Bowel adhesions

Physicians consider intestinal adhesions the result of a pathophysiological process that develops in the abdominal cavity and can either be asymptomatic or manifest itself with a variety of symptoms.

To date, intestinal adhesions after surgery (postoperative peritoneal adhesions) remain a serious clinical problem for both surgeons and patients.

Epidemiology

• Adhesive intestinal after operation on the abdominal organs (especially on the small and large intestine) are formed in 80-85% of patients;
• After repeated laparotomy, adhesions occur in 93-96% of patients;
• Adjuvant spasms after appendicitis are noted one year after appendectomy in 23% of operated patients, and after three years - in 57%;
• adhesions of the intestine and uterus, as well as adhesions of the intestine and ovary occur in 70% of cases of surgical treatment of gynecological pathologies;
• in 10-20% of cases, spikes accidentally occur in patients who have not undergone surgery.

[1], [2], [3], [4], [5], [6]

Causes of the intestinal adhesions

The term "adhesions" (in the English version - adhesions, that is, adhesion or adhesion) refers to the process of scar tissue formation between the intestinal loops, and between individual parts of the intestine and the inner membrane of the abdominal wall (peritoneal lining). These are adhesions of the small intestine and adhesions of the large intestine.

Other abdominal organs and pelvic organs may also be affected: liver, gall bladder, uterus (adhesions of intestine and uterus), fallopian tubes, ovaries (intestinal and ovarian adhesions), bladder.

The key reasons for the formation of intestinal adhesions after surgery - including intestinal adhesions after appendicitis (appendectomy) and after cesarean section (surgical delivery method) - are due to the fact that during abdominal surgery by laparotomy:

• the integrity of the tissues of the peritoneum and internal organs is disturbed;
• mucous membranes of internal organs lose moisture (it is proved that drying of tissues during surgery increases the formation of adhesions);
• internal tissues are contacted with foreign substances (instrumentation, tampons, sutures, etc.);
• on the tissues inside the abdominal cavity remain blood or its clots.

Much less often they are the result of closed injuries of the abdominal cavity and inflammatory processes, that is, are not associated with abdominal surgery. Thus, chronic intestinal adhesions can be formed with prolonged inflammations in the mesenteric part of the small intestine (enteritis), the blind and sigmoid colon of the large intestine, as well as with gynecological infections and radiation damage to tissues during radiotherapy of malignant tumors in the abdominal cavity.

Adhesion of the intestine in children at an early age can arise due to congenital anomalies of the intestinal structure: small intestinal atresia, dolichosigma (lengthening of the sigmoid colon), coloptosis (abnormal colon position), embryonic colon cramps, intussusception of the intestine. Also, intestinal adhesions in children are formed, as in adults, after abdominal operations in the abdomen or pelvis.

[7], [8], [9], [10], [11], [12]

Risk factors

Almost everyone who goes through an operation with laparotomy is likely to have adhesions; and the risk factors for adhesive processes in the intestine are violations of the fibrinolytic system of the body (functionally opposite to the blood coagulation system). The presence of problems with fibrinolysis can be tracked by specialists by examining the level of the inhibitor of the plasminogen activator in the blood, the tissue plasminogen activator, and the fibrin degradation products in the peritoneal fluid.

According to surgeons, chronic intestinal adhesions without a previous operation are more likely to occur in inflammatory processes against abdominal obesity, that is surplus of adipose tissue in the zone of the large epiploon (folds located behind the visceral leaf of the peritoneum and the lap of the intestine). Because the loose connective tissue of the omentum is particularly susceptible to the formation of adhesions under the pressure of fat deposits in the abdomen.

[13], [14], [15], [16], [17]

Pathogenesis

Studies of cellular and humoral mechanisms of adhesion formation have shown that their pathogenesis lies in the violation of the local balance between fibrin synthesis and its fibrinolysis. In the course of bandages or inflammations, the mesothelial layer of the tissues of the organs and blood vessels is damaged, causing a natural protective inflammatory reaction with simultaneous activation of inflammatory mediators, a cascade of coagulation and deposition on the damaged fibrin site, an insoluble basis for the formation of a blood clot.

As a result, the permeability of the blood vessels rises, and the damaged tissue secrete the supporting healing process serous-hemorrhagic exudate. It contains leukocytes, platelets, interleukins, macrophages, plasma protein fibrinogen, hyaluronic acid, proteoglycans. Under normal conditions, fibrin undergoes lysis under the influence of tissue plasminogen activators, but in operations fibrinolytic activity decreases, and excess fibrinogen is converted into highly adhesive fibrin gel matrices that cover the tissues. Fibroblasts begin to expand and bind together the anatomically distinct structures of the abdominal cavity, turning, in fact, into internal scars - intestinal adhesions in the form of fibrous joints.

