Overview of intra-abdominal adhesions

Adhesions are scars, ie abnormal fibrous tissue that can form inside the abdomen, between different abdominal organs, or between abdominal organs and the abdominal wall. 

The underlying mechanism involves the disruption of the underlying surface of intra-abdominal structures that possibly triggers subsequent inflammatory processes and fibrosis.¹

The main causes for acquired intra-abdominal adhesions are:¹

1. Post-surgical adhesions: Surgery involving the abdomen or the pelvis is responsible for 90% of intra-abdominal adhesions
2. Post-inflammatory adhesions: Pelvic inflammatory disease (PID) and tubal endometriosis are the most common causes in women. Diverticulitis, Crohn’s disease (inflammatory conditions of the bowel) and abdominal tuberculosis in either sex
3. Post-radiation adhesions: Radiotherapy used in the treatment of abdominal or pelvic malignancy can induce adhesion formation

Adhesions can be asymptomatic in some patients, while they can cause disturbing symptoms in others. These include but are not limited to abdominal pain, bloating, abnormal bowel motion, and bowel obstruction. An adhesive disease is defined as symptomatic adhesions.¹

Diagnosis of adhesive disease is difficult and usually requires multimodal evaluation. The lack of specific laboratory tests or radiological imaging can contribute to the prolongation of underdiagnosis of the condition. Consequently, the patient undergoes extensive testing. The gold standard for confirming the diagnosis is a surgical procedure, which allows the direct visualization of intra-abdominal contents, also known as laparoscopy or laparotomy.¹

Identifying the underlying cause of adhesion formation can guide the management and assist in the prediction of the disease prognosis.¹

In this article, we are comparing a specific type of intra-abdominal adhesions, that is Fitz-Hugh-Curtis Syndrome (FHCS), with other adhesive diseases. The main aim of the article is to highlight the clinical presentation, work up, and management of each disorder. 

Fitz-Hugh-Curtis Syndrome (FHCS) 

Definition and pathophysiology

The Fitz-Hugh-Curtis syndrome (FHCS) is a complication of pelvic inflammatory disease (PID). It is characterised by inflammation of the liver capsule ( perihepatitis) and is associated with adhesion formation, most commonly observed between the liver capsule and the anterior abdominal wall or between the liver capsule and the diaphragm.²

Pelvic inflammatory disease (PID) is an infection of the genital tract of sexually active women. Microorganisms associated with PID can spread to the inside of the abdominal cavity and cause this complication.² There are three possible ways² these microorganisms can spread:

1. Microorganisms ascend through the female genital tract, reaching the abdominal cavity through the Fallopian tubes
2. Microorganisms spreading through the lymphatic system
3. Microorganisms spreading through blood vessels

Epidemiology

FHCS is an uncommon complication of PID, affecting around 4% of sexually active adolescents with PID in the United States. Many PID microorganisms can cause this complication. However, the most commonly associated pathogen is Chlamydia trachomatis.²

Clinical presentation

FHCS is related to pain in the right upper part of the abdomen, which usually worsens with movement and breathing, typically seen in women of childbearing age.²

Unfortunately, there are quite many conditions that cause this type of pain. Therefore, a detailed history and high index of suspicion are required to establish the correct diagnosis.²

Assessing for a previous medical history of PID or the presence of its risk factors can facilitate in narrowing down the probable causes. These include age of less than 25 years, age of first sexual encounter younger than 15 years, use of intrauterine device (IUD), use of hormonal contraceptives, vaginal douching, or any exposure to a symptomatic sex partner.²

Patients with FHCS may also complain of pain in the lower abdomen or pelvis, vaginal discharge, fever, nausea and vomiting among others. Examination may reveal fever (> 38°C), abdominal tenderness, and signs of lower genital tract infection on pelvic examination or other related tenderness.²

Work-up and diagnosis 

Patients suspected to have FHCS usually undergo extensive testing since there is no single method that offers a 100% accurate diagnosis except for surgical procedures.² The evaluation consists of laboratory tests, imaging, surgery or biopsy as follows: 

Lab tests

• Pregnancy test is essential in any woman of childbearing age presenting with abdominal pain so as to exclude possible pregnancy
• Complete blood count (CBC) for high white blood cell counts in cases of PID
• Complete metabolic panel for any derangements
• Assessment of vaginal discharge if present
• Culture for spotting chlamydia ot other pathogens, like gonorrhea

