5-Minute Clinical Consult

Abdominal Adhesions

Basics

  • Pathologic bands of scar tissue that form between two previously separated structures
  • Adhesions most commonly between:
    • Omentum
    • Bowel loops
    • Abdominal wall

Description

  • Adhesions may be congenital or acquired.
  • Acquired adhesions are usually the result of surgery, traumatic injury, or postinflammatory injury.
  • Adhesions are not merely nonfunctioning scars; they can be highly vascular and cellular.
  • Adhesions vary in structure. They can be thin membranous tissue or thick fibrous tissue with neurovascular structures, or even direct connections between organs.
  • Although most adhesions are asymptomatic, some patients may experience small bowel obstruction, infertility, and chronic pain.

Epidemiology

Incidence
  • True incidence is difficult to determine because some patients have asymptomatic adhesions.
  • Postoperative: 63–97% develop in the 10 years following laparotomy.
    • 1/3 of patients with open pelvic/abdominal surgery are readmitted for possible adhesive disease.
    • Laparoscopy reduces adhesion formation by 45% and reduces the need for reoperation.
    • Open colorectal surgeries and open ovarian surgeries have the highest risk of adhesion formation.
  • Congenital (4.7%)
  • Inflammatory (2.3%)

Etiology and Pathophysiology

  • Congenital: formed during organogenesis
  • Acquired adhesions
  • Postinflammatory: most commonly from diverticulitis, appendicitis, endometriosis, peritonitis, radiotherapy, long-term peritoneal dialysis, and inflammatory bowel disease. Adhesion formation is part of the normal peritoneal defense mechanism.
  • Posttraumatic: physical trauma to the abdomen Postinflammatory and postoperative: imbalance between fibrin deposition and breakdown (1)[C]
    • Increased fibrinogen from inflammatory and procoagulatory response mediated by plasminogen activator inhibitor-1 (PAI-1)
    • Decreased fibrinolysis by decrease in tissue plasminogen activator (tPA)
    • Morbidity caused by the anchoring of organs to nearby structures, impeding normal movement and promoting kinks, deformity, and blockage

Risk Factors

History of the following: abdominal infection, inflammation, surgery, or other trauma

General Prevention

  • Primary prevention: Avoid abdominal infection or need for abdominal surgery.
  • Surgical technique
    • Laparoscopic surgery is associated with less adhesive disease.
    • Intraoperative techniques that reduce adhesions:
      • Minimal peritoneal trauma
      • Delicate tissue handling
      • Irrigation
      • Meticulous hemostasis
      • Decreased operating time
      • Reduce foreign body, synthetic material, blood, necrotic material
  • Other modalities:
    • Barrier films such as Seprafilm, Gore-Tex, and Interceed have had mixed results in terms of preventing adhesions and reducing complications (2)[A],(3)[B].
    • Medications such as NSAIDs, steroids, vitamin E, and tPA do not conclusively decrease adhesions.

Diagnosis

Adhesions are primarily diagnosed through patient history and/or intraoperatively. The number of adhesions does not correlate with symptoms.

ALERT
Small bowel obstructions in patients without a history of abdominal surgery should not be routinely ascribed to adhesive disease without further workup, to exclude obstruction due to malignancy or other processes (4)[C].

History

  • Prior abdominal surgery
  • History of abdominal infection or pelvic inflammatory disease
  • Bowel complaints may include:
    • Crampy abdominal pain
    • Nausea, vomiting
    • Minimal to no flatus
    • Loud bowel sounds (borborygmi)
    • Abdominal distension
  • If involving a pelvic structure, complaints may include:
    • Lower abdominal pain (either chronic or acute)
    • Infertility
    • Nausea/vomiting

Physical Exam

  • Vital sign abnormalities (evidence of ischemia, dehydration, or infection)
  • Fever
  • Tachycardia
  • Diffuse abdominal tenderness
  • Peritoneal signs: guarding, rebound, rigidity
  • Abdominal scars
  • In the case of small bowel obstruction:
    • Abdominal distention
    • Tympany
    • Altered bowel sounds

Diagnostic Tests & Interpretation

Initial Tests (lab, imaging)
  • No lab or imaging tests definitively demonstrate adhesions. Workup should include WBC, lactate, electrolytes, BUN/creatinine
  • Imaging modalities such as supine and erect abdominal x-ray (4)[B], water-soluble oral-contrasted CT scan (4)[B], and water-soluble contrast follow-through can help diagnose small bowel obstruction (SBO) (4)[A].

Treatment

Surgery/Other Procedures

  • Nasogastric decompression for patients with evidence of partial SBO without specific indications for surgery (4)[A]
  • Adhesiolysis
    • Performed for symptomatic complications of adhesions, although criteria for surgery in these cases depends on the specific complication
      • Indications for adhesiolysis in setting of SBO include signs of strangulation or peritonitis, surgery within 6 weeks, carcinomatosis, irreducible hernia, no signs of resolution within 72 hours (4)[A].
      • With adhesiolysis, there is always the risk of new adhesions.
  • Laparoscopic: primarily for pelvic adhesions
    • Appropriate for highly selected patient (4)[B]
    • May be most effective in removing abdominal wall adhesions and least effective for adnexal adhesions (5)[C]
    • Helps treat chronic pelvic pain only when severe
  • Open: primarily for peritoneal adhesions
    • Laparotomy is the preferred surgical resolution to SBO related to adhesions in cases of failed conservative management (4)[B].

