Adhesions

Adhesions are abnormal connections that form between tissues and organs, most often as a result of inflammation. Most adhesions form in the belly or pelvis following surgery.[1] They are more common after surgery on the colon, appendix, or uterus than after surgery on the stomach, gallbladder, or pancreas. The risk of developing adhesions increases with the time elapsed since the surgery. Adhesions are the most common cause of small bowel obstruction, but they can also obstruct the large bowel. Sometimes adhesions are present at birth, and may not cause problems till later in life.[2]

Other Names
Adhesions of the uterus are sometimes called synechiae.

Types

 * Abdominal adhesions. Adhesions in the belly frequently develop after surgery.


 * Adhesive capsulitis. Adhesive capsulitis is also called frozen shoulder. These adhesions develop between shoulder joint surfaces and can restrict a person's arm movement.


 * Asherman syndrome. Asherman syndrome is the presence of adhesions that form in the uterus after dilation and curettage. They can cause infertility.


 * Labial adhesions


 * Penile adhesions after circumcision

This article will chiefly discuss abdominal adhesions.

Signs and Symptoms
Some abdominal adhesions may cause no symptoms. However, they can cause problems for the same reason that ropes strung randomly across a room could entangle people and things in the room. Abdominal adhesions can cause partial or complete blockage of the intestines, or bowel obstruction, as a result of pulling on or kinking the intestines. Symptoms of a bowel obstruction depend on the degree and the location of the obstruction. The following are common symptoms of a bowel obstruction.


 * Cramp-like abdominal pain


 * Vomiting


 * Bloating


 * Inability to pass gas


 * Constipation

Causes
Adhesions form as part of the normal healing process. After an injury, such as surgery, a layer of a meshlike protein called fibrin is deposited over the injured site. The fibrin seals off the damaged surface and attracts cells to the area to encourage the healing process. Sometimes the fibrin attaches not only to the injured site but also to an adjacent organ or tissue. This creates an adhesion between the two organs.[1] Often these adhesions heal and disappear, but sometimes they are permanent. Scientists are studying the reasons why some adhesions disappear while others persist. It is thought that several important molecules are involved, including TGF-beta, interleukin-1, and substance P.[1]

Surgery requiring a lot of manipulation of the bowel contents on the part of the surgeon (for example, an operation to remove bags of cocaine from drug smugglers who have swallowed them, which requires the surgeon to check every inch of intestine to make sure none are missed) are more likely to cause adhesions.

Another factor that can cause adhesions in the belly is endometriosis.

Diagnosis
Abdominal adhesions are not usually diagnosed until they cause symptoms of a bowel obstruction.

History and physical examination
Patients with bowel obstructions generally come to the emergency room with belly pain. The pain is often crampy, meaning it comes and goes; this is because the pain is worse when the intestines contract and it subsides when they relax. The physician will ask about vomiting and whether the patient has passed stool or gas lately. He or she will look for scars on the abdomen that indicate prior surgeries, and will ask the patient what and when those were. He or she will ask if the patient has ever had a bowel obstruction before.

On physical examination, a person with a bowel obstruction will often have a swollen, tender belly filled with gas that makes a particular type of drumlike or "tympanitic" sound when percussed by the physician's fingers.

Tests
Plain abdominal x-rays can often diagnose that a bowel obstruction is present by showing abnormal patterns of gas and liquid in the intestines. A CT scan (computed tomography)] or barium contrast studies may be used to locate the exact spot where the adhesion is causing obstruction. Exploratory surgery can also locate the adhesions and the source of pain.

Treatment
Abdominal adhesions cause symptoms only if the intestines are partially or completely blocked. Partial obstructions may clear up without treatment. In these cases, treatment consists of diet restriction to fluids only or to nothing at all (NPO), and nasogastric tube insertion (a tube inserted through one nostril into the stomach) to drain any excess fluid and to prevent vomiting. If the obstruction resolves on its own, the tube is removed and the person's diet can gradually be advanced from liquids to solids. For people whose intestines are only partially blocked, a diet low in fiber, called a low-residue diet, allows food to move more easily through the affected area.

If the partial obstruction does not completely resolve, or if complete obstruction is present, surgery is necessary to remove the adhesions, reposition the intestine, and relieve symptoms. This is called lysis of adhesions. It can be done laparoscopically. Unfortunately, the risk of developing more adhesions increases with each additional surgery. The video illustrates what adhesions look like and how they are cut during a laparoscopic lysis of adhesions operation.

Prevention
Methods to prevent adhesions include gentle surgical techniques; using biodegradable membranes or gels to separate organs at the end of surgery; or performing laparoscopic (keyhole) surgery, which reduces the size of the incision and cuts down on handling of the organs.

During surgery, several steps can be taken to cut down on the irritation of the organs that stimulates adhesions to form. Powdered gloves should be rinsed to remove the powder. Organs should be handled very gently and as little as possible. Fluids to rinse out the abdomen should not be too warm.

But these steps only cut down on adhesions; they do not prevent them completely.[1] Several types of films and membranes have been tried over the years, and some have worked better than others. The most effective type so far is a kind based on a natural substance called hyaluronan.[1]

Chances of Developing Adhesions
About 93%–100% of people undergoing belly or pelvic surgery will form adhesions, but luckily most do not have complications of the adhesions.[1]

Adhesions may also result from infectious processes, such as pelvic inflammatory disease.

Related Problems
There are a number of problems that can arise from a person's having abdominal adhesions.[1]


 * 1) They may develop bowel obstructions, as discussed above.
 * 2) The adhesions may cause infertility in women.
 * 3) The adhesions can make peritoneal dialysis—a procedure in which fluid rinsing the insides of the belly allows dialysis to take place—impossible.
 * 4) Future surgery is rendered more complicated if adhesions are present.

Clinical Trials
For a list of American government-sponsored clinical trials studying adhesions, visit here.

Research
Experiments in mice suggest that some (non-steroidal anti-inflammatory drugs (NSAIDs)) are useful in preventing the formation of abdominal adhesions.[3] In the study, mice were given implants to promote intestinal adhesions. Mice treated for ten days with the NSAIDS celecoxib (Celebrex), rofecoxib (Vioxx), indomethacin (Indocin), naproxen (Aleve), or ibuprofen (Motrin) for ten days after surgery had significantly fewer adhesion formations than did mice given salicylic acid (Aspirin) or no treatment. Of all the NSAIDs, celecoxib was the most effective in preventing adhesion formation. The authors suggest that the NSAIDs prevent adhesion formation by inhibiting the growth of blood vessels. The effectiveness of celecoxib for the prevention of adhesions is now being investigated in clinical trials.

Many other methods of preventing adhesions are being studied as well, including the use of biofilms and membranes.