What is the best course of management for a patient with abdominal adhesions due to prior abdominal surgery, who has normal liver function tests and normal imaging studies, including magnetic resonance cholangiopancreatography (MRCP), liver ultrasound (US), and computed tomography (CT) scan?

Management of Abdominal Adhesions with Normal Imaging Studies

For a patient with abdominal adhesions due to prior abdominal surgery who has normal liver function tests and normal imaging studies (MRCP, liver US, CT scan), the recommended approach is conservative management with targeted symptom control, followed by consideration of adhesiolysis only in cases of persistent symptoms or bowel obstruction.

Understanding Abdominal Adhesions

• Adhesions develop in 70-90% of patients who undergo abdominal surgery, forming internal scar tissue that can cause various complications 1
• While most adhesions remain asymptomatic, they can lead to adhesive small bowel obstruction (ASBO), chronic pain, infertility, and difficulties during subsequent surgeries 1
• Adhesions are the leading cause of intestinal obstruction, accounting for more than 40% of all cases and 60-70% of small bowel obstructions 2

Initial Management Approach

• Since imaging studies (MRCP, liver US, CT scan) are normal and there's no evidence of obstruction, conservative management is the first-line approach 3
• Conservative management should include:
  • Pain management with appropriate analgesics, which may include opioids for severe pain 3
  • Pro-kinetic agents such as metoclopramide to improve gastrointestinal motility if the patient has symptoms of delayed gastric emptying 3
  • Monitoring for development of bowel obstruction symptoms (increasing pain, vomiting, abdominal distension) 3

Symptom Management

• For chronic pain related to adhesions:
  • Regular analgesics should be prescribed according to the WHO pain ladder 3
  • Consider non-pharmacological approaches such as physical therapy and dietary modifications 4
  • In cases of severe pain unresponsive to conventional analgesics, referral to a pain specialist may be warranted 4

Monitoring and Follow-up

• Regular follow-up is recommended to assess symptom progression or resolution 3
• Patients should be educated about warning signs of bowel obstruction that require immediate medical attention:
  • Severe abdominal pain
  • Persistent vomiting
  • Abdominal distension
  • Inability to pass gas or stool 3

When to Consider Surgical Intervention

• Surgical intervention (adhesiolysis) should be considered if:
  • The patient develops signs of bowel obstruction that fails to resolve with conservative management 3
  • The patient experiences persistent, severe symptoms that significantly impact quality of life despite conservative management 1
• Recent studies have demonstrated that elective adhesiolysis with the use of adhesion barriers for pain can be effective in selected patients 1
• Novel imaging techniques such as cineMRI can help select patients in whom adhesiolysis would be safe and effective 1

Surgical Considerations

• If surgery becomes necessary:
  • Laparoscopic approach should be attempted when feasible, though it may be technically challenging due to adhesions 3
  • Use of adhesion barriers during surgery should be considered to reduce the risk of recurrence 1, 5
  • The risk of recurrent adhesions after adhesiolysis is high, with some studies reporting recurrence rates of up to 85% without the use of adhesion barriers 5

Potential Complications and Pitfalls

• Adhesiolysis carries significant risks including:
  • Inadvertent enterotomy (bowel injury)
  • New adhesion formation
  • Prolonged ileus
  • Infection 4
• The decision to perform adhesiolysis should carefully weigh these risks against potential benefits, particularly in patients with normal imaging studies 4
• Patients should be informed that adhesions may recur even after successful adhesiolysis 2

Preventive Measures for Future Surgeries

• If the patient requires any future abdominal surgeries:
  • Minimally invasive techniques should be preferred when feasible 4
  • Meticulous surgical technique with minimal tissue handling is recommended 4
  • Consider the use of adhesion barriers such as sodium hyaluronate-based bioresorbable membranes, which have been shown to significantly reduce the incidence, extent, and severity of postoperative adhesions 5