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Internal Medicine

Intra-abdominal adhesions

Intra-abdominal vascular adhesion after an appendectomy | Hic et nunc - Public Domain, https://commons.wikimedia.org/w/index.php?curid=5993892

Introduction

Abdominal adhesions are fibrous bands that span two or more intra-abdominal organs and/or the inner abdominal wall (i.e. peritoneal membrane).

Types

  • Filmy (usually asymptomatic)
  • Vascular (M/severe)
  • Cohesive

Aetiology

Post-surgical (M/C, 90%):

  • Laparotomy (open surgery) > laparoscopic surgeries (5% cases)

Post-inflammatory/infectious:

  • Endometriosis and pelvic inflammatory disease (PID) (M/C in women)
  • Diverticular disease (particularly of small bowel)
  • Crohn’s disease
  • Abdominal tuberculosis (in endemic areas)

Post-radiation (abdomino-pelvic):

Can cause adhesions as a late sequela, the severity of which depends on the anatomic extent of the area treated, the degree of dose fractionation, and the total dose of radiation

Pathophysiology

figure-overview-of-pathophysiological-interrelationships-and-factors-thought-to-be
Overview of pathophysiological interrelationships and factors thought to be involved in the origin of adhesions (modified from Holmdahl, L., Eriksson, E., al-Jabreen, M., & Risberg, B. (1996). Fibrinolysis in human peritoneum during operation. Surgery, 119(6), 701–705.) | Brüggmann, D., Tchartchian, G., Wallwiener, M., Münstedt, K., Tinneberg, H.-R., & Hackethal, A. (2010). Intra-abdominal adhesions: definition, origin, significance in surgical practice, and treatment options. Deutsches Arzteblatt International, 107(44), 769–775. https://doi.org/10.3238/arztebl.2010.0769

Clinical features

Due to the firm & fibrotic nature of adhesive bands, they have the potential to interfere with the normal intestinal motility and transit processes, among other physiologic functions.

Asymptomatic (M/C)

Symptomatic state “Adhesive disease”:

Non-specific symptomology:

  • Chronic (persistent/intermittent) bloating
  • Abdominal cramping and borborygmi
  • Altered bowel habits, including constipation or frequent loose stools (e.g. from development of small intestinal bacterial overgrowth)
  • Nausea ± early satiety
  • Bowel obstruction (transient, partial, or complete)
    • M/C cause of intestinal obstruction (Western countries)
  • Female infertility and dyspareunia
  • Rectal bleeding and dyschezia (i.e. painful defecation) during menses (typically indicate colorectal involvement of endometriosis)

Diagnosis

No characteristic laboratory features and are not readily visible by currently available imaging methods, many cases will go undiagnosed for prolonged periods of time, causing medical providers in a diagnostic and therapeutic quandary.

Differential diagnosis:

  • Lactose intolerance
  • Endometriosis
  • Acalculous cholecystitis
  • Fatty liver
  • Other disorders:
    • Atypical presentation of peptic ulcer disease, small bowel strictures, GI tract tumours, small bowel diverticula, celiac disease, inflammatory bowel disease (IBD), chronic mesenteric ischemia, pancreatobiliary disorders (e.g. choledocholithiasis, Sphincter of Oddi dyskinesia) or porphyria cutanea tarda

Management

Laparoscopy/laparotomy with adhesiolysis (definitive management)

 

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