[18], [19], [20], [21], [22],

Symptoms of the intestinal adhesions

What are the symptoms of intestinal adhesions? Most of the adhesions of the abdominal cavity remain unnoticed, but if the existing pathology shows itself, then its first signs are a sensation of pain.

It should be noted that periodically arising pains during intestinal adhesions are localized in the abdominal cavity or in the small pelvis - depending on the place of formation of fibrous connections between the intestinal loops and surrounding anatomical structures.

Painful spasms or pulling pain can become more intense after a short time after eating and during physical exertion. As doctors emphasize, the pain associated with intestinal adhesions often imitates pain with inflammation of the appendix, endometriosis, or diverticulitis.

Symptoms of intestinal adhesions also include: a feeling of discomfort in the abdominal cavity due to increased formation of intestinal gases (flatulence) and internal pressure on the abdominal wall (in the umbilical region or slightly lower), loud rumbling in the abdomen and its swelling.

Regular constipation occurs during intestinal adhesions, which is associated with a difficult movement of the contents of the intestine due to violations of peristalsis. After eating, you may experience nausea and even vomiting. If there are chronic intestinal adhesions, then, in addition to these symptoms, there is a decrease in body weight.

Despite the gradual increase in the level of fibrinogen in pregnant women by the end of the period, new intestinal adhesions during pregnancy are not formed. However, the existing "internal scars" can make themselves felt and create additional problems: from slight pain in the abdomen (30-45 minutes after eating) to intense drawing and stitching pains.

[23], [24]

Complications and consequences

What are dangerous intestinal adhesions? Adhesions of the small intestine in the abdominal cavity often cause such negative consequences for the functioning of the digestive system, which can only be a reoperation.

According to gynecologists, intestinal and uterine adhesions can lead to secondary dysmenorrhea, and intestinal and ovarian adhesions or intestinal loops with fallopian tubes - to the impossibility of becoming pregnant.

The presence of intestinal adhesions significantly complicates any surgical intervention in the abdominal cavity, increasing the risk of bleeding and intestinal perforation.

But the most dangerous complications of peritoneal fibrous adhesion are intestinal obstruction with spikes, which account for more than 40% of all cases of obstruction and 60-70% of small intestinal obstructions. The cause of intestinal obstruction in pregnant women in 55% of cases are also intestinal adhesions after surgery, postponed until pregnancy.

Adhesion of the intestine can bend, stretch and rotate individual parts of the intestines so that their lumen decreases or completely overlaps. This causes the development of intestinal obstruction, when the contents of the gastrointestinal tract - partially or completely - ceases to move through the corresponding parts of the intestine. Complete obstruction of the intestine - an acute, life-threatening condition requiring immediate medical attention, including surgical.

Intestinal obstruction with adhesions (or bowel obstruction) causes severe pain and cramping in the abdomen, vomiting, constipation and retention of intestinal gases, swelling of the abdominal cavity; with acute obstruction, skin blanching, cold sweating, a sharp decrease in blood pressure and tachycardia are also observed. Local blood supply due to twisting of the intestinal loops stops, which can lead to tissue necrosis and the development of peritonitis.

Infants with intestinal obstruction are attacked by crying, pulling the legs and the whole body, less often urinate, the skin over the fontanel is retracted, and the vomitic masses are green.

[25], [26], [27], [28], [29]

Diagnostics of the intestinal adhesions

To date, the ability to identify and locate the location of peritoneal fibrous adhesion is provided only by instrumental diagnostics.

In this pathology the most informative and objective method is diagnostic laparoscopy.

Also gastroenterologists apply: irrigography (intestinal X-ray with the introduction of barium, can detect abnormal angulation of intestinal loops); Colonoscopy (endoscopic examination of the rectum); electrogastroenterography; ultrasound examination (ultrasound) and computed tomography (CT) scan of the intestine and abdominal organs.

A doctor can prescribe a general blood test to rule out the development of inflammation.

[30]

Differential diagnosis

Since both abdominal pain, and constipation, and the rest of the symptomatology is nonspecific, differential diagnosis by ultrasound and CT is necessary, which allows excluding other causes of obstruction, for example, a tumor or stricture of the intestine.

Treatment of the intestinal adhesions

It should be noted immediately that in modern clinical practice, including foreign medicine, the treatment of intestinal adhesions - with severe symptoms and the problems caused by them - is performed surgically: the medical method of "breaking" fibrous fibers that connect the intestinal structures can not yet. Especially, if the spikes formed long ago, and the fibrin strands managed to become dense and durable.

