World J Surg. 2006 Mar 13; [Epub ahead of print]
Laparoscopic Lysis of Adhesions.Szomstein S, Menzo EL, Simpfendorfer C, Zundel N, Rosenthal RJ.Bariatric Institute, Section of Minimally Invasive Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, Florida, 33331, USA, szomsts@ccf.org.
BACKGROUND: Intra-abdominal adhesions constitute between 49% and 74% of the causes of small bowel obstruction. Traditionally, laparotomy and open adhesiolysis have been the treatment for patients who have failed conservative measures or when clinical and physiologic derangements suggest toxemia and/or ischemia. With the increased popularity of laparoscopy, recent promising reports indicate the feasibility and potential superiority of the minimally invasive approach to the adhesion-encased abdomen.
METHODS: The purpose of this study was to assess the outcome of laparoscopic adhesiolysis and to provide technical tips that help in the success of this technique.
RESULTS: The most important predictive factor of adhesion formation is a history of previous abdominal surgery ranging from 67%-93% in the literature. Conversely, 31% of scars from previous surgery have been free of adhesions, whereas up to 10% of patients without any prior surgical scars will have spontaneous adhesions of the bowel or omentum. Most intestinal obstructions follow open lower abdominopelvic surgeries such as colectomy, appendectomy, and hysterectomy. The most common complications associated with adhesions are small bowel obstruction (SBO) and chronic pain syndrome. The treatment of uncomplicated SBO is generally conservative, especially with incomplete obstruction and the absence of systemic toxemia, ischemia, or strangulation. When conservative treatment fails, surgical options include conventional open or minimally invasive approaches; the latter have become increasing more popular for lysis of adhesions and the treatment of SBO. Generally, 63% of the length of a laparotomy incision is involved in adhesion formation to the abdominal wall. Furthermore, the incidence of ventral hernia after a laparotomy ranges between 11% and 20% versus the 0.02%-2.4% incidence of port site herniation. Additional benefits of the minimally invasive approaches include a decreased incidence of wound infection and postoperative pneumonia and a more rapid return of bowel function resulting in a shorter hospital stay. In long-term follow up, the success rate of laparoscopic lysis of adhesions remains between 46% and 87%. Operative times for laparoscopy range from 58 to 108 minutes; conversion rates range from 6.7% to 43%; and the incidence of intraoperative enterotomy ranges from 3% to 17.6%. The length of hospitalization is 4-6 days in most series.
CONCLUSIONS: Laparoscopic lysis of adhesions seems to be safe in the hands of well-trained laparoscopic surgeons. This technique should be mastered by the advanced laparoscopic surgeon not only for its usefulness in the pathologies discussed here but also for adhesions commonly encountered during other laparoscopic procedures.PMID: 16555020 [PubMed - as supplied by publisher]
Wednesday, March 29, 2006
"Adhesions and Bowel Resections"
Is A Resection Necessary?
If your surgeon mentions a "Bowel Resection" as part of his or her surgical intervention for
"Adhesion Related Disorder"
ASK QUESTIONS!!
For what reason would a bowel resection be warranted?
How does the surgeon determine if your bowel is diseased or not?
If your surgeon tells you the resection is for constipation, could that constipation be from pain medications your on?
(The most common side affect of an analgesic (pain medication) is Constipation!)
How can your surgeon determine if the constipation is from pain medication or a diseased bowel?
What does "diseased" mean to your surgeon?
(IBS, Colitis, Chrohns? All of those can be diagnosed and they have specific symptoms associated to them.)
Does having "adhesions" on the external bowel mean it is diseased?
If so, how is it diseased?
How will the surgeon determine which section of the bowel needs to be resected? What if there are adhesions in a number of areas of the bowel?
(Adhesions of the bowel are usually located in more then one area! Tell your surgeon that you WILL be asking for a video of the procedure!)
Why would a resection help your pain and problems?
How will the surgeon determine if the resection was successful?
What will the surgeon do if and when your pain and constipation return?
How will your surgeon determine if the constipation is due to the medication, which causes constipation?
Will ANOTHER resection be warranted?
