Adhesions Types, Symptoms and Treatment

Caecal Volvulus And Bascule

• It is a rare cause of intestinal obstruction. Presumably, it is more likely to occur following any surgical procedure.
• Which might require some degree of medial visceral rotation or disruption of the fusion plane between the caecum or ascending colon with the lateral peritoneum, providing sufficient mobility and allowing caecal volvulisation to occur.
• A constant feature of caecal bascule is the presence of a constricting band across the ascending colon. This may be found at laparotomy.
• In a plain X-ray abdomen, caecum produces round
• shadow in the centre of the abdomen.
• Resection is the ideal treatment.
• The lateral peritoneum, providing sufficient mobility allowing caecal volvulisation to occur.
• A constant feature of caecal bascule is the presence of a constricting band across the ascending colon. This may be found at laparotomy.
• In a plain X-ray abdomen, caecum produces a round shadow in the centre of the abdomen.
• Resection is the ideal treatment.

Caecal Bascule:

• Caecum folds anteromedial to the ascending colon, with production of a flap-valve occlusion at the site of flexion.
• Caecum will be markedly distended and will be found in the centre of the abdomen.
• Occasionally, it is associated with malrotation of the gut.
• There will be a constricting band across the ascending colon.
• It is also argued that caecal bascule can also be due to lack of fixation of large bowel. Resection is ideal even though fixation (caecopexy) is also another alternative.
• Bascule is a French term for seesaw and balance

Comparison of Caecal Volvulus and Sigmoid Volvulus:

1. Caecal volvulus:

• Rare
• Clockwise twist
• Mobile caecum
• Middle-aged  Elderly, debilitated
• Kidney-shaped gas shadow with single shaped.
• Treated only by   surgery be attempted in all cases, provided there is no ischaemia

2. Sigmoid volvulus:

• Common
• Anticlockwise
• The long mesentery is the cause
• Elderly, debilitated
• Omega sign or coffee  Two fluid levels fluid level on the can be found. left side
• Nonoperative treatment should

Adhesions And Bands

Adhesions Introduction

• Intra-abdominal adhesions develop after abdominal surgery as part of the normal healing processes that occur after damage to the peritoneum.
• The early balance between fibrin deposition and degradation seems to be the critical factor in adhesion formation.
• They also cause significant morbidity, including adhesive small bowel obstruction, infertility and increased difficulty with reoperative surgery.
• Thus, high chances of causing intestinal fistula after reexploration.

Adhesions Definition

• Peritoneal adhesions can be defined as abnormal fibrous bands between organs or tissues or both in the abdominal cavity that are normally separated.
• They are common causes of intestinal obstruction in the western world,
• Chinese population of Malaysia, etc. In India, adhesions and obstructed hernia are the two common causes in adults

Adhesions Causes

• Infection: Laparotomy done for acute appendicitis with or without perforation, perforation peritonitis, and intra-abdominal abscess have higher incidence of adhesions. Surgery is the commonest cause of peritoneal adhesions.
• Ischaemia: Lack of blood supply, particularly venous occlusion can cause adhesions, e.g. mesenteric vascular occlusion.
• Iatrogenic: It refers to talc, silk thread, foreign body (mop), etc. used for surgery which can induce extensive adhesions due to foreign body reaction (spilled gallstone also).
•  Injury: Injury to the bowel can result in adhesions.
• Irradiation: Irradiationenteritis is becoming common due to irradiation for carcinoma of the cervix.

Adhesions Pathogenesis

Ischaemia and irritation of the intestines are the chief factors responsible for adhesions.

Adhesions Types

1. Fibrinous adhesions (bread and butter adhesions):

• They are the causes of early postoperative
• obstruction, which settles down within 3–5 days.
• Majority of them disappear in due course of time.

2. Fibrous adhesions:

• If the infection is continuing or if foreign body is present, the fibrinous material is converted to a fibrous band.
• They also occur at the site of ischaemia.
• They will cause late intestinal obstruction.

3. Tuberculous adhesions: Tuberculous adhesions are dense adhesions that result in matting of intestinal coils. Separating them at laparotomy is extremely difficult.

