What Are Colon Adhesions?

Adhesive intestinal obstruction is mostly intestinal obstruction. Previous survey statistics show that the incidence is about 40% of intestinal obstruction, of which 70% to 80% have a history of abdominal surgery. Adhesive intestinal obstruction is mostly manifested as simple intestinal obstruction, and a few are also converted into strangulated intestinal obstruction, and even the latter is the primary manifestation.

Zhu Weiming	(Chief physician)	General Surgery, Nanjing Military Region General Hospital
Cao Lei	(Attending physician)	General Surgery, Nanjing Military Region General Hospital

Adhesive intestinal obstruction refers to the intestinal adhesions in the abdominal cavity caused by various reasons, which causes intestinal contents to not pass and run smoothly in the intestine. When the intestinal contents are blocked, a series of symptoms such as abdominal distension, abdominal pain, nausea and vomiting, and defecation disorders can occur. It belongs to the category of mechanical intestinal obstruction. It can be divided into acute intestinal obstruction and chronic intestinal obstruction according to the onset of onset. According to the degree of obstruction, it can be divided into complete intestinal obstruction and incomplete intestinal obstruction. , Low intestinal obstruction and colonic obstruction; according to the intestinal blood supply is divided into simple intestinal obstruction and strangulated intestinal obstruction. Part of the disease can be resolved by non-surgical treatment, but most recurrent or conservative treatments are ineffective and still require surgical treatment.

Western Medicine Name: Adhesive intestinal obstruction
English name: Adhesive Intestinal Obstruction
Affiliated Department: surgical-
Disease site: Small intestine, colon

The main symptoms: Bloating, abdominal pain, nausea and vomiting, defecation disorders
Main cause: Congenital abnormalities, acquired abdominal inflammation, abdominal injury, bleeding, foreign body in the abdominal cavity, etc.
Contagious: Non-contagious

Epidemiology of adhesive intestinal obstruction

Causes of Adhesive Intestinal Obstruction

Adhesive intestinal obstruction is mostly acquired except for a few congenital factors in the abdominal cavity, such as congenital abnormalities or meconium peritonitis. Common causes are abdominal inflammation, injury, hemorrhage, and foreign bodies in the abdominal cavity. They are more common after abdominal surgery or abdominal inflammation. Adhesion after abdominal surgery is currently the leading cause of intestinal obstruction. In addition, abdominal radiotherapy and intraperitoneal chemotherapy can also cause sticky intestinal obstruction. Pelvic surgery (such as after gynecological surgery, appendectomy, and colorectal surgery) and lower abdominal surgery are particularly prone to intestinal adhesions and intestinal obstructions because the pelvic small intestine is more free and the upper abdominal small intestine is relatively fixed. However, patients with intestinal adhesions do not necessarily have intestinal obstruction, and the occurrence of adhesive intestinal obstruction does not necessarily mean that there is extensive and severe adhesion in the abdominal cavity. Only when the intestinal adhesion points form an acute angle to hinder the passage of the intestinal contents, the two ends of the adhesion band are fixed to bind the intestines, or a group of intestines adhere to form a group, and the intestinal wall is scarred and narrowed to cause adhesive intestinal obstruction. ^[1]

Clinical manifestations of adhesive intestinal obstruction

The main clinical manifestations of adhesive intestinal obstruction are the symptoms of mechanical intestinal obstruction: abdominal pain, vomiting, abdominal distension, and stopping exhaust defecation.

(1) Abdominal pain: When intestinal obstruction, due to intestinal peristalsis enhancement, paroxysmal abdominal cramps often occur. During the onset of abdominal pain, the patient often feels that there is gas in the abdomen, and the bowel type can be seen or choked. Hearing bowel sounds can be heard; if the intestinal obstruction is incomplete, when the gas passes through the obstruction, the pain suddenly decreases or disappears; Excessive stretch, pain is continuous and paroxysmal aggravation; late in the course of the disease due to excessive expansion of the intestinal tract above the obstruction, weak contraction, the degree and frequency of pain are reduced; when intestinal paralysis occurs, abdominal pain changes to persistent abdominal distension.

(2) Vomiting: The frequency of vomiting, the amount of vomiting, and the characteristics of vomiting vary with the level of the obstruction. The upper small intestinal obstruction and vomiting occur earlier and more frequently, and the amount of vomiting is higher; in the low small intestinal obstruction and colonic obstruction, vomiting occurs late, and the number of vomiting is less, and the vomit is often fecal.

(3) Abdominal distension: abdominal distension caused by intestinal dilatation during obstruction. The degree of bloating varies depending on whether the obstruction is complete and the location of the obstruction. The more complete the obstruction, the lower the site, the more obvious the abdominal distension; sometimes the obstruction is complete, but due to the loss of intestinal storage, early and frequent vomiting, abdominal distension may not occur; if you do not pay attention to this situation, it may lead to missed diagnosis and misdiagnosis. If the obstruction of the intestinal canal becomes closed, it often shows asymmetrical abdominal distension, and sometimes the dilated intestine can be reached there.