Operative treatment for extensive adhesions is carried out by laparotomy, that is, with a sufficiently large incision of the peritoneum, after which the dissection of the intestinal adhesions is performed on the open surgical field. However, there is a high probability (30-40%) that after this operation there will be new spikes.

In the presence of single adhesions, their dissection is performed by a laparoscopic method (with the introduction into the abdominal cavity of a special endoscopic device through small incisions). And although laparoscopic surgery is certainly the best option, but traumatizing the tissues when dissecting the fibrous strand is also fraught with relapse of the adhesion process.

Also, minimally invasive treatment of intestinal adhesions with a laser is practiced - with a small area of the fibrous joint and its clear localization.

Treatment of intestinal adhesions without surgery

Domestic physicians perform treatment of intestinal adhesions without surgery with the help of certain drugs that should prevent the conversion of fibrinogen into fibrin or activate the fibrinolytic system of the body.

The most commonly used drugs are:

• anticoagulant Heparin - is administered right after the operation in the subcutaneous fatty tissue (5000 units twice a day); contraindicated in bleeding and increased bleeding, problems with kidney or liver, leukemia and anemia.
• corticosteroid Hydrocortisone (2.5%) is injected into the abdominal muscle or into the cavity after the operation (100-500 mg) 4 times a day; although among the contraindications of the drug (except for severe arterial hypertension, nephritis, osteoporosis, stomach ulcers and diabetes), recent surgical interventions are indicated. Side effects of Hydrocortisone include inflammation of the pancreas, decreased immunity, as well as anaphylactic shock and cardiac arrest.
• Enzyme preparation of Hyaluronidase (Lidase), according to the instructions, is used if necessary to remove joint contracture, remove bruises and soften scars on the skin.
• Urokinase (fibrinolytic), is used by intravenous infusions with thrombophlebitis, pulmonary embolism and the formation of other arterio-venous thrombi. The standard dose is 1000-2000 IU / kg / hour. Among the contraindications appear bleeding and the risk of their occurrence, open wounds, and among the relative contraindications indicated recently transferred operations.
• the drug Fibrinolysin has the same indications and contraindications as Urokinase, since both drugs act, respectively, on the blood coagulation system and fibrinolysis. Fibrinolysin is usually administered during surgery in the abdominal cavity (often in combination with Heparin).

In addition, with severe pain, such painkillers are used for intestinal adhesions, like Paracetamol, Spasmalgon, No-shpa (1-2 tablets up to three times a day). Assign and vitamins, as a rule, it is tocopherol and folic acid.

Treatment of intestinal adhesions without surgery, according to tradition, includes physiotherapy treatment - in the form of electrophoresis with various drugs, applications of paraffin to the abdomen, etc. However, the expediency of physiotherapy is highly questioned by many specialists, since they do not lead to the elimination of the formed adhesions. For the same reason, do not do an intestinal massage with spikes that occurred long before the manifestation of the symptoms of the pathology.

Alternative treatment and homeopathy

Among alternative methods, the most medically acceptable is alternative treatment using leeches, whose saliva contains anticoagulant hirudin.

Undoubtedly useful is the advice to use olive oil with large intestine adhesions, since unsaturated omega acids of this oil have a beneficial effect on the mucous membranes of the gastrointestinal tract. In addition, olive oil (which can be replaced by almost any other) prevents the formation of so-called fecal stones, greatly complicating the process of defecation with adhesions of the large intestine.

But castor oil, alternative healers are advised to apply externally - in the form of warm compresses on the stomach. It is said that this oil is especially good for women who have intestinal and uterine adhesions, as well as intestinal and ovarian adhesions. Castor oil derived from castor oil seeds (Ricinus L.) contains ricinoleic acid, which is easily absorbed into the body through the skin, stimulates lymphatic drainage and enhances the excretion of tissue metabolism products.

As a multifunctional symptomatic, it is recommended to take alcohol tincture of the juniper bark. To prepare it, 50 g of dry bark is poured into 150 ml of vodka and insisted for 20 days. Tincture should be taken on 25-30 drops twice a day (before meals).

You can try herbal treatment, for example, to relieve spasms of the intestines, a decoction of chamomile flowers, crushed root of ara and leaves of peppermint (in a ratio of 2: 1: 1) is used - a tablespoon of the mixture for 200 ml of water. It is taken several sips three times a day.

It is recommended to cook and take half a cup twice a day (half an hour before eating) a decoction of flowers of red clover, grass, St. John's wort, peony roots, bark of the twig (mammal or fang). Decoctions are prepared at the rate of one tablespoon of raw material for 250 ml of water. You can also prepare a water infusion of safflower dye (Carthamus tinctorius).