Imaging

• Transvaginal ultrasound for signs of PID
• CT scan of the abdomen can demonstrate liver capsule inflammation and CT of the pelvis can reveal signs of PID in the genital organs or pelvic cavity
• MRI can reveal associated pelvic pathologies

Surgical procedures

• Laparoscopy is the gold standard for the diagnosis of FHCS through direct visualization of adhesions
• Laparotomy is reserved for specific cases
• Biopsy of liver capsule

Treatment/management

The main part of FHCS treatment is the management of PID. The goal is to eradicate the infection and relieve the symptoms. FHCS is usually treated effectively by outpatients with antibiotics covering the most common microorganisms with ceftriaxone and azithromycin. For complicated cases of PID, ceftriaxone, doxycycline and metronidazole are recommended.² However, if symptoms persist after 72 hours of antibiotic treatment, re-evaluation for surgical intervention is indicated. This is usually done with a laparoscopy to release the adhesions (known as adhesiolysis) and to treat any other associated PID complication, if present. The main concern is to prevent the risk of long-term complications of untreated PID, which may cause infertility.²

Brief overview of other adhesive diseases

Pelvic Inflammatory Disease (PID) 

Definition

PID is an infection of the female genital tract, usually as a result of sexually transmitted infections (STIs), most commonly from chlamydia or gonorrhea.³

Clinical presentation

PID are either asymptomatic, or cause symptomsthat can range from mild to disturbing likelower abdominal pain, fever, abnormal vaginal discharge, burning pain while urinating, pain or bleeding during sexual intercourse.³

Treatment 

Antibiotics are the mainstay in PID treatment. An important principle in the management of PID is for the sexual partner to also test for STIs and to receive treatment as well as to abstain from sexual intercourse until treatment is finished.³

Prognosis

Early diagnosis and treatment of PID prevent long-term complications, such as abdominal or pelvic pain, ectopic pregnancy, and infertility.³

Endometriosis

Definition

It is a condition of the female genital tract where the tissue that lines the uterus (endometrium) grows abnormally outside the uterus, like in other parts of the genital tract or abdomen.⁴

Clinical presentation

Endometriosis can either be asymptomatic or cause pain in the abdomen or the pelvis, pain during sexual intercourse, pain while urinating and defecating, painful and heavy periods, and sometimes infertility.⁴

Treatment

The definitive diagnosis of endometriosis is confirmed with surgery. The treatment includes analgesic medications to control the pain, hormonal therapy to suppress the disease, as well as surgical interventions to excise the abnormal tissue.⁴

Prognosis

Recurrence of endometriosis is not uncommon despite treatment, and may indicate that a more extensive surgical intervention is needed.⁴

Post-surgical adhesions 

Definition

Adhesions are a common complication of different surgeries. They usually occur after abdominal, heart, intrauterine and tendon surgeries.⁵

Clinical presentation

Adhesions are either asymptomatic, or cause a variety of symptoms depending on the site they are formed. For example, if they are formed Intra-abdominally, pain, discomfort, bowel obstruction, and even infertility in women can occur. In joints, pain, stiffness and loss of function are the most common symptoms.⁵

Treatment

The ultimate goal is to prevent adhesion formation. The mechanism for adhesion formation involves disruption at a cellular level and is associated with molecular signaling. Effective preventive methods include post-operative mechanical barriers and anti-adhesive agents that interfere with adhesion pathways. Additionally, post-operative physiotherapy may also improve outcomes and reduce adhesion formation. However, even though the use of these methods can reduce adhesion formation, total prevention remains elusive. After adhesions have formed, reoperation may be necessary.⁵

Prognosis

The prognosis is variable between patients, with some patients never developing symptoms after treatment, while others may be required to undergo surgery again.⁵

Summary 

FHCS is one of the causes of intra-abdominal adhesions. FHCS from other causes is important in order to guide management, and to predict prognosis. Patients with FHCS usually report a previous history of PID or one or more of the risk factors of PID. The intra-abdominal adhesions in FHCS are restricted to the liver area. Management of FHCS is the treatment of PID with a course of antibiotics. The main concern of the disease is to prevent the long-term complications which can occur if PID is left untreated.