If so, how can your surgeon determine if the constipation is from pain medication or a diseased bowel?
Why it is important to question Bowel Resections with an Adhesiolysis!
Today, a small percent of surgeons will do a "bowel "resection for adhesions because the patient suffers "constipation or, because the adhesions were to dense for the surgeon to lyse usefully!?
Now THAT is the answer to adhesion symptoms? Remember, pain meds CAUSE constipation! How does the surgeon know IF the meds are causing that constipation, and what else would be causing it anyway? What diagnostic tests can the surgeon offer you to determine just what IS causing that constipation before he starts to resect the ARD patients bowels?? And what happens when the pain returns after that resection, and the patient gets back on pain meds, and then gets constipated again...more bowel resections!? After reading just that small statement regarding surgeons and bowel resections, do YOU think it important enough for a patient to be aware of this prior to agreeing to a surgery when there is talk of a bowel resection or is it important to be informed before agreeing to ANY surgery??The point is this my friends,Where these surgeons five years ago? What were their experiences with ARD back then? What are they doing different today that they didn't do or know back then? Where did they all of a sudden gain all this experience in dealing with adhesions? WHY didn't they talk to us about it 5 years ago if they are "specialist" today?
The question to ask any surgeon you’re interested in seeing when it comes
to dealing with your adhesion symptoms, is to ask them, " What did they do about adhesions five years ago?' What experience have they had in the past 5 years to claim to be able to deal with adhesion symptoms? What is their philosophy of adhesions? What do they know about ARD symptoms, and how did they learn about it? What is the cause of adhesion "symptoms" not just the cause of the "adhesions!" How many cases of ARD have they dealt with in the past 5 years. and what were the outcomes of those interventions? Can you provide to me a list of your patient who had this procedure?
And, last but certainly not least,
" What makes them think they are "Adhesion Specialists?"
Unfortunately, for the victims of ARD, more then not the surgeon is NOT an adhesion specialist anymore then the Pope is Lutheran!
And if you don't know the answers to all those questions going into that appointment with a surgeon, your going to believe anything you’re told...and only YOU will suffer for not being informed enough to recognize a when you meet one!If you do nothing else, print out material you secure from ARD sites and take it with you to back you up or to educate the "specialists!
Think About this...And whatever you do Do it for you!
Please read this report if you think your Dr. or Surgeon did not have any means to learn about ARD or how to perform surgery that might offer less adhesion formation..and NO bowel resection!
1932 the Vick report and we are still adhered
If your surgeon mentions a "Bowel Resection" as part of his or her surgical intervention for
"Adhesion Related Disorder"
ASK QUESTIONS!!
For what reason would a bowel resection be warranted?
How does the surgeon determine if your bowel is diseased or not?
If your surgeon tells you the resection is for constipation, could that constipation be from pain medications your on?
(The most common side affect of an analgesic (pain medication) is Constipation!)
How can your surgeon determine if the constipation is from pain medication or a diseased bowel?
What does "diseased" mean to your surgeon?
(IBS, Colitis, Chrohns? All of those can be diagnosed and they have specific symptoms associated to them.)
Does having "adhesions" on the external bowel mean it is diseased?
If so, how is it diseased?
How will the surgeon determine which section of the bowel needs to be resected? What if there are adhesions in a number of areas of the bowel?
(Adhesions of the bowel are usually located in more then one area! Tell your surgeon that you WILL be asking for a video of the procedure!)
Why would a resection help your pain and problems?
How will the surgeon determine if the resection was successful?
What will the surgeon do if and when your pain and constipation return?
How will your surgeon determine if the constipation is due to the medication, which causes constipation?
Will ANOTHER resection be warranted?
If so, how can your surgeon determine if the constipation is from pain medication or a diseased bowel?
Why it is important to question Bowel Resections with an Adhesiolysis!
Today, a small percent of surgeons will do a "bowel "resection for adhesions because the patient suffers "constipation or, because the adhesions were to dense for the surgeon to lyse usefully!?
