para>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.
REFERENCES
11 Arung W, Meurisse M, Detry O. Pathophysiology and prevention of postoperative peritoneal adhesions. World J Gastroenterol. 2011;17(41):4545-4553.22 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):1228-1240.33 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):1118-1121.44 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):42.55 Ward BC, Panitch A. Abdominal adhesions: current and novel therapies. J Surg Res. 2011;165(1):91-111.
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.
- Dupr © 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.
- 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.
- Oua ¯ssi 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.
SEE ALSO
Algorithm: Intestinal Obstruction; Infertility
CODES
ICD10
- K66.0 Peritoneal adhesions (postprocedural) (postinfection)
- Q43.3 Congenital malformations of intestinal fixation
- N99.4 Postprocedural pelvic peritoneal adhesions
- N73.6 Female pelvic peritoneal adhesions (postinfective)
ICD9
- 568.0 Peritoneal adhesions (postoperative) (postinfection)
- 751.4 Anomalies of intestinal fixation
- 614.6 Pelvic peritoneal adhesions, female (postoperative) (postinfection)
SNOMED
- adhesion of abdominal wall (disorder)
- peritoneal adhesion (disorder)
- Congenital intestinal adhesions (disorder)
- Postprocedural pelvic peritoneal adhesions (disorder)
- Female pelvic peritoneal adhesions
- Adhesion of intestine (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.