What is Bowel Adhesions?

Bowel adhesions are abnormal strips of scar tissue that connect two parts of the body that typically aren’t connected. They can form when the body is trying to heal from disturbances like surgery, infections, physical damage, or radiation. While the formation of these adhesions in the abdomen can be a routine response to injury, they may lead to negative health impacts. These can range from blockages in the small intestine, decreased fertility in women, and chronic abdominal pain, to complicating future surgeries.

If these adhesions are present during subsequent surgeries, it may lead to a handful of problems. These may include hard access to the abdominal area, complications with laparoscopic surgery, unintended injuries to other organs, longer surgery times, and more blood loss.

What Causes Bowel Adhesions?

In Western countries, the main cause of abdominal adhesions, which are bands of tissue that can cause organs to stick together, is from having undergone previous abdominal surgery. The types of surgeries most likely to result in these adhesions are gynecological surgeries, the creation of an ileal pouch-anal anastomosis (a surgical procedure for bowel diseases like ulcerative colitis), and colectomy (surgery to remove part or all of the colon).

Other things that can cause these adhesions include injuries, diverticulitis (an inflammation or infection of small pouches in the colon), inflammatory bowel disease, the placement of a ventriculoperitoneal shunt (a medical device that relieves pressure on the brain), peritonitis (inflammation of the inner layer of your stomach), pelvic inflammatory disease, and treatments like abdominal or pelvic radiation.

Certain birth defects, such as malrotation, which is an abnormal rotation of the intestine, may also be associated with a type of adhesions known as Ladd’s bands.

Risk Factors and Frequency for Bowel Adhesions

Adhesions are a major health concern and are responsible for roughly 1% of all general surgical admissions and 3% of all surgeries involving opening the abdomen (known as laparotomies). They are estimated to cost the U.S. more than $2 billion annually in dealing with complications related to these adhesions. Often, issues with medical malpractice claims related to adhesions arise from failing to properly warn patients about possible internal injuries during the approval process, not using necessary preventative measures, or delayed diagnosis and failure to diagnose complications.

Signs and Symptoms of Bowel Adhesions

Bowel adhesions are a condition where parts of your intestines stick together. Most people with bowel adhesions do not have any symptoms. Some of the people who do have symptoms have a history of surgeries in the abdomen area. Others have a history of inflammation inside their abdomen or pelvis, which may include cancer. People with symptoms usually experience either a complete or partial intestinal blockage, chronic pain, or infertility in women.

Bowel adhesions are the main cause of intestinal blockages in Western countries. If a person who has previously had surgery in the abdomen or pelvis area is experiencing an intestinal blockage, it might be due to bowel adhesions. Typical symptoms include feeling nauseous, vomiting, having abdominal cramps and constipation. Pain around the belly button and cramping can be usual. If the pain is more directed, it might indicate irritation of the tissue lining the inside of the abdomen and abdomen walls. If a person suddenly experiences severe pain, it could be a sign of acute inadequate blood supply to the intestines and a possible rupture in the intestines. A physical examination can reveal a dehydrated patient with a swollen abdomen. Changes in bowel sounds on examination of the abdomen with a stethoscope can also be observed. These sounds can be high-pitched ringing sounds or absent sounds depending on whether the intestines are distended with air or fluid.

In some cases, chronic abdominal or pelvic pain can be associated with adhesions. Although not well understood, larger adhesions seem to limit the free movement of organs which results in organ-specific pain. Adhesions can contribute to a woman not being able to become pregnant. This is because adhesions can disrupt the egg’s path and movement or they can hinder the sperm’s path and the implantation of the embryo.

A thorough physical examination should be performed for a person suspected of having adhesion-related symptoms. If the symptoms indicate the blockage of the intestines or inflammation of the peritoneum, the person should be immediately referred for a surgical consultation.

Testing for Bowel Adhesions

Doctors usually consider a diagnosis of adhesions if the patient’s medical history shows a likelihood for this condition. The most accurate way to identify adhesions, which are bands of scar-like tissue, is through direct viewing during procedures like laparoscopy or laparotomy. While imaging methods such as X-rays, ultrasounds, MRIs, CT scans, and small bowel contrast studies can be used, they aren’t as accurate as direct viewing, especially when determining if adhesions are causing obstruction in the intestines. However, these imaging methods can still be useful in diagnosing obstruction.

Obstruction from adhesions can be recognized on imaging by certain signs. These include the “fat-bridging sign” which is a cord-like structure containing abdominal fat and forming a bridge across the lining of the abdominal cavity, the “whirl sign” which is a twisting of the connective tissues surrounding the intestines, and the “anchoring of the omentum” sign which represents an attachment of fatty tissues within the belly.

Typical laboratory tests for investigating abdominal adhesions include a complete blood count, a full metabolic panel, and lactic acid tests. These tests, while not specific for adhesions, can help determine the severity of any obstruction and potential intestine damage due to a poor blood supply. If the patient shows signs of systemic illness like fever, fast heart rate, low blood pressure, or altered mental status, then arterial blood gas and blood culture tests may be considered. Changes in blood acidity levels may occur, for example, alkalosis due to vomiting or acidosis due to intestine damage from poor blood supply. A procalcitonin test can also be helpful in measuring inflammation levels.

