Adhesive disease is a constant companion to any surgical intervention in the abdominal cavity. The severity of symptoms depends on the severity and extent of the process. It can be asymptomatic or cause significant discomfort to the patient. Some scientists believe that abdominal surgery in 100% of cases is accompanied by the formation of adhesions, but later some of the adhesions resolve on their own.
Occasionally, symptoms of congenital adhesions occur, which are found in newborns who have not previously undergone surgical interventions.
Laparoscopy is considered a new factor in the increasing incidence of adhesive disease.
Adhesive Disease Clinic
Adhesions formed in the abdominal cavity, regardless of the cause of their occurrence, cause a disorder of normal intestinal motility, which leads to difficulty in emptying the contents of the intestinal loops, causing pain in the abdomen and constipation. Bloating of the intestinal loops creates tension on the fixed omentum, which also gives rise to pain. When the adhesions are pulled, the nerves present in them can also contribute to increased pain. Sometimes adhesions create a constriction of the intestinal loop and cause acute intestinal failure. Due to the fact that the adhesive process can be located in different parts of the abdominal cavity, various organs can be involved in it.
Taking into account the complaints of patients, two clinical forms of adhesive disease can be distinguished:
- Adhesive disease with pain in the abdominal cavity.
- Adhesive disease with periodically recurring attacks of OKN.
Painful sensations during adhesive disease depend, on the one hand, on the irritation of the nervous apparatus of the intestinal loops, and on the other hand, on the irritation of the nervous elements. With adhesive disease, patients may experience pain in various parts of the abdomen, depending on the location of the adhesions, but the patient’s main complaint will be abdominal pain. In this group you can find patients with a relatively calm course of this disease - they have a history of 1-2 laparotomies.
Many patients begin to aggravate due to addiction to narcotic drugs. Abdominal pain can be small, aching in nature, in most cases it is constant pain, sometimes periodically intensifying. The pain often intensifies with physical stress or with errors in diet.
Increased pain forces patients to resort to using heating pads, after which the pain decreases and disappears completely. Along with abdominal pain, patients experience dyspeptic symptoms: nausea, constipation, bloating, etc. Patients of this type do not lose their ability to work, but constant aching pain forces them to often go to the clinic. Prescribing physiotherapeutic procedures in the form of diathermy and iontophoresis improves the condition and reduces pain. Patients can use HBOT, sulfur mud baths, which brings relief for some time.
A number of patients, against the background of constant abdominal pain, periodically experience severe painful attacks that require the administration of drugs. During such attacks, patients are admitted to hospitals, where they undergo a new laparotomy. The appearance of severe pain attacks is associated with great physical stress of the patient or with the consumption of large amounts of food, after nervous disorders.
Patients with frequently recurring attacks of pain become irritated, they develop psychasthenia, lose weight, decrease appetite, and often become drug addicts. Often these patients are harsh, rude, and their ability to work is usually reduced. Contact with such a patient is quite difficult. An objective examination reveals several postoperative scars; upon palpation outside of an attack, the abdomen is soft, usually painless; During a painful attack, a sharp pain is detected in certain parts of the abdomen, and there may be muscle tension. Various painkillers and physiotherapy provide only temporary relief.
The omentum sometimes adheres to the postoperative scar on the anterior abdominal wall and this often leads to pain. The tension of the omentum attached to the scar significantly increases pain when extending the body backwards. If the patient is asked to bend forward, the pain decreases. If there are positive symptoms of omental tension, patients are subject to surgical intervention, the purpose of which is to cut off the greater omentum and its resection.
In adhesive disease with periodically recurring attacks of OKN, along with abdominal pain and constipation, attacks of acute intestinal obstruction with typical clinical symptoms are observed: cramping abdominal pain, vomiting, impaired passage of gases, bloating, postoperative scars on the abdominal wall, palpation reveals some tension in the abdominal muscles, pain in the areas of bloating (P.N. Napalkov said: “the intestines stand like a stake”). Patients in these conditions are excited, Valya's symptom is determined, with a slight shock a splashing noise is detected - Sklyarov's symptom.