(4) Stop exhaust defecation: Intestinal obstruction Because the intestinal contents cannot be discharged, the anus stops exhaust defecation. However, it must be noted that the contents of the intestine distal to the obstruction site can still be delivered by peristalsis. Therefore, even with complete obstruction, the patient can continue to have defecation before these contents are cleared, and there is no more defecation after defecation. Of course, in incomplete obstruction, the phenomenon of exhaust defecation will not completely disappear. In addition, the clinical symptoms of intestinal obstruction include water, electrolyte and acid-base balance disorders. In the case of strangulated obstruction, intestinal necrosis, shock, peritonitis, and gastrointestinal bleeding may appear.

Differential diagnosis of adhesive intestinal obstruction

Adhesive intestinal obstruction

Imaging examination is very important for the qualitative and localized diagnosis of adhesive intestinal obstruction. X-ray examination of the abdomen shows a step-like liquid level of different lengths; the distribution of flatulence and bowel crests can be seen in the lying position. The small intestine is centered and the colon occupies the periphery of the abdomen. When the high jejunum is obstructed, a large number of stomachs appear. Gas and liquid; low intestinal obstruction, the liquid level is more; in complete obstruction, there is no gas or only a small amount of gas in the colon; in strangulated intestinal obstruction, there are round or lobular soft tissue mass images in the abdomen, and It can be seen that the individual inflated fixed bowel loops are "C" -shaped expansion or "coffee bean sign". Abdominal CT and MRI can help doctors more intuitively determine the cause, location, degree and intestinal stenosis of patients with intestinal obstruction, especially enhanced CT and MRI with angiography, which can well identify the presence of intestinal torsion or intestinal blood Provide obstacles to avoid misdiagnosis and delay treatment. For incomplete adhesion intestinal obstruction, water-soluble contrast agent gastrointestinal angiography can not only help judge the location of the obstruction, the time it takes to reach the right half of the colon to infer the success of non-surgical treatment, or even play a therapeutic role. Hematological examinations showed that hemoglobin and white blood cell counts were normal in the early stages of adhesive intestinal obstruction. Obstruction for a long time, when signs of dehydration, blood concentration and white blood cells can occur. Increased leukocytes with left shifts may indicate bowel strangulation. Measurements of serum electrolytes (K, Na, Cl-), carbon dioxide binding capacity, blood gas analysis, urea nitrogen, and hematocrit are all important to determine dehydration and electrolyte disturbances, and to guide fluid input. The determination of serum inorganic phosphorus, creatine kinase and its isoenzymes is of great significance in the diagnosis of strangulated intestinal obstruction. Many experiments have shown that intestinal wall ischemia and necrosis increased blood inorganic phosphorus and creatine kinase.

Differential diagnosis of adhesive intestinal obstruction

The main points of diagnosis of adhesive intestinal obstruction include: a previous history of intestinal adhesions, clinical manifestations of mechanical intestinal obstruction, and exclusion of other causes that may cause mechanical intestinal obstruction (such as extra abdominal hernia, intestinal torsion, intussusception , Intestinal foreign body blockage, abdominal tumors and intestinal stenosis, etc.) At the same time, the site of the obstruction, whether it is a complete obstruction, and whether the intestinal tract is narrowed, are needed to guide the development of treatment plans. In differential diagnosis, it is particularly important to emphasize a special type of intestinal obstruction, that is, "early postoperative inflammatory intestinal obstruction", which cannot be confused with the concept of adhesive intestinal obstruction. Early postoperative inflammatory intestinal obstruction refers to early postoperative (about 2 weeks), edema and exudation of the intestinal wall due to abdominal surgical trauma or intra-abdominal inflammation, etc., followed by mutual intestinal adhesion and intestinal peristalsis. A mechanical and dynamic intestinal obstruction is formed. This type of intestinal obstruction does not require surgery. After the conservative treatment, the inflammation and edema subsides, and the adhesions between the intestines and palate loosen, and the obstruction symptoms can recover. If the surgical treatment is reversed, it will aggravate intestinal damage and even cause intestinal fistula, with catastrophic consequences. In addition, adhesive intestinal obstruction needs to be distinguished from blood-borne intestinal obstruction and paralytic intestinal obstruction. Blood transfusion intestinal obstruction is caused by intestinal blood supply failure. Can often cause intestinal wall muscle activity to disappear, such as intestinal blood supply can not be restored, the intestinal tube is very prone to necrosis, especially the intestinal tube through the terminal branch of blood supply. Obstruction of intestinal blood supply is more common in mesenteric arterial thrombosis or embolism caused by various reasons, and mesenteric venous thrombosis, etc. If the treatment is not timely, it may cause patients with short bowels, intestines or even life-threatening. Paralytic intestinal obstruction is due to intestinal wall neuromuscular disturbance, which causes intestinal contents to fail to run, but there are mechanical factors inside and outside the intestinal cavity that cause intestinal obstruction, which is not a cure for surgery.

