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OUTLINE
INTRODUCTION
PATHOPHYSIOLOGY
CLINICAL FEATURES
MANAGEMENT
PREVENTION OF ADHESIONS
PERITONEAL ADHESION INDEX
CONCLUSION
INTRODUCTION
Intra-abdominal adhesions are the most common cause of small bowel obstruction (SBO) in
industrialised countries, accounting for approximately 65-75% of cases. Estimated risk of SBO;
Appendectomy 1-10%, cholecytectomy 6.4%, intestinal surgery 10-25%, restorative proctocolectomy
17-25%. There is a changing trend in causes of intestinal obstruction in semi-urban Nigerian
hospitals; adhesive obstruction is the commonest cause. Obstructed hernia becoming increasingly less
common.
Causes;
Types;
1. Type 1; fibrinous adhesion occur during 5-10th post surgical period. It usually get resolve
completely. It is avascular and flimsy.
2. Type 2; fibrous adhesion. Becomes collagenised and vascularised
PATHOPHYSIOLOGY
The peritoneal fluid contains inflammatory cells including leucocytes and macrophages. These cells,
along with the mesothelium secrete various cellular mediators that have roles in peritoneal healing.
Following peritoneal injury, there is bleeding and increase vascular permeability with leakage of
protein rich fluid (esp. fibrinogen) from injured surface.
The inflammatory cells release pro-inflammatory cytokines and activation of the complement and
coagulation cascade. Activation of the coagulation cascade results in formation of thrombin, which is
necessary for the conversion of fibrinogen to fibrin. Fibrin functions to restore injured tissue and once
generated, is deposited along peritoneal surfaces. It causes adjacent organs or injured serosal surfaces
to coalesce.
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Under normal circumstance, degradation of this filmy fibrous adhesion by locally released proteases
of the fibrinolytic system occurs with 72hours of injury. The fibrinolysis allows mesothelial cells to
proliferate and the peritoneal defects to be restored within 4 to 5 days, preventing the permanent
attachment of adjacent surfaces.
If fibrinolysis does not occur within 5-7 days, or if local fibrinolytic activity is reduced, the fibrin
matrix persists. The matrix gradually becomes organized as collagen-secreting fibroblast infiltrate the
matrix. Over time, it becomes cellular structure that contains arterioles, venules, capillaries and nerve
fibres.
In the body systems, there is maintenance of balance between the Activators and inhibitors of
fibrinolysis.
Activators;
They activate plasminogen to plasmin which in turn degrades extracellular matrix including fibrin.
Inhibitors;
Under normal conditions, fibrinolytic capacity exceeds coagulation in the peritoneum. However,
conditions causing peritoneal injury depress the fibrinolytic capacity. Cytokines especially TGF-B
release contributes to a decrease in peritoneal fibrinolytic capacity and may have role in preventing
the early dissolution of fibrous adhesions.
CLINICAL FEATURES
NB:
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INVESTIGATIONS
MANAGEMENT
Expectant management
1) IV fluid
2) N-G tube
3) IV antibiotics
4) Urethral catheter
5) An enema saponis or use of flatus tube insertion may be considered
6) Observation
a) Half-hourly pulse and blood pressure
b) Four-hourly measurement of abdominal girth
c) N-G tube drainage- amount and colour
d) Passage or otherwise of flatus
e) Persistence or otherwise of pain
f) Presence or otherwise of abdominal tenderness or rebound tenderness
I. A rising pulse rate and or falling BP. Indicative of worsening of general condition
II. Increasing girth suggestive of increasing distension of gut
III. Persistence of abdominal pain indicative of continuing obstruction
IV. Increasing amount of N-G tube aspiration or change in colour from clear or bilous to brown.
Suggestive of worsening of obstruction
V. Tenderness, rebound tenderness and or guarding or rigidity or palpable tender mass denoting
onset of strangulation.
Some surgeons advocate operative intervention in any patient who fails to show improvement within
48 hours. Others advocate a more liberal use of nonoperative therapy, citing a mean time to
successful resolution of up to 4.6 days.
However, prompt operative intervention is mandatory in patient who develop signs and symptoms
suggestive of strangulation obstruction. These parameters include fever, tachycardia, leukocytosis,
localized tenderness, continuous abdominal pain and peritonitis.
The presence of any three of these signs has 82% predictive value for strangulation, presence of four
has near 100% predictive value for strangulation.
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Operative management
ADHESIOLYSIS;
Open
Laparoscopic: is becoming popular, safer, ideal with less recurrent adhesion rate and gives
good results
Approach; At laparotomy, safe entrance may be best achieved by approaching this from the extreme
of the previous incision at virgin area rather than going through the mid portion of the incision.
Once in the peritoneal cavity, first is to identify site and cause of obstruction. Release fibrous
adhesions with sharp dissection. Inspect bowel for viability non-viable bowel should be resected.
Explore all four quadrants look for bowel injury or nonviable segments.
In noble placation of the intestine, adjacent coils of small intestine, arranged parallel are sutured at the
antimesenteric ends to prevent in-going for further recurrent adhesion. The bowel is initially freed
from the DJ junction to the ileocecal junction. Placation starts from above. Done for recurrent
adhesions.
Similarly, after freeing the bowel from adhesions from DJ junction to the ileocecal junction, the
mesentry is plicated 2-3cm from the bowel. It prevents crumpling of bowel and adhesion formation.
PREVENTION OF ADHESIONS
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PERITONEAL ADHESION INDEX
This is a classification system for adhesion to standardize their definition. It is based on the
macroscopic appearance of adhesions and their extent to the different region of the abdomen. The
surgeon can assign the index ranging from 1-30, there by giving the precise description of the intra
abdominal condition.
Right upper
Epigastrium
Left upper
Left flank
Left lower
Pelvis
Right flank
Central
Bowel to bowel
0 – no adhesion
PAI is then estimated by computing the adhesion grade score for each of the regions. It ranges
from 1-30
A standardized classification and quantification of adhesion allows more integration of results from
several studies and comprehensive approach to the management.
COMPLICATIONS OF ADHESIONS
Intestinal obstruction
Secondary female infertility
Ectopic gestation
Chronic abominal and pelvic pain
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REFERENCES
1. Attad JP, MacLean AR. Adhesive small bowel obstruction: epidemiology, biology and
prevention. Can J Surg 2007, 50:4 p 291-300
2. Coccolilni et al. Peritoneal adhesion index(PAI): proposal of a score for the ignored
iceberg of medicine and surgery. World journal of emergency surgery 2013,8:6 p3-5.
3. McGregor AL. Treatment of chronic adhesive obstruction by noble procedure. S A Med
J 1956, 30:9 p937-941
4. Guido M S et al. Small bowel obstruction. In: Maingot’s Abdominal operation. 12th ed.,
McGrawHill; 2013. 600-607
5. SRB manual of surgery. 5th ed.,Jaypee Brothers; 2016.p934-936.
6. Naaeder SB, Tandoh JFK. Acute intestinal obstruction.In: BAJA’s principles and
practice of surgery including pathology in the tropics. 5th ed., Repro India Ltd; 2015.
601p
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