What Are Adhesions?
This article describes abdominal adhesions, bowel (intestinal) adhesions and pelvic adhesions.
Adhesions (Latin adhere= to stick, to hold tight) are abnormal bands of scar tissue that form between internal organs and glue them together. Normally, scar tissue is formed only within an injured area, as part of a healing process, but in case of adhesions, it also appears on adjacent surfaces and can connect them.
Abdominal adhesions mostly appear after abdominal surgery or inflammation, and pelvic adhesions after gynecological operations or pelvic inflammatory disease (PID), mostly resulting from sexually transmitted diseases (STDs).
Abdominal or pelvic adhesions may develop inside the intestine and uterus, or between surfaces of organs and abdominal membrane (peritoneum), thus pulling organs from their original positions, obstructing passage of food and blood supply, causing abdominal or pelvic pain, bloating, constipation, urinary retention, irregular menstrual bleeding or infertility.
What Causes Abdominal or Pelvic Adhesions?
1. Abdominal or Pelvic Surgery
Surgical removal of the appendix, gallbladder, any operation on the bowel, resolving ectopic pregnancy, cesarean section or any major abdominal or pelvic surgery may result in adhesions formation. Surgery inside the uterus, like “dilatation and curettage”, may result in intrauterine adhesions (Asherman’s syndrome) (1).
Inflammation, like appendicitis, pelvic inflammatory disease (PID), Crohn’s disease or ulcerative colitis may all result in adhesions.
- In Crohn’s disease, bacterial infection can result in abscesses formation in or around the bowel wall, especially around the rectum and anus. Abscess healing can result in intestinal adhesions.
- Sexually transmitted diseases (STDs), like chlamydia or gonorrhea, may result in adhesions within the uterus, Fallopian tubes and around ovaries and cause chronic pelvic pain, irregular menstrual bleeding, infertility or ectopic pregnancy. Bacteria can travel up to the liver and cause the so called “violin string adhesions” between the liver and diaphragm (2).
- Intestinal tuberculosis (3)
- Infection of a surgical wound
4. Other Causes
- Internal abdominal bleeding due to perforation of the bowel
- Cancer in the abdominal or pelvic cavity
- Radiation therapy or chemotherapy of abdominal or pelvic cancer
- Foreign body, like a piece of gauze or a part of surgical equipment remained in the abdominal cavity after surgery
- Adhesions can be, rarely, present at birth from various causes
What Are Symptoms of Adhesions?
Symptoms caused by adhesions depend on adhesion location and complications, and include:
- Abdominal pain: sudden or chronic, occasional or constant, cramping or pulling; adhesions above the liver may cause pain with deep breathing; intestinal adhesions may cause pain during stretching or reaching an object above your head. Pain is caused by bowel obstruction.
- Pelvic pain: acute or chronic; adhesions near the vagina can cause painful intercourse. Pain is caused by pulling nerves in displaced organs.
- Poor appetite and nausea are common.
- Occasionally, pain is followed by vomiting, which relieves the pain.
- Other symptoms are mentioned under complications (see below).
Adhesions Related Disorder (ARD)
Sometimes, adhesions may result in the following combination of problems:
- Chronic abdominal or pelvic pain
- Gastro-esophageal reflux disease (GERD)
- Frequent urination or urine retention
- Painful bowel movement
- Pain on walking, sitting or laying in certain positions.
- Anemia and nutrient deficiencies due to poor eating habits or loss of appetite
- Loss of employment due to lost work days
- Loss of family and social life
- Depression, suicidal thoughts
Complications of Adhesions
1. Intestinal Obstruction
Fibrous tissue can obstruct the intestinal lumen or pull intestinal loops in the way that blocks passage of food. Obstruction may cause poor appetite, dry skin and mouth, severe thirst, infrequent urination (from dehydration), nausea, vomiting, abdominal cramps, constipation, inability to pass gas, abdominal swelling (from collection of food, fluid and gas in the bowel) and fever (from intestinal inflammation).
Adhesion may cause twisting of the bowel along its axis thus affecting blood supply and eventual death (gangrene) of the affected part of the bowel in as few as 6 hours. Symptoms of this disorder, known as strangulation, include sudden, severe, crampy or steady abdominal pain, nausea, vomiting and rectal bleeding.
3. Vaginal and Labial Adhesions
Bacterial vaginosis, diaper rash or irritation by clothes may cause vaginal or labial adhesion in infants, girls or adult women. Adhesion is usually mild and is resolved spontaneously or by minor intervention by a doctor.