Adhesive intestinal obstruction treatment

The treatment of adhesive intestinal obstruction includes non-surgical treatment and surgical treatment, and the two are not contradictory. The purpose of non-surgical treatment is to alleviate the symptoms of obstruction in patients, and to prepare for possible surgery. And surgical treatment can not solve all adhesive intestinal obstruction, such as intestinal obstruction caused by scar adhesion caused by sclerosing peritonitis, only rely on non-surgical treatment for remission.

Non-surgical treatment of adhesive intestinal obstruction

Non-surgical treatment is suitable for patients with simple adhesive intestinal obstruction. Its core content is to minimize the amount of intestinal contents, reduce intestinal cavity pressure, eliminate intestinal edema, maintain homeostasis, and improve the nutritional status of patients. If you decide to perform non-surgical treatment of intestinal obstruction, you must implement each treatment measure in place, not in the form: gastrointestinal decompression is not simply a drainage tube built into the patient's stomach, so that intestinal reduction is not achieved. For the purpose of compression, the tip of the pressure reducing tube must be placed near the obstruction to keep the intestinal tube empty, so that the obstruction is easily relieved.

In order to reduce intestinal swelling caused by intestinal contents, in addition to fasting and gastrointestinal decompression, a sufficient amount of somatostatin or its analogs should be used to minimize the secretion and loss of digestive juices. Intestinal wall edema is also one of the important reasons for the difficulty in relieving intestinal obstruction. Increasing the plasma colloid osmotic pressure through diuresis and dehydration can help alleviate intestinal wall edema, expand the inner diameter of the intestine, and improve the intestinal oxygen supply. Glucocorticoids. Unless antibiotics can be used for short-term antibiotics when obstructed intestinal tracts cause excessive growth of bacteria in the intestinal tract, such intestinal obstructions generally do not require antibiotics. Nutritional support improves plasma colloid osmotic pressure by improving nutritional status, and can provide the body with the necessary nutrients to maintain normal physiological needs. It is a necessary choice for patients with intestinal obstruction.

In recent years, the role of water-soluble contrast agents in the non-surgical treatment of intestinal obstruction has been valued. Water-soluble contrast agents can accelerate the remission of incomplete small bowel obstruction and paralytic intestinal obstruction, and shorten the expected hospital stay of patients.

Surgical treatment of adhesive intestinal obstruction

Surgical treatment is suitable for the majority of patients with adhesive intestinal obstruction that are not effective in non-surgical treatment and recurrent. The timing of surgery should be performed before the intestinal obstruction develops to strangulation. The so-called coffee-like feces and bloody ascites are signs of intestinal strangulation. These signs must not be understood simply as indicators of surgical exploration, let alone because there is Waiting passively for the above symptoms and not performing surgery until these symptoms appear is a serious misconduct. It is well known that intestinal adhesions become worse in about 2 weeks after they start, and are most significant in 3 months. After 3 months, the adhesions gradually begin to loosen. Therefore, surgical treatment is best when intestinal adhesions occur for more than 3 months, or within 2 weeks. Of course, if the patient cannot be relieved by non-surgical treatment, surgery should be performed at any time, but the surgical method should be selected carefully and should not be too complicated. In addition to considering the possibility of the adhesion of the intestinal canal apart from the patient's medical history, a physical examination of the abdomen is also helpful. If the abdomen is tough, it indicates that the abdominal cavity is severely adherent. If the abdomen is soft, the adhesive intestine can easily separate. Abdominal CT can also understand the degree of intestinal adhesions and the possibility of separation. Intestinal perforation is a treatment to prevent re-adhesive intestinal obstruction after surgery, but it is not the first choice and should not be widely used. Adhesive intestinal obstruction still occurs after multiple surgeries and extensive bowel separation, the intestinal wall is rough, and the intestinal serous membrane layer is damaged. It is applicable to predict that intestinal obstruction will inevitably occur. ^[2]

Adhesive intestinal obstruction disease prevention

Adhesive intestinal obstruction is important to prevent. Preventive measures include reducing tissue ischemia, protecting the intestines, reducing injuries, flushing the abdominal cavity with a large amount of normal saline at the end of the operation, and removing foreign bodies, blood clots and other pollutants. The author believes that simple adhesion intestinal obstruction can be treated with non-surgical treatment first. If the obstruction is treated early, the condition can be relieved. During the treatment, the patient's symptoms and signs should be closely observed. If the symptoms gradually worsen during the treatment, surgical exploration should be performed. In the past, it was often thought that adhesive intestinal obstruction was not suitable for surgery, and that there was still adhesion after surgery, and intestinal obstruction could still occur. In fact, adhesion and obstruction were conflated. For recurrent intestinal obstructions that affect normal life and work, there must be organic problems. Surgical treatment should be performed. Do not wait until the bowel is narrowed before deciding on surgery. The adhesion between the intestines may be as simple as a single cord, or it may be a wide and dense adhesion in the entire abdominal cavity.Therefore, all necessary preparations including the adjustment of the patient's internal stability and the technical and physical conditions of the surgical group should be performed before surgery. .