Adhesions, General and After Surgery

An adhesion is a band of scar tissue that binds 2 parts of your tissue together. They should remain separate. Adhesions may appear as thin sheets of tissue similar to plastic wrap or as thick fibrous bands.

The tissue develops when the body's repair mechanisms respond to any tissue disturbance, such as surgery, infection, trauma, or radiation. Although adhesions can occur anywhere, the most common locations are within the stomach, the pelvis, and the heart.

• Abdominal adhesions: Abdominal adhesions are a common complication of surgery, occurring in up to 93% of people who undergo abdominal or pelvic surgery. Abdominal adhesions also occur in 10.4% of people who have never had surgery.
  
  
  • Most adhesions are painless and do not cause complications. However, adhesions cause 60%-70% of small bowel obstructions in adults and are believed to contribute to the development of chronic pelvic pain.
    
    
  • Adhesions typically begin to form within the first few days after surgery, but they may not produce symptoms for months or even years. As scar tissue begins to restrict motion of the small intestines, passing food through the digestive system becomes progressively more difficult. The bowel may become blocked.
    
    
  • In extreme cases, adhesions may form fibrous bands around a segment of an intestine. This constricts blood flow and leads to tissue death.
  
  
• Pelvic adhesions: Pelvic adhesions may involve any organ within the pelvis, such as the uterus, ovaries, fallopian tubes, or bladder, and usually occur after surgery. Pelvic inflammatory disease (PID) results from an infection (usually a sexually transmitted disease) that frequently leads to adhesions within the fallopian tubes. A woman's eggs pass through her fallopian tubes into her uterus for reproduction. Fallopian adhesions can lead to infertility and increased incidence of ectopic pregnancy in which a fetus develops outside the uterus.
  
  
• Heart adhesions: Scar tissue may form within the membranes that surround the heart (pericardial sac), thus restricting heart function. Infections, such as rheumatic fever, may lead to adhesions forming on heart valves and leading to decreased heart efficiency.

Adhesions develop as the body attempts to repair itself. This normal response can occur after surgery, infection, trauma, or radiation. Repair cells within the body cannot tell the difference between one organ and another. If an organ undergoes repair and comes into contact with another part of itself, or another organ, scar tissue may form to connect the 2 surfaces.

Doctors associate signs and symptoms of adhesions with the problems an adhesion causes rather than from an adhesion directly. As a result, people experience many complaints based on where an adhesion forms and what it may disrupt. Typically, adhesions show no symptoms and go undiagnosed.

Most commonly, adhesions cause pain by pulling nerves, either within an organ tied down by an adhesion or within the adhesion itself.

• Adhesions above the liver may cause pain with deep breathing.
  
  
• Intestinal adhesions may cause pain due to obstruction during exercise or when stretching.
  
  
• Adhesions involving the vagina or uterus may cause pain during intercourse.
  
  
• Pericardial adhesions may cause chest pain.
  
  
• It is important to note that not all pain is caused by adhesions and not all adhesions cause pain.

• Small bowel obstruction (intestinal blockage) due to adhesions is a surgical emergency.
  
  
  • These adhesions trigger waves of cramplike pain in your stomach. This pain, which can last seconds to minutes, often worsens if you eat food, which increases activity of the intestines.
    
    
  • Once the pain starts, you may vomit. This often relieves the pain.
    
    
  • Your stomach may become tender and progressively bloated.
    
    
  • You may hear high-pitched tinkling bowel sounds over your stomach, accompanied by increased gas and loose stools.
    
    
  • Fever is usually minimal.

• Such intestinal blockage can correct itself. However, you must see your doctor. If the blockage progresses, these conditions may develop:
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  • Your bowel stretches further.
    
    
  • Pain becomes constant and severe.
    
    
  • Bowel sounds disappear.
    
    
  • Gas and bowel movements stop.
    
    
  • Your belly will grow.
    
    
  • Fever may increase.
    
    
  • Further progression can tear your intestinal wall and contaminate your abdominal cavity with bowel contents.

See a doctor any time you experience abdominal pain, pelvic pain, chest pain, or unexplained fever. If you have undergone surgery or have a history of medical illness, discuss any changes in your recovery or condition with your doctor.

Go to the nearest emergency department if chest pain, abdominal pain, pelvic pain, or unexplained fever occurs.

Doctors typically diagnose adhesions during a surgical procedure such as laparoscopy (putting a camera through a small hole into the stomach to visualize the organs). If they find adhesions, doctors usually can release them during the same surgery.

Studies such as blood tests, x-rays, and CT scans may be useful to determine the extent of an adhesion-related problem. However, a diagnosis of adhesions usually is made only during surgery. A physician, for example, can diagnose small bowel obstruction but cannot determine if adhesions are the cause without surgery.

|Self-Care at Home|

Adhesions must be diagnosed and treated by a physician.

|Medical Treatment|

Treatment varies depending on the location, extent of adhesion formation, and problems the adhesion is causing. Adhesions frequently improve without surgery. Therefore, unless a surgical emergency becomes evident, a doctor may treat symptoms rather than perform surgery.

|Surgery|

Two common surgical techniques used to treat abdominal adhesions are laparoscopy and laparotomy.

• With laparoscopy, a doctor places a camera into your body through a small hole in the skin to confirm that adhesions exist. The adhesions then are cut and released (adhesiolysis).

• In laparotomy, a doctor makes a larger incision to directly see adhesions and treat them. The technique varies depending on specific circumstances.

|Follow-up|

If you have undergone surgery or have a history of medical illness, always discuss changes in your recovery or condition with your doctor.

|Prevention|

Several surgical products have been developed to prevent adhesions from forming during surgery. However, the effectiveness of these products is debatable.

|Outlook|

Adhesions requiring surgery commonly come back because surgery itself causes adhesions.

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Author: Eugene Hardin, MD, FACEP, FAAEM, Chair and Associate Professor, Department of Emergency Medicine, Charles R Drew University of Medicine and Science; Chair, Department of Emergency Medicine, Martin Luther King, Jr/Drew Medical Center.

Coauthor(s): Christopher R Westfall, DO, Staff Physician, Department of Emergency Medicine, Kern Medical Center.

Editors: Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Anthony Anker, MD, FAAEM, Attending Physician, Emergency Department, Mary Washington Hospital, Fredericksburg, VA.