its rate of production and/or dissolve it. However, in the case of scar tissue, this process is incomplete and an adhesion is the end result when repair cells such as fibroblasts and macrophages produce substances like collagen to create a permanent structure. This structure may grow over time and become tighter.
The most frequent cause of abdominal adhesions is surgery. The events during surgery that lead to adhesion formation include incisional procedures, dehydration of abdominal tissues and organs, foreign body contact like gloves with internal tissues, and stale blood not removed during / after the surgery. Certain organs and structures within the abdomen, like the omentum, are more susceptible to developing adhesions.
Nearly all post-operative adhesions, as indicated in one study, are found in the omentum. Furthermore, spontaneous adhesions, although rare (less than 10% of all adhesions), tend to also occur mostly in the omentum.
Non-surgical causes of abdominal adhesions arise from complications such as a ruptured appendix, radiation therapy, and abdominal as well as gynecological infections.
Diagnosis and Treatment of Abdominal Adhesions
While diagnosing abdominal adhesions, it is important to take a thorough clinical history in order to substantiate suspicions. This is crucial because a confident diagnosis will not be obtained by any other means, except intraoperatively.
Adhesions may occur anywhere in the body, but are most commonly found in the gastrointestinal tract, heart, and pelvis. Tissue injury due to surgery, trauma, infection, or radiation triggers cells in the body such as macrophages and fibroblasts to begin the process of healing.
This process results in the formation of bands of scar tissue or adhesions, which create an interface between tissues that are not usually joined together. While these adhesions themselves are painless, they generate adhesion-related complications that can cause pain and obstruction, which, in some instances, can be potentially life threatening.
The diagnosis of abdominal adhesions is typically done with the assistance of laparoscopy. This procedure involves using a camera to visualize the organs within the abdominal cavity. Routine tests such as X-rays, CT scans, and blood work are useless in diagnosing the adhesion itself. However, they are great choices in identifying adhesion-related complications like bowel obstruction, which restricts the movement of food, fluid, stool, and intestinal gases.
Management
Treating an abdominal adhesion depends widely on the adhesion-related problems, the location of the adhesion and the extent to which it is formed. There are two primary surgical techniques used to treat abdominal adhesions: laparotomy and laparoscopy. In laparoscopy, a small incision is made and with the help of the camera adhesions are cut and released.
This technique is known as adhesiolysis and is done under general anesthesia. It is indicated in patients who present with obstruction of the small bowel and no signs of inflammation of the peritoneum, hemodynamic instability, or bowel ischemia or perforation.
In laparotomy, a larger incision is made to directly see the adhesions and treat them. This technique is also known as open adhesiolysis and is associated with potential complications such as acute renal failure, sepsis, myocardial infarctions, respiratory failure, and wound infections. Moreover, the paradoxical relationship between treating adhesions surgically and surgery as the most common cause of adhesions makes the treatment of adhesions particularly difficult to manage.
Prevention
Preventing abdominal adhesions is not an easy feat. However, surgical techniques can effectively minimize the occurrence of abdominal adhesions. Laparoscopic surgery is great, because the incisions are smaller than that of laparotomy.
If, for whatever reasons, laparoscopic surgery cannot be done, and open adhesiolysis is required, a wax-like film is placed between the organs and the incisional area to help prevent the formation of new adhesions. The film is absorbed by the body within a week and it hydrates the organs in the process. This prevents dehydration, a strongly suspected cause of adhesion formation.
There have not been any studies published to support nutrition or diet as protective or causative factors in the development of abdominal adhesions. However, other steps that may be taken during surgery to reduce incidence are minimizing surgery time and intermittently moistening incisional area with saline, swabs, and drapes. Furthermore, latex- and starch-free gloves as well as the gentle handling of organs and tissues have shown promising results in terms of reducing the chances of developing post-operative abdominal adhesions.
Reviewed by Susha Cheriyedath, MSc
MEDtable 