Treatment Options for Bowel Adhesions

Adhesive disease, a medical condition caused by tissue sticking together, is usually treated based on symptoms. Common symptoms include blockage of the bowel (obstruction). Initial treatment for this involves giving the patient fluids by IV and replacing lost electrolytes to manage hydration. In severe cases, a patient may need to see a surgeon who can consider removing the adhesions. If the condition isn’t severe, it might require less food intake, and if hospitalization is required, the patient shouldn’t eat anything. To understand the problem better, doctors may use X-ray or CT scans.

A tube might be placed in the patient’s nose and guided into their stomach (nasogastric tube) to help relieve pressure in the bowels and manage nausea and vomiting. Pain relief is usually provided via IV, but strong, persistent pain might signal the need for surgery. Opiates are used cautiously as they might slow down the bowel function.

Sometimes, the non-surgical approach can resolve bowel blockages. Resting the bowel alongside using a nasal tube for relief often results in successful treatment. In some cases, administering a contrast agent (a substance that enhances the visibility of internal structures in imaging) via the nasal tube or orally can improve the results of non-surgical treatment. Several X-rays are taken over time to confirm that the contrast agent is moving into the colon, signaling that the blockage is clearing. If the agent doesn’t move as expected, usually in 24 hours, surgery is usually considered.

Other triggers for surgical intervention include an increase in abdominal pain, the high output from the nasal tube, unstable vital signs, or high inflammatory markers such as lactic acid or white blood cells. If these complications are suspected, the patient would usually be taken for examination and potential surgery.

Surgical intervention using techniques such as laparoscopy or laparotomy is often the final approach to managing symptomatic bowel adhesions. However, these procedures carry potential risks, and it’s essential to discuss these with the patient or their family when possible. There’s strong evidence that surgeries which are less invasive, like laparoscopy or robotic surgery, can prevent the formation of adhesions compared to open surgery, and they’re often the preferred approach.

Patients with chronic conditions, such as infertility suspected to be caused by adhesions or inflammatory bowel disease, can be monitored and may require non-hospital-based (outpatient) follow-up care.

During any surgical procedure, it’s crucial to handle tissues gently to reduce the risk of injuring the membrane lining the abdominal cavity and forming more adhesions. Use of materials, such as laparotomy sponges, should be avoided, and preventing a reaction to foreign materials, such as excessive suture thread, lint, or talc, can help prevent more adhesions from forming. Regardless of whether the lining of the abdomen is closed after surgery or not, the chance of adhesions forming remains the same.

Minimally invasive surgery techniques, which involve smaller incisions and less handling of the tissues, can help reduce adhesion formation. However, longer surgery durations and higher pressure used during insufflation (the process of inflating the abdomen with gas during minimally invasive surgery) can increase the risk of adhesions.

Severe inflammation of the bile duct (acute cholangitis)
Infection of the gallbladder and painful spasms of the bile duct (cholecystitis and biliary colic)
Condition characterized by high levels of ketones and acid in the body due to heavy alcohol use (alcoholic ketoacidosis)
Difficulty in passing stools or infrequent bowel movements (constipation)
Inflammation or infection of small, bulging sacs in the digestive tract (diverticulitis)
Painful periods (dysmenorrhea)
Loss of a pregnancy within the first 20 weeks (early pregnancy loss)
A painful condition where tissue similar to the tissue that normally lines the inside of the uterus, grows outside (endometriosis)
Inflammation of the appendix (appendicitis)
Long-term conditions causing inflammation in the gut (inflammatory bowel disease)

It’s essential to understand that these medical conditions can exhibit similar symptoms and hence can often be mixed up. Therefore, it is vital to get an accurate diagnosis to ensure proper treatment.

What to expect with Bowel Adhesions

At present, there’s no confirmed way to treat bowel adhesions without resorting to surgery. Patients showing symptoms due to adhesions face a high likelihood of recurring symptoms. Moreover, the more instances of blockage occur, the higher the chance of it happening again. Most reoccur within 5 years of the initial event, but a significant risk persists even 10 to 20 years afterward.

While surgical treatment may lower the chances of repeated hospital admissions because of bowel obstruction, the possibility of new episodes requiring surgical intervention remains the same. It’s also worth noting that patients who have received treatment for symptomatic adhesions often report more abdominal pain than the average person.

Possible Complications When Diagnosed with Bowel Adhesions

Like any surgery within the abdomen, operations to treat intra-abdominal adhesions can lead to similar issues. These could involve bleeding, infection, harm to nearby body parts including accidental cuts or tears during the procedure. Moreover, there’s an increased chance of these adhesions appearing again in the future. Such patients might also face complications linked with anesthesia such as troubles with heart and lung functions, or blood clots obstructing blood vessels.

