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Abdominal adhesions are scar tissue which is created inside the abdomen and
connects organs either to other organs or to the inner surface of the abdomen
(the peritoneum).
We are born with a certain amount of adhesions in our abdomen which are
called congenital adhesions. Congenital adhesions serve to support internal
organs and structures and for the most part are harmless, although in rare
occasions they can cause damage of the bowel.
Acquired adhesions occur after any abdominal infection or operation. They are
scar tissue which grows in response to injury, ulceration, abscess, infection or
simply surgical incision of the tissues.
Adhesions are the result of normal healing. When you cut your skin you
can watch a scar formed over a period of a few days. This scar undergoes
some changes but subsequently becomes permanent. In exactly the same way,
after any event as those described above, adhesions are formed in the
abdomen. They grow around incisions, perforations, stumps of removed bowels,
cavities of abscesses, fistula tracks etc. Their role is protective and defensive.
Adhesions are an important part of the healing process. Also they attract the
omentum, which a large piece of tissue called th “policeman of the abdomen”
which moves around the abdominal cavity and covers diseased or infected
areas to prevent spread of the infection.
When you have a stomach perforation from a ulcer or a perforated diverticulum
of the colon, the omentum and adhesions will surround it, cover it and seal it. In
this way, even if you do not have surgery, it is possible that further leak or
infection will be stopped and after a short illness your life will be saved. When
you have acute appendicitis and you do not seek help in time at a hospital,
adhesions will form around your inflamed appendix a mass which will isolate it
from the rest of the abdomen and will prevent peritonitis.
So, adhesions are beneficial. Well, not always. What may be a beneficial effect
temporarily, may in the long term, become a risk factor for problems. Adhesions
can be soft, in which case they do not cause serious problems, or hard and
fibrotic.
Fibrotic adhesions can cause kinking or twisting of small bowel loops and can
cause obstruction. They can cause symptoms of pain, bloating, nausea and
vomiting, peritonitis, perforation and sepsis. In some cases these problems
present as an acute episode. The majority of these attacks (90%) will settle
“conservatively”, i.e. by fasting and intravenous fluids, within 48-72 hours.
However 10% of patients will need an operation for “division of adhesions or
adhesiolysis”.
Many patients do not develop a attack severe enough to be admitted to the
hospital but they have mild symptoms which drag on for months or years and,
eventually, compromise their quality of life. Women who have had
gynaecological infections (“Pelvic Inflammatory Disease”) may develop
adhesions in the pelvis which can cause infertility. Some of those patients may
need surgery in an attempt to resolve the problems. Unfortunately, after
surgery, the adhesions and their problems may return. Some individuals have a
tendency to form extensive adhesions, in the same way that others have a
tendency to grow unsightly skin scars. A number of solutions called “barriers”
have been developed which are supposed to decrease the risk of adhesions.
Although some indications on their efficiency exist there is not solid evidence yet
and at the moment the NHS does not fund in most regions those barrier
solutions.
The diagnosis of adhesions is not always easy. A history of previous surgery
is necessary for the presence of acquired adhesions. Symptoms of cramping
pains (although the pattern and location of pain may vary), nausea and
vomiting, with concurrent distension of the abdomen which settles if the patient
stays without food and fluids, are highly suspicious of adhesions.
A CT scan of the abdomen and a small bowel contrast study can put the
diagnosis in many cases. In other cases laparoscopy (examination of the
abdomen with a camera) may detect the adhesions and at the same time
provide the treatment with adhesiolysis.
In some cases however adhesions are present without any signs on the scans
or investigations. In many cases they are coincidental findings during operations
for other causes.
The solution of the problems caused by adhesions is not always easy.
The majority of the patients will get rid of them after one operation.
Unfortunately it is impossible to guarantee that there will be no recurrence. This
is because formation of adhesions depends, among other things, on the
immune system of the patient and this is very variable. A small number of
unfortunate patients have recurrent problems and repeat operations. We hope
that in the next few years with the development of more efficient barrier
solutions the problem may be tackled more efficiently.
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Abdominal Adhesions