Homeopathy can offer preparations of Aconitum napellus C6 (in granules), drops based on the seeds of the flesh of Staphysagria, Arnica montana (granules C3, C6), drops with daisy extract Bellis perennis for the treatment of intestinal adhesions. Dosage is determined by a homoeopathic physician individually.

How is mustard used for intestinal adhesions? The composition of liquid homeopathic remedy Thiosin Aminum, which is made from mustard seed oil, containing a whole complex of biologically active substances, including polyunsaturated fatty acids, vitamins A, D, B3, B4, B6, E, etc.

[31], [32], [33], [34]

Diet with intestinal adhesions

Digestive problems and diet with intestinal adhesions are one of the biggest difficulties in this pathology, because in some cases food is not normally digested. Therefore, it is recommended to take only moderately warm soft food. In this case, eat more often, but in small portions. Overeat is categorically contraindicated!

[35],

What foods can not be consumed with intestinal adhesions?

From the diet should exclude foods high in fiber and vegetable fibers, so that they do not overload the intestines and do not increase the formation of intestinal gases (and at the same time, pain). So the consumption of bread is reduced to 150 grams a day, you can only look at fresh fruits and vegetables, and porridge during intestinal adhesions, especially during periods of intense symptoms, will have to be very digested and made semi-liquid. Read more - Diet in flatulence

To undesirable products, dietitians include whole milk, all fatty, spicy, canned and fried. It is necessary to drink enough water (still), fresh kefir and green tea are very useful - with adhesions of the large intestine.

Although such a diet with intestinal adhesions does not match the needs of the body in nutrients, it can reduce abdominal pain while treatment is under way.

What can I eat with intestinal adhesions? Dietary recommendations

Soups with low fat broth and cream soups, low-fat fish and chicken (boiled or steamed), boiled eggs and omelets, all sour-milk (including cheese and cottage cheese).

Limitations and recommendations for products can vary depending on the nature of intestinal complications, so even an approximate menu for intestinal adhesions should be tailored to the individual characteristics of each patient.

Gymnastics for intestinal adhesions

Therapeutic exercises with intestinal adhesions are designed to provide both a sufficient (but not excessive) level of physical activity, and a purposeful dynamic impact on the problem area - the abdominal cavity.

The most useful exercises with intestinal adhesions should activate local blood supply of intestinal tissues, strengthen the abdominal wall and increase the elasticity of internal muscle fibers.

You should do all the exercises in a hurry, each - 8-10 times and better - lying on your back on a hard surface.

1. Simultaneous bending of the legs in the knees with the subsequent straightening to the starting position.
2. After the legs were bent, laying both hands behind the head, raise the shoulder blades (the abdominal press strains at the same time); then the starting position is taken (legs straight, hands along the body).
3. With bent knees, the waist and pelvis break away from the floor and are held in this position at the expense of 1-2-3 (emphasis on the feet and shoulder blades, arms stretched along the trunk).
4. Simultaneous bending of the legs in the knees with a subsequent tilt of them first to the right, and then to the left (without tearing the back and waist from the floor).
5. The famous "bicycle" is made with the maximum amplitude of the shins towards the abdominal wall and chest.
6. Alternate bending of the legs (with separation from the floor) and touching the knee with the opposite elbow, with a slight turn of the body towards the knee bent in the knee.

Yoga during intestinal adhesions is, in the main, in the "belly-breathing" known to everyone. Exercise is best performed while standing. First you need to put the right palm on the chest area, and the left one - on the stomach, below the navel. Through the nose, a deep breath is taken, at the same time the lower part of the lungs is filled with air (the abdominal wall must be raised and strained, and this can be seen on the left palm, which also rises). It is very important that the palm resting on the chest during the inspiration remains fixed.

Filling your stomach with air to the limit, you should breathe it out through your nose very slowly and literally "squeeze" it out of yourself, pulling the abdominal wall as deep as possible (towards your back). During this breathing, there is a natural self-massage of the intestinal structures located immediately behind the peritoneum. But such an exercise is contraindicated for violations of the heart rhythm.

Prevention

Adhesion of the intestine is difficult to prevent, but modern surgical technologies can reduce the risk of their occurrence with the help of unique materials - biodegradable (not requiring removal) films that protect abdominal tissue from peritoneal fibrous adhesion.

Today, in operations performed by laparotomy (with large incisions with a scalpel and an extensive operating area), prevention of intestinal adhesions can be carried out using the adhesion barriers Hyalobarrier, PrevAdh, Intercoat, Evicel, Surgiwrap, CoSeal, Seprafilm.

[36], [37], [38], [39], [40], [41], [42]

Forecast

Leading surgeons believe that modern science is able to defeat intestinal adhesions after surgery, and in the near future the prognosis for patients will be only favorable, and they will not suffer from the consequences and complications of intestinal adhesions.

[43], [44], [45]