Adhesions Clinical Features

• Recurrent abdominal pain, vomiting and distension are the typical features. Often the attacks are mild and self-limiting. However, persistent symptoms require monitoring and treatment.
• There may be peristalsis as in cases of terminal ileum.
• Gangrene is not common in cases of adhesive obstruction. However, these cases have to be closely monitored for any changes in the type of pain or new abdominal signs.

Severe pain, tachycardia, temperature, tachypnoea and tenderness in the abdomen indicate gangrene or perforation

Gilroy Benan triad of adhesive pain:

• Pain gets aggravated or relieved on a change of posture.
• Pain in the region of old abdominal scar.
• Tenderness elicited by pressure over the scar.

Adhesions Investigations

• Plain X-ray abdomen and small bowel enema: Very useful investigations to prove the obstruction.
• Computed tomography (CT): Enhanced with oral contrast:
• Detects air-fluid level: Complete obstruction
• The absence of mass lesion
• Dilated and collapsed loop junction
• Thickening and oedema of the bowel wall suggest intestinal ischaemia. The presence of intramural air is a late sign (gangrene)
• CT has a sensitivity of 90% and specificity of 88%
• Thus, CT and MRI are very helpful in patients with small bowel obstruction.

Adhesions Treatment

1.  Conservative Treatment:

• In the form of nasogastric aspiration, IV replacement of fluids and electrolytes to correct dehydration may be successful in early postoperative obstruction.
• If it is not successful, reoperation is required. Generally 48–72 hours is the waiting period in patients who present to the hospital as late adhesive obstruction. Further delay may result in perforation or gangrene of the bowel.
• Record pulse rate, blood pressure, abdominal girth and intake output. Increasing pulse rate, hypotension, increasing abdominal girth and oliguria in spite of adequate IV fluids will suggest gangrene. Such cases need to be explored immediately.

2. Surgical Methods: 

• Where fibrous bands are the cause, they need to be divided to relieve obstruction.
• Laparoscopic adhesiolysis is more often being used and it is indicated in pelvic adhesion, selected cases of abdominal adhesion, single band adhesion and obstruction with mild distension.

How to Decrease Adhesions?

• Handle the bowel carefully. Good suturing without tension. Avoid anastomotic leak.
• Raw peritoneal areas should not be sutured
• Thorough peritoneal toilet in cases of peritonitis with saline or dextran to drain pus, bile, and blood clots.
• Avoid spillage of contents—bile, faecal matter.
• Prefer a Pfannenstiel incision to a midline incision.
• Noble’s plication.
• Laparoscopic method produces decreased adhesions than laparotomy.
• Membrane barriers

3. Prevention of Adhesion:

1. Recently absorbable and nonabsorbable membrane barriers such as expanded polytetrafluoroethylene (PTFE) and membrane composed of hyaluronic acid and carboxy-methyl cellulose have been used.
2. Noble’s plication: By suturing loops together so that they are fixed in a suitable relation to one another (not very successful) describes summary of adhesive obstruction.

Membrane Barriers:

• The bioresorbable membrane called seprafilm is currently the most effective membrane barrier.
• It consists of hyaluronic acid and carboxymethylcellulose.
• At the completion of surgery, these films are placed at the potential sites of adhesion formation—such as pelvis, between the intestinal loops.
• Mechanism of action: Within the next 24 to 48 hours, the seprafilm membrane hydrates to form a gel-like barrier. It slowly resorbs within 7 days.
• These barriers should not be used to cover the anastomosis—chances of leak rates are high.

Adhesive Intestinal Obstruction

• It is the most common cause of intestinal obstruction (in the West).
• The most common cause of adhesion is inflammatory peritonitis.
• It is the cause of recurrent intestinal obstruction—often partial.
• Conservative treatment is successful in the majority of cases.
• One can wait for 3–4 days with careful monitoring before a decision of laparotomy is undertaken (worsening situation).
• Repeated X-ray abdomen and CT scans will show changes and progression of the obstruction.
• Most valuable clinical signs of ischaemia/gangrene are tachycardia and tenderness.
• Adhesiolysis/resection is the treatment.