Ongoing Care

Prognosis

  • Adhesions are typically asymptomatic. Once present, they cannot be fully removed.
  • No single approach has been satisfactory in removing adhesions.

Complications

  • Most common complication is bowel obstruction (either partial or complete)
  • Chronic pelvic pain
  • Infertility
  • Surgical complications:
    • Prolonged surgery
    • Intraoperative bleeding
    • Trocar injury (adhesions to ventral abdominal wall)
    • Conversion of laparoscopy to laparotomy
    • Inadvertent enterotomy or other organ damage
    • Prolonged length of hospital stay
    • Postoperative morbidity/mortality is slightly higher than virgin abdomen.

Additional Reading

  • Blumenfeld YJ, Caughey AB, El-Sayed YY, et al. Single-versus double-layer hysterotomy closure at primary caesarean delivery and bladder adhesions. BJOG. 2010;117(6):690–694.
  • Diamond MP, Burns EL, Accomando B, et al. Seprafilm(®) adhesion barrier: (2) a review of the clinical literature on intraabdominal use. Gynecol Surg. 2012;9(3):247–257.
  • Dupré A, Lefranc A, Buc E, et al. Use of bioresorbable membranes to reduce abdominal and perihepatic adhesions in 2-stage hepatectomy of liver metastases from colorectal cancer: results of a prospective, randomized controlled phase II trial. Ann Surg. 2013;258(1):30–36.
  • Esposito AJ, Heydrick SJ, Cassidy MR, et al. Substance P is an early mediator of peritoneal fibrinolytic pathway genes and promotes intra-abdominal adhesion formation. J Surg Res. 2013;181(1):25–31.
  • Hackethal A, Sick C, Szalay G, et al. Intra-abdominal adhesion formation: does surgical approach matter? Questionnaire survey of South Asian surgeons and literature review. J Obstet Gynaecol Res. 2011;37(10):1382–1390.  [PMID:20352368]
  • Hellebrekers BW, Kooistra T. Pathogenesis of postoperative adhesion formation. Br J Surg. 2011;98(11):1503–1516.
  • Lauder CI, Garcea G, Strickland A, et al. Abdominal adhesion prevention: still a sticky subject? Dig Surg. 2010;27(5):347–358.  [PMID:22765994]
  • Ouaïssi M, Gaujoux S, Veyrie N, et al. Post-operative adhesions after digestive surgery: their incidence and prevention: review of the literature. J Visc Surg. 2012;149(2):e104–e114.  [PMID:20551759]

Codes

ICD-10

  • K66.0 Peritoneal adhesions (postprocedural) (postinfection)
  • N73.6 Female pelvic peritoneal adhesions (postinfective)
  • N99.4 Postprocedural pelvic peritoneal adhesions
  • Q43.3 Congenital malformations of intestinal fixation

ICD-9

  • 568.0 Peritoneal adhesions (postoperative) (postinfection)
  • 614.6 Pelvic peritoneal adhesions, female (postoperative) (postinfection)
  • 751.4 Anomalies of intestinal fixation

SNOMED

  • 197201009 Postprocedural pelvic peritoneal adhesions (disorder)
  • 204748003 Congenital intestinal adhesions (disorder)
  • 29886007 Adhesion of intestine (disorder)
  • 30689000 adhesion of abdominal wall (disorder)
  • 62394006 Female pelvic peritoneal adhesions
  • 70190001 peritoneal adhesion (disorder)

Clinical Pearls

  • Abdominal adhesions result primarily from abdominal infection or trauma (including surgery).
  • Most adhesions are asymptomatic; the most common complication is bowel obstruction (partial or complete).
  • The degree of pain does not correlate with the number of adhesions.

Authors


Charles K. Grigsby, MD
Caleb J. Mentzer, DO
James R. Yon, MD

Bibliography

  1. Arung W, Meurisse M, Detry O. Pathophysiology and prevention of postoperative peritoneal adhesions. World J Gastroenterol. 2011;17(41):4545–4553. [PMID:22147959]
  2. Robb WB, Mariette C. Strategies in the prevention of the formation of postoperative adhesions in digestive surgery: a systematic review of the literature. Dis Colon Rectum. 2014;57(10):1228–1240. [PMID:25203381]
  3. van der Wal JB, Iordens GI, Vrijland WW, et al. Adhesion prevention during laparotomy: long-term follow-up of a randomized clinical trial. Ann Surg. 2011;253(6):1118–1121. [PMID:21502860]
  4. Di Saverio S, Coccolini F, Galati M, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg. 2013;8(1):42. [PMID:24112637]
  5. Ward BC, Panitch A. Abdominal adhesions: current and novel therapies. J Surg Res. 2011;165(1):91–111. [PMID:20036389]


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