Due to the presence of scars on the abdominal wall, intestinal peristalsis is usually not observed. Hepatic dullness may be pushed aside by distended intestinal loops. Auscultation reveals bowel sounds of varying intonation. When examining the rectum, there may not be anything typical: sometimes the ampulla can be swollen, sometimes collapsed (the Obukhov hospital symptom appears quite late).
An X-ray examination reveals Kloiber's cups; with a pronounced adhesive process, Kloiber's cups do not move in different positions - a symptom of fixation. In this kind of patients, quite often the symptoms of obstruction are relieved after using the usual measures: a heating pad, a cleansing enema, but if we cannot completely exclude OKN, we need to observe the patient over time - radiologically trace the passage of barium suspension through the gastrointestinal tract. Usually, when a patient is admitted with an unclear clinical picture of OKN, the patient undergoes a survey X-ray of the abdominal cavity and after that they drink about 200 ml of barium suspension and, at an interval of 3 hours, the patient undergoes an X-ray of the abdominal cavity. To speed up the movement of barium, sometimes the suspension is made in very cold water (since cold water enhances peristalsis).
In this type of patient, it is often possible to stop the obstruction and they are discharged, and after a few days they can be admitted again. Such obstruction is often interpreted as dynamic intestinal obstruction of a spastic nature. The use of sedatives eliminates intestinal spasm, thereby restoring its patency. According to many authors, conservative treatment in this group of patients eliminates the symptoms of obstruction in 75% of cases. Surgical intervention for this type of obstruction without the use of conservative measures will be a surgeon’s mistake. At the same time, the surgeon faces a difficult task: is there a mechanical obstruction in this case that cannot be eliminated by conservative measures? A barium test helps here.
To eliminate mechanical obstruction, surgical intervention is necessary. The earlier the intervention is applied, the better the prognosis. We must always remember about the possibility of developing mechanical intestinal obstruction during adhesive disease. To eliminate mechanical intestinal obstruction, emergency surgical intervention is used, the volume of which varies (depending on the amount of intestinal necrosis).
Differential diagnosis of mechanical and dynamic intestinal obstruction is possible with the mandatory use of x-ray examination.
Clinic of adhesive disease in tuberculous peritonitis: as a rule, young people suffer; patients can palpate intestinal conglomerates; during an attack, loud peristalsis can be heard; the onset of pain is often preceded by an abdominal injury or sudden muscle tension. The clinical picture during an attack resembles acute intestinal obstruction with characteristic cramping pain and other symptoms. Some discrepancy between the existing phenomena of obstruction with a clearly expressed dysfunction, and the absence of peristalsis can help in diagnosis. The presence of a tumor formation with a smooth surface and fibrous encysted chronic peritonitis in the abdomen provides significant assistance for recognition - but this does not always happen.
Laboratory data do not provide anything pathognomonic for adhesive disease: ESR may be accelerated, leukocytosis may appear when a painful attack occurs, and the same can be observed with the development of acute intestinal obstruction. To establish a diagnosis of adhesive disease, it is necessary to conduct an X-ray examination of the gastrointestinal tract, since the presence of laparotomies in the anamnesis does not indicate the presence of adhesions in the abdominal cavity. Until recently, laparoscopy was contraindicated, as there is a high risk of damage, but modern endoscopists use laparoscopy for adhesive disease.
X-ray diagnostics is based on the detection in a polypositional study of various types of deformations, unusual fixation, adhesions with the abdominal wall; they study the state of the relief of the mucous membrane, the elasticity of the intestinal walls, especially in the deformation zone: the folds of the mucous membrane, although deformed, do not break off, unlike the tumor process. The adhesive process is not characterized by rigidity of the intestinal wall, which is characteristic of a malignant tumor.