Common Complications:

Bleeding
Infection
Damage to surrounding structures
Increased risk for formation of adhesions in the future
Cardiopulmonary complications related to anesthesia
Thromboembolic events (blood clots blocking blood vessels)

Recovery from Bowel Adhesions

For patients who have had surgery for a blocked bowel, the focus of post-surgery care is making sure the blockage signs have gone away and they’re able to eat and drink properly. Typically, patients start off by taking in clear liquids, and their intake is increased as they are able to accept more. It’s possible to confirm that the bowel is working again by checking if the patient is passing gas or stool, and also by using medical imaging.

Preventing Bowel Adhesions

It’s important for everyone undergoing abdominal surgery to understand that there might be some side effects like adhesions. Adhesions can cause complications over a long period. Nausea, vomiting, bloating, belly pain, and severe constipation are some of the signs of a condition called a small bowel obstruction, which can be tied to these adhesions. If you notice any of these symptoms, you should seek medical help immediately.

Frequently asked questions

Bowel adhesions are abnormal strips of scar tissue that connect two parts of the body that typically aren't connected.

Bowel adhesions are responsible for roughly 1% of all general surgical admissions and 3% of all surgeries involving opening the abdomen.

Signs and symptoms of Bowel Adhesions include: - Complete or partial intestinal blockage - Chronic pain - Infertility in women - Nausea - Vomiting - Abdominal cramps - Constipation - Pain around the belly button - Cramping - Irritation of the tissue lining the inside of the abdomen and abdomen walls - Sudden severe pain, which could indicate inadequate blood supply to the intestines and a possible rupture - Dehydration and a swollen abdomen on physical examination - Changes in bowel sounds, such as high-pitched ringing sounds or absent sounds, depending on whether the intestines are distended with air or fluid - Chronic abdominal or pelvic pain - Limitation of free movement of organs, resulting in organ-specific pain - Disruption of the egg's path and movement, leading to infertility in women - Hindrance of the sperm's path and the implantation of the embryo, also contributing to infertility in women If a person experiences symptoms that indicate intestinal blockage or inflammation of the peritoneum, they should be immediately referred for a surgical consultation.

The main causes of Bowel Adhesions include previous abdominal surgery, injuries, diverticulitis, inflammatory bowel disease, placement of a ventriculoperitoneal shunt, peritonitis, pelvic inflammatory disease, treatments like abdominal or pelvic radiation, certain birth defects such as malrotation, and inflammation inside the abdomen or pelvis.

The doctor needs to rule out the following conditions when diagnosing Bowel Adhesions: 1. Severe inflammation of the bile duct (acute cholangitis) 2. Infection of the gallbladder and painful spasms of the bile duct (cholecystitis and biliary colic) 3. Condition characterized by high levels of ketones and acid in the body due to heavy alcohol use (alcoholic ketoacidosis) 4. Difficulty in passing stools or infrequent bowel movements (constipation) 5. Inflammation or infection of small, bulging sacs in the digestive tract (diverticulitis) 6. Painful periods (dysmenorrhea) 7. Loss of a pregnancy within the first 20 weeks (early pregnancy loss) 8. A painful condition where tissue similar to the tissue that normally lines the inside of the uterus, grows outside (endometriosis) 9. Inflammation of the appendix (appendicitis) 10. Long-term conditions causing inflammation in the gut (inflammatory bowel disease)

The types of tests that are needed for bowel adhesions include: 1. Direct viewing procedures: Laparoscopy or laparotomy are the most accurate ways to identify adhesions by directly viewing the abdominal cavity. 2. Imaging methods: While not as accurate as direct viewing, imaging methods such as X-rays, ultrasounds, MRIs, CT scans, and small bowel contrast studies can be useful in diagnosing obstruction caused by adhesions. 3. Laboratory tests: Laboratory tests such as a complete blood count, a full metabolic panel, lactic acid tests, arterial blood gas tests, blood culture tests, and procalcitonin tests can help determine the severity of obstruction and potential intestine damage. It is important to note that the specific tests ordered may vary depending on the individual patient and their symptoms.

Bowel adhesions are usually treated based on symptoms. Initial treatment involves giving the patient fluids by IV and replacing lost electrolytes to manage hydration. In severe cases, a patient may need to see a surgeon who can consider removing the adhesions. Non-surgical approaches, such as resting the bowel and using a nasal tube for relief, can sometimes resolve bowel blockages. Pain relief is usually provided via IV, but surgery may be necessary if the pain is strong and persistent. Surgical intervention using techniques such as laparoscopy or laparotomy is often the final approach to managing symptomatic bowel adhesions. Minimally invasive surgery techniques can help reduce adhesion formation.

The side effects when treating Bowel Adhesions include: - Bleeding - Infection - Damage to surrounding structures - Increased risk for formation of adhesions in the future - Cardiopulmonary complications related to anesthesia - Thromboembolic events (blood clots blocking blood vessels)

The prognosis for bowel adhesions is that there is no confirmed way to treat them without resorting to surgery. Patients with adhesions face a high likelihood of recurring symptoms, and the more instances of blockage occur, the higher the chance of it happening again. Most reoccur within 5 years of the initial event, but a significant risk persists even 10 to 20 years afterward. Surgical treatment may lower the chances of repeated hospital admissions, but the possibility of new episodes requiring surgical intervention remains the same.

A surgical consultation is recommended for Bowel Adhesions.