What are the symptoms and management of abdominal adhesions?

Symptoms and Management of Abdominal Adhesions

Abdominal adhesions are fibrous tissue bands that connect surfaces or organs within the peritoneal cavity that are normally separated, causing significant morbidity through symptoms like small bowel obstruction, chronic pain, and potential complications requiring surgical intervention. 1

Symptoms of Abdominal Adhesions

Common Presenting Symptoms

• Abdominal pain - can be chronic, intermittent, or episodic 2
• Abdominal distension - common presentation during obstruction 1
• Vomiting - typically bilious in nature during obstructive episodes 1, 3
• Constipation - may be absolute during complete obstruction 1, 3
• Abnormal bowel movement patterns - ranging from constipation to diarrhea 2
• Nausea - frequently accompanies other gastrointestinal symptoms 2

Important Considerations

• Symptoms may not always be present in their entirety, especially in elderly patients 1
• Symptoms can range from daily persistent issues to intermittent episodes of obstruction 2
• Chronic pelvic pain and infertility are significant complications, particularly in women 1, 4
• Symptoms can be life-altering when not properly recognized and addressed 2

Etiology and Epidemiology

Causes of Adhesions

• Most commonly result from previous abdominal surgery 1
• Other causes include:
  • Radiotherapy 1
  • Endometriosis 1
  • Abdominal or pelvic inflammation 1
  • Local response to tumors 1
  • Congenital adhesions (remnants of physiological organogenesis) 1

Epidemiology

• Adhesions develop after nearly every abdominal surgery 5
• Adhesive small bowel obstruction accounts for 5-16% of all small bowel obstructions in patients with no prior abdominal surgery (virgin abdomen) 1
• Approximately 5% of adhesions lead to readmission due to adhesion-related disorders 6
• Adhesions account for an estimated $1.18 billion in healthcare costs annually 5

Diagnosis

Clinical Assessment

• Thorough evaluation of symptoms including pattern, duration, and severity 2
• Identification of risk factors (prior surgery, radiation, inflammatory conditions) 1

Imaging Studies

• CT scan - helps differentiate between complete and incomplete obstruction 1
• Water-soluble contrast agents (WSCA) - useful for diagnosis and potential therapeutic effect 1
• Both CT and WSCA can help identify the cause of small bowel obstruction 1

Management Approaches

Non-operative Management

• Indicated for partial (incomplete) obstructions 1
• Components include:
  • Bowel rest (NPO status) 3
  • Nasogastric tube decompression 3
  • Adequate fluid therapy - critical but often inadequately administered 3
  • Water-soluble contrast agents - both diagnostic and potentially therapeutic 1

Surgical Management (Adhesiolysis)

• Indications for surgery:
  • Complete bowel obstruction 1
  • Failed non-operative management 1
  • Signs of bowel ischemia or perforation 3
• Surgical approaches:
  • Open adhesiolysis - traditional approach 4
  • Laparoscopic adhesiolysis - may result in fewer newly formed adhesions in selected patients 4

Complications of Adhesiolysis

• Potential complications during surgery include:
  • Seromuscular injury - damage to serosa and smooth muscle layer 1
  • Enterotomy - full thickness injury to the bowel 1
  • Delayed diagnosed perforation - unrecognized injuries during surgery 1

Prevention Strategies

• Various antiadhesive agents are under investigation 6
• Minimally invasive surgical techniques may reduce adhesion formation 4
• Careful surgical technique with minimal tissue trauma is essential 6

Important Clinical Considerations

• Delayed surgical intervention (>72 hours after symptom onset) increases risk of ischemic gut injury 3
• Adequate fluid therapy is critical but often inadequately administered 3
• Chronic symptoms may be overlooked or misdiagnosed, leading to delayed treatment 2
• Recurrence is common, requiring ongoing monitoring and potential repeat interventions 1