Lecture notes for medical students

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3. First show the blank slides (eg. Aetiology ) > Ask
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aetiologies.
4. At the end rerun the show – show blank> ask questions >
show next slide.
5. This will be an ACTIVE LEARNING SESSION x
three revisions.
6. Good for self study also.
7. See notes for bibliography.

2. Learning Objectives

3. Learning Objectives
1. Introduction & History
2. Relevant Anatomy, Physiology
3. Aetiology
4. Pathophysiology
5. Pathology
6. Classification
7. Clinical Features
8. Investigations
9. Management
10. Prevention
11. Guidelines
12. Take home messages

4. Introduction & History.
•

5. Introduction & History.
• Adhesions are fibrous bands that form
between tissues and organs.
• Peritoneal adhesions are scars of peritonitis
or laparotomy
• autopsy. For example, Thomas Hodgkin,1
in 1836, commented on the matted bowel
found at autopsy in patients with
tuberculous peritonitis and also on the
tendency of adhesions to occur in the lower
abdomen in patients dying of pelvic sepsis.

6. Introduction & History.
• Laparotomy started being done in 1880.
• Simultaneously post.op.adhsions started
being reported.

7. Aetiology

8. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoning/ Toxins/ Drug induced

9. Etiology
• Idiopathic
• Congenital : Rare
• Traumatic: Post operative
• Infections : peritonitis
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative

10. Pathophysiology

11. Pathophysiology
• Injury to the peritoneal epithelium resulting
in fibrin matrix deposition to the injured
intra-abdominal surfaces. Fibrinolysis by
plasmin is typically inadequate in the
postoperative period, and the nondegraded
deposits lead to adhesion .
• Cornstarch gloves’ powder.
• Intra-abdominal adhesions develop in 90-
95% of patients after surgery.

12. Clinical Features
•

13. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

14. Clinical Features
• Mostly asymptomatic.
• It Causes Acute and subacute intestinal
obstruction.
– It has replaced obstructed herenia as leading
cause of acute intestinal obstruction.
• chronic abdominal pain
• female infertility.

15. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

16. Management
•

17. Management
• conservative management with bowel rest
• surgical intervention, sometimes requiring
bowel resection.

18. Indications for Surgery

19. Indications for Surgery
• Acute/Subacute Intestinal Obstruction.
• Chronic Abdominal pain
• Infertility

20. Indications for Surgery
Acute/Subacute Intestinal Obstruction.
• Frank peritoneal signs on abdominal
examination findings
• hemodynamic instability
• lactic acidosis or elevated base deficit
• increasing abdominal pain
• rising white blood cell (WBC) count
• acidosis that worsens despite adequate
resuscitative measures

21. What Surgery
Acute/Subacute Intestinal Obstruction.
• Release of obstruction +/- Resection
• Open adhesionolysis.
• Laparoscopic adhesionolysis.*

22. Prevention

23. Prevention
• Screening
• Risk reduction

24. Prevention
• Attempts to prevent postoperative adhesions
can be classified into:
– Prevention of fibrin deposition
– Removal of fibrin exudates between damaged
surfaces
– Inhibition of fibroblastic proliferation
– Separation of surfaces
None has been successful

25. Prevention of fibrin deposition
• Citrate
• heparin (both topically and systemically)
• dicumoral.
– Severe bleeding even fatal

26. Removal of fibrin exudates
between damaged surfaces

27. Removal of fibrin exudates
between damaged surfaces
• saline,
• hypertonic dextrose
• pepsin, trypsin,
• streptokinase, and streptodornase.
• Tissue plasminogen activator*

28. Inhibition of fibroblastic
proliferation

29. Inhibition of fibroblastic
proliferation
• antihistamines and steroids given topically
and systemically.
• fluorouracil in rats.

30. Separation of surfaces

31. Separation of surfaces
• saline, Ringer’s solution, dextran, gelatine,
olive oil, paraffin, silicones, plasma,
lanoline, polyvinyl pyrrolidine,
• Membranes—amnion, fish bladder, carp
peritoneum, calf peritoneum, oiled silk,
silver or gold foil, and free grafts of
omentum.
• a membrane composed of hyaluronic acid
and carboxymethylcellulosea membrane
composed of hyaluronic acid and
carboxymethylcellulose*

32. Future
• Use powder free gloves for operations and
examination.
• Please sign my petition on change.org for
ban on prepowdererd gloves.

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