Adhesions in the uterus or Fallopian tubes can result in infertility (which can be sometimes successfully treated) (1).
5. Ectopic Pregnancy
Adhesions in Fallopian tubes increase the risk of ectopic (tubal) pregnancy.
How Can Be Adhesions Diagnosed?
Your doctor may not be always aware of adhesions as a possible cause of chronic abdominal pain, constipation, bloating or infertility; so you can remind him/her and also provide your complete medical history, including eventual surgeries, injuries, radiation treatment, and any abdominal inflammation or infection at any time of your life.
During physical examination, doctor may find distended abdomen, tender spots, unusual mass, loud (or absent) abdominal sounds due to intestinal obstruction, pale or dry skin due to anemia or dehydration.
Ultrasound and X-ray usually can not reveal abdominal adhesions. X-ray after barium swallow (upper GI) can reveal adhesions within the small intestine (strictures), and barium enema (lower GI), adhesions within the colon. Unusual course of intestinal loops revealed by these investigations may raise suspicion for adhesions outside the intestine.
CTcan sometimes reveal adhesions outside the small bowel (4). MRI can sometimes reveal adhesions inside and outside the small and large intestine and uterus (5). Laparoscopy can often reveal abdominal adhesions outside the bowel. Any of these investigations can fail to reveal adhesions, so often an exploratory surgery is needed for diagnosis.
Histeroscopy (uterine endoscopy) can reveal uterine adhesions and hysterosalpingography (contrast X-ray of uterus and tubes) adhesions in the uterus and Fallopian tubes.
Treatment with Adhesion Lysis (Adhesiolysis)
In general, adhesions can be successfully removed by operation called adhesion lysis or adhesiolysis. This can be performed during laparoscopy or during open surgery – laparotomy. In both cases, scissors, harmonic scalpels, laser or electrosurgery can be used; operation can last from 2-4 hours. Adhesiolysis is usually successful, but every adhesion-removing procedure may result in new adhesions, so this operation should be done only in severe and debilitating symptoms, and to resolve intestinal obstruction, infertility or other complications.
Adhesion creation can be prevented to some extent by (6):
- Performing minimally invasive surgical techniques, like gasless laparoscopy (without inflating carbon dioxide) instead of open surgery (what is not always possible), minimal handling of tissues, using non-reactive sutures, avoiding gloves containing starch or talc, preventing desiccation of organ surfaces by using moist sponges, etc.
- Inserting adhesion barriers (SprayGel™, sheets made of oxidized cellulose, etc.) that separate organ surfaces during and after operation thus preventing adhesion formation. SprayGel™ stays on surfaces of organs for 5-7 days and prevents adhesion formation, then is naturally cleared from the body in 7-14 days.
- Administering of intra-abdominal steroids to prevent inflammation.
- Avoiding repeated surgical adhesion removal, since each operation raises a risk for new adhesions
Adhesions Formation Pathophysiology and Prognosis
Within few hours after a surgical procedure (or other cause of tissue injury), inflammatory cells and fibrin from the blood are attracted to the site of injury; the end result is a scar formed between two cut surfaces. The same scaring process can start to develop adjacent to the site of injury because of mechanical irritation, drying, foreign bodies (piece of gauze, talc from surgical gloves) or lack of oxygen in peritoneum – abdominal membrane. In first days, fibrionous adhesions made of fibrin (clotting substance derived from the blood), may appear and cause temporary bowel obstruction with abdominal pain and constipation. These fibrionous adhesions may disappear or develop into permanent fibrous adhesions, made of fibrous tissue from collagen,produced by fibroblasts, which may start to trigger symptoms months or years after surgery. Permanent fibrous adhesions do not likely resolve spontaneously.
How to Find a Doctor for Adhesiolysis
If you plan to have adhesiolysis, find a doctor who takes abdominal/pelvic pain seriously, is experienced in adhesion treatment and has necessary equipment available. Maybe someone on an online adhesion message forum can help you find appropriate doctor in your area.
- Asherman’s syndrome caused by intrauterine adhesions (nwh.org)
- Adhesions between the liver and diaphragm in STD (emedicine.medscape.com)
- Adhesions in intestinal tuberculosis can be shown by CT or investigations with barium (saudijgastro.com)
- CT can reveal small bowel adhesions (ncbi.nlm.nih.gov)
- Laparoscopic surgery for adhesions: techniques, prevention of adhesions (emedicince.medscape.com)