Case Studies
 

Abdominal Adhesions Resulting in Jejunal Entrapment and Torsion.

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VETERINARIAN SPECIALTY CASE STUDY

Adhesions are bands of fibrous tissue which can form between abdominal organs and other surfaces within the abdomen. They result from inflammatory processes or physical insults to intra-abdominal structures.

By Heather McDonnell Siemon, DVM
and Stephen Bilbrey, DVM, MS
Diplomate American College of Veterinary Surgeons

1. Referral

“Marley” a one year old, female spayed, Mastiff mix dog, was seen through the ASG emergency and critical care service after vomiting several times. She initially vomited the night before her presentation after eating dinner and was presented to her primary veterinarian for evaluation. Despite administration of an anti-nausea medication and subcutaneous fluids, she vomited several more times throughout the night and was referred to ASG the next morning. She seemed otherwise normal to her owners, including still having an appetite and good energy level. Marley had a history of dietary indiscretion but no other significant medical conditions.

2. Examination

On initial examination by the veterinarians in the emergency department, “Marley” was quiet, alert, and responsive. Her vital signs were within normal limits. The only clear abnormality was a painful abdomen, with a hard mass effect felt on palpation of the middle portion of the abdomen. The remainder of the examination was within normal limits.

3. Diagnostics

Abdominal radiographs were obtained and submitted for radiologist review. The radiologist reported “small intestinal distention with gastric fluid and gas highly suggestive of a small intestinal obstruction from soft tissue opaque foreign material or less likely a stricture or intussusception.” An exploratory laparotomy was recommended based on the radiographic findings. Prior to surgery, a CBC and biochemistry profile were obtained. These showed a mildly decreased level of potassium and a mildly increased white blood cell count. Based on the radiographs and blood work, the most likely diagnosis was small intestinal obstruction.

4. Treatment

“Marley” was taken to surgery the same day for an exploratory laparotomy. She was prepared for surgery with routine anesthetic methods and sterile preparation of her skin. An incision was made through her abdominal midline to enter the abdomen. Upon routine exploration of the abdomen the surgeons encountered serosanguinous abdominal fluid. Examination of the intestines revealed multiple mature adhesions and a section of the small intestine that was black and foul-smelling. This involved a 12-15 cm loop of the distal jejunum.

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Figures 2

Further examination of this abnormality revealed that a segment of the jejunum had become entrapped by an adhesion and become strangulated, disrupting the blood supply (Fig. 2). As this segment was no longer viable it was isolated from the remainder of the bowel for removal.

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Figures 3

The torsion was not reduced in order to prevent release of endotoxin and subsequent reperfusion injury (Fig. 3).

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Figures 4

After removal, this segment was dissected showing a clear line of demarcation between normal and devitalized tissues (Fig. 4). A significant margin of healthy intestine was included in the resection to ensure that the remaining intestine would heal after surgery.

The abnormal intestine was resected and the normal intestine was anastomosed to create a functional small intestinal tract. The remainder of the abdomen was fully explored. Numerous other adhesions were found within the abdomen however the remainder of the gastrointestinal tract was deemed healthy. The abdomen was routinely closed and “Marley” was recovered from her surgery.

5. Diagnosis

Abdominal adhesions causing jejunal entrapment and torsion, treated with resection and anastomosis.

6. Discussion

Adhesions are bands of fibrous tissue which can form between abdominal organs and other surfaces within the abdomen. They result from inflammatory processes or physical insults to intra-abdominal structures. In a normal abdomen, all of the contents of the abdomen are coated in a thin layer of peritoneal fluid which prevents structures from adhering to one another. This includes the abdominal organs, blood and lymphatic vessels, mesentery, and other structures which all exist in close proximity to one another. To meet the changing needs of the body, these structures must expand and contract without affecting their neighbors. This can become disrupted, leading to an initial fibrinous adhesion that can mature in time to a firm adhesion between structures that can restrict their movement and otherwise compromise their health.

In order for the cascade of events that results in adhesion formation to begin, an inflammatory process must take place within the abdomen. This initial inflammatory process can be caused by abdominal surgery or any other injury to the abdomen. Once the initial inciting inflammation is triggered, the coagulation cascade is activated, resulting in fibrin deposition at any sites of injury within the abdomen. Fibrin is the initial basis for the formation of an adhesion. In many cases, fibrin is cleared away by the innate balance system of the body which triggers fibrinolysis (the destruction of fibrin). When this does not occur, an adhesion can be formed.

In “Marley’s” case, an adhesion formed between two sections of small intestine. Without the adhesion, the small intestine would move freely within a section of the abdomen and expand and contract in response to the normal digestion of food. In her case, the adhesion trapped a segment of small intestine and resulted in torsion of a 12-15 cm segment of the jejunum. Once this segment became twisted, the blood supply was severely compromised to this segment and it became devitalized (Fig. 4). This resulted in the clinical signs of vomiting, abdominal pain, and radiographically apparent intestinal dilation.

In most cases abdominal adhesions do not require treatment and exist within the abdomen without causing clinical signs or any apparent problems. Since we know these can occur as a common side effect of surgery, great care is taken to minimize the chances of them forming. This is done with gentle tissue handling, keeping structures within the abdomen moist and healthy, resection of unhealthy tissue, careful suture selection, and other techniques that minimize contamination and damage within the abdomen. Even with careful surgical technique, some adhesions may form and may never be discovered as long as they do not result in interference with the normal function of abdominal structures. When these adhesions are found incidentally during abdominal surgery for other reasons, they can sometimes be gently released although they may recur.

7. Recovery

In “Marley’s” case, treatment of her intestinal adhesions required resection and anastomosis of the affected segment of small intestine. The specific cause of the adhesions present in “Marley” is unknown. “Marley” recovered well from her surgery and was discharged from the hospital two days later.


REFERENCES: [1] Arung W, Meurisse M, Detry O. Pathophysiology and prevention of postoperative peritoneal adhesions. World Journal of Gastroenterology : WJG. 2011;17(41):4545-4553. [2] Johnson, S, Tobias K. Veterinary Surgery: Small Animal Second Edition. St. Louis, MO: Elsevier, 2018; [3] Fossum, T, Hedlund C, Hulse D, Johnson A, Seim H, Willard M, Carroll G Small Animal Surgery. St. Louis, MO: Mosby Year Book, Inc. 1997; [4] Bojrab M.J, Monnet E. Mechanisms of Disease in Small Animal Surgery 3rd Edition. Jackson, WY: Teton NewMedia. 2010

Animal Specialty Group

DVM, MS, Diplomate American College of Veterinary Surgeons

Dr. Stephen Bilbrey has received multiple awards for academics and teaching, and has authored numerous scientific papers for veterinary surgery publications and textbooks. As a board-certified surgeon since 1991, his special interests include thoracic, abdominal, oncologic, plastic, and reconstructive surgery.