Conservative treatment of adhesive disease: usually adhesive disease has a chronic course, only periodically giving attacks - exacerbation of pain. Therefore, conservative treatment in remission is modified when a painful attack occurs. A painful attack with some gas retention can be stopped with a cleansing enema, heat on the stomach, and antispasmodics. In a hospital setting, epidural blockade of trimecaines has a positive effect. Previously, lumbar blockades according to Vishnevsky were widely used, however
If you have constipation, it is recommended to eat foods that enhance intestinal motility, but not too much. If constipation continues, mild laxatives should be used and regular meals are necessary. You should not eat food that can cause severe bloating - soy food, large amounts of cabbage, milk, etc. Physiotherapeutic procedures should be periodically applied - solar plexus diathermy, paraffin or ozokerite applications on the stomach, iontophoresis, mud therapy can be recommended. Physiotherapeutic procedures must be combined with a diet. If the diet is not followed, physiotherapeutic procedures are ineffective. Heavy physical work should be avoided; muscle tension increases pain. By following a diet, monitoring regular bowel movements, and periodically applying physiotherapeutic procedures, patients with adhesive disease can live tolerably for a long time. But a violation of this lifestyle immediately leads to an exacerbation of adhesive disease.
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Diet rules for illness
Diet during adhesive disease plays a huge role in preventing the development of intestinal obstruction. It is not recommended to follow a variety of diets, as they provoke constipation. The correct eating pattern affects the entire functioning of the gastrointestinal tract.
It is recommended for patients with adhesions:
- eat nutritiously, often and in small portions;
- avoid hunger strikes and overeating (it is advisable to adhere to a strict regimen of eating at the same time);
- drink at least 2.5 liters of clean water per day;
- give up alcohol, coffee, spicy foods, canned food, white sugar, foods that cause flatulence (cabbage, legumes, grapes, corn, radishes).
It is also advisable to avoid drinking whole milk and carbonated drinks and include calcium-rich foods in your diet: cottage cheese, hard cheeses, kefir.
Abdominal adhesions significantly worsen the quality of life of patients, therefore, after any surgical intervention, it is recommended to begin measures to prevent the development of the pathological process.
Adhesions in the intestines, adhesions in the pelvis, adhesive disease of the abdominal cavity ... Very painful phenomena that cause a lot of discomfort and lead to serious complications. Today we will talk about the causes of their occurrence, symptoms and signs, conservative and surgical treatment, and, of course, the prevention of adhesions.
Adhesions are connective tissue that forms between organs, subsequently leading to their fusion. If you do not resort to timely treatment, the adhesive process can lead to very serious consequences for a person.
Surgical treatment of adhesive disease
Treatment is a very difficult task - you can never be sure that a laparotomy performed for adhesive disease will be the last for the patient and will eliminate the process that caused the adhesive process. Therefore, it is always worth considering the feasibility of a particular operation and drawing up a clear plan based on a clinical examination. Only in emergency cases should this scheme be abandoned. The question of the soldering of small intestinal loops to the scar remains open. Therefore, during laparotomy, the old scar should not be excised - the incision is made 2-3 cm away from the scar.
When separating intestinal adhesions, it is advisable to use hydraulic preparation with novocaine. Deserosed areas of the intestinal walls must be carefully sutured. The soldered sections of the gland should be crossed between the applied ligatures. In cases where the intestinal loops form very adherent conglomerates, and it is not possible to separate them, it is necessary to apply a bypass anastomosis between the adductor and efferent intestines (as if to shunt), since the separation of this conglomerate will take a lot of time, and secondly, it will cause additional trauma to the peritoneum . Before deciding on planned surgical intervention, patients require a high-quality X-ray examination. During surgery, releasing intestinal loops from adhesions is a rather difficult task, which, according to Noble, takes about 90% of the operation time. In 1937, Noble proposed an operation, which was called Noble enteroplication of the intestine.
The essence of the operation is that after separation of the adhesions, the intestinal loops were laid horizontally or vertically and sutured together in the area of the mesenteric edge with a continuous thread. Thus, the intestinal loops were fixed in a certain position, and later they grew together. Recurrences of intestinal obstruction were observed after surgery - 12-15%, so this operation was treated with caution. In addition, stitching the intestinal loops takes a lot of time, then the loops begin to peristalt worse.
In 1960, this operating principle was modified by Chalds and Phillips, who proposed to perform enteroplication not by suturing intestinal loops, but by suturing the mesentery of the small intestine with a long needle. Surgery using this method provides better peristalsis and an easier postoperative period. In addition, less time is spent on this operation.
In 1956, White and in 1960, Deder proposed fixation of intestinal loops with an elastic tube inserted into the intestinal lumen by enterostomy. Dederer proposed performing a microgastrostomy, through which a long tube with many holes was inserted throughout the entire length of the small intestine. This method is not bad at all due to the fact that the tube was a frame for intestinal loops and the loops were fixed and fused in a functionally advantageous position. But opening the stomach cavity (Dederer) or intestine (White) was unfavorable with regard to infection of the abdominal cavity. However, during operations for intestinal obstruction, the tube is passed transnasally, bringing it almost to the ileocecal angle.
The tube is fixed to the wing of the nose; later, during the period of intestinal paresis, the contents of the intestine are drained through this tube; nutrients can be introduced into this tube. But basically it is removed a few days after surgery, after reliable restoration of peristalsis, since long-term removal of intestinal contents can cause electrolyte imbalances.
Prevention
Prevention of adhesive disease consists of timely surgical intervention for acute diseases of the abdominal organs, without harsh actions, without stopping tampons (there are indications for installing tampons - unstoppable bleeding, when an abscess opens in the abdominal cavity), using tubes made of erective materials. Sanitation of the abdominal cavity is important, which must be carried out using an electric suction, using gentle methods and only drying in hard-to-reach places with tampons.
After suffering peritonitis, the patient must remain under the supervision of a surgeon for a long time. Very early after surgery, it is necessary to stimulate intestinal peristalsis; this is facilitated by the placement of an epidural catheter, HBOT, proserin, and hypertensive enemas. To prevent the occurrence of adhesions, the introduction of anticoagulants, novocaine, prednisolone with novocaine has been proposed. The positive effect of intra-abdominal influence of fibrinolysin with hydrocortisone has been proven. However, all these methods are not reliable. Examination of disability. Adhesive disease reduces the ability to work, causing them some kind of disability. After surgery, patients are referred to VTEK. More often, a decrease in working capacity allows them to be assigned to group 3 disability. Patients should be transferred to work with physical stress. Abdominal injuries in patients with adhesive disease can often lead to intestinal rupture, since the intestinal loops are fixed and cannot move with a direct blow.
Symptoms of adhesions
The symptoms of the adhesive process depend on the location of its occurrence:
- Respiratory system - when adhesions appear, shortness of breath appears, and it becomes more difficult for a person to breathe.
- Intestinal area - the adhesive process of the abdominal cavity is characterized by bloating, with stool disturbances, increased gas formation, as well as pain during bowel movements.
Symptoms of adhesions in the pelvic area are characterized by:
- Menstrual irregularities.
- Increased body temperature.
- The appearance of vomiting, attacks of nausea.
- The occurrence of bleeding during the intermenstrual period.
- Pain in the lower abdomen of a pulling or acute nature.
People who have adhesions in the intestines or pelvis are characterized by a constant unsatisfactory general condition of the body, manifested in:
If the adhesive process in the pelvis or abdominal cavity is acute, then a rise in temperature is possible, nausea, vomiting, development of intestinal obstruction with severe pain, bloating, and signs of general intoxication develop.