Now THAT is the answer to adhesion symptoms? Remember, pain meds CAUSE constipation! How does the surgeon know IF the meds are causing that constipation, and what else would be causing it anyway? What diagnostic tests can the surgeon offer you to determine just what IS causing that constipation before he starts to resect the ARD patients bowels?? And what happens when the pain returns after that resection, and the patient gets back on pain meds, and then gets constipated again...more bowel resections!? After reading just that small statement regarding surgeons and bowel resections, do YOU think it important enough for a patient to be aware of this prior to agreeing to a surgery when there is talk of a bowel resection or is it important to be informed before agreeing to ANY surgery??The point is this my friends,Where these surgeons five years ago? What were their experiences with ARD back then? What are they doing different today that they didn't do or know back then? Where did they all of a sudden gain all this experience in dealing with adhesions? WHY didn't they talk to us about it 5 years ago if they are "specialist" today?
The question to ask any surgeon you’re interested in seeing when it comes
to dealing with your adhesion symptoms, is to ask them, " What did they do about adhesions five years ago?' What experience have they had in the past 5 years to claim to be able to deal with adhesion symptoms? What is their philosophy of adhesions? What do they know about ARD symptoms, and how did they learn about it? What is the cause of adhesion "symptoms" not just the cause of the "adhesions!" How many cases of ARD have they dealt with in the past 5 years. and what were the outcomes of those interventions? Can you provide to me a list of your patient who had this procedure?
And, last but certainly not least,
" What makes them think they are "Adhesion Specialists?"
Unfortunately, for the victims of ARD, more then not the surgeon is NOT an adhesion specialist anymore then the Pope is Lutheran!
And if you don't know the answers to all those questions going into that appointment with a surgeon, your going to believe anything you’re told...and only YOU will suffer for not being informed enough to recognize a when you meet one!If you do nothing else, print out material you secure from ARD sites and take it with you to back you up or to educate the "specialists!
Think About this...And whatever you do Do it for you!
Please read this report if you think your Dr. or Surgeon did not have any means to learn about ARD or how to perform surgery that might offer less adhesion formation..and NO bowel resection!
1932 the Vick report and we are still adhered
THE question when it come to prescribing "Zelnorm!"
In my opinion, ZELNORM is a useless medication!
Bev Doucette ask’s THE question when it come to prescribing "Zelnorm!"
Q. How does the prescribing physician KNOW if the patient has " abdominal adhesions causing pain and/or intestinal blockage.” (#7 below)
In my opinion, ZELNORM is a useless medication as there is no way the prescribing Dr. can diagnose "adhesions as the cause of pain or intestinal blockage" without a surgical procedure being done, and not all Dr.’s prescribing it are surgeons! In my opinion and based on what other persons who are afflicted with "Adhesion Related Disorder" have shared with me, that Dr.’s who prescribed "ZELNORM" to them told them that their symptoms were from IBS!
Once many of these patients had an adhesiolysis, pain and associated symptoms were resolved! So much for IBS! Of course, if a patient who presents with a history of abdominal/pelvic surgeries, and prior operatives that state "adhesions lysed" to a Dr. who is not up to date on his/her medicine, (antiquated medical practices) and has limited knowledge of "Adhesion Related Disorder," then it would be no surprise if the patient did in fact have some IBS! But that IBS would be the result of those office visits! (And whose bowels wouldn’t be "irritable" being all tethered by adhesions! Go figure, Doc!)
Check out the "NEW" discovery on:
"New guidelines given for severe or persistent constipation!"
American Journal of Gastroenterology [April, 2005].
AND
Check out 2/06 Bev’s Opinion on:
"Constipation & Adhesions"
Questions and Answers on Zelnorm (tegaserod maleate)1. What prompted FDA to work with Novartis to alert the public to new safety information about Zelnorm?
http://www.fda.gov/cder/drug/infopage/zelnorm/zelnorm_QA.htm
Since the time of Zelnorm’s initial marketing in the U.S. in August 2002 through March 2004, FDA’s postmarketing adverse event reporting system has received reports of patients taking Zelnorm who experienced serious adverse events. These reports include 21 patients taking Zelnorm who have experienced serious consequences of diarrhea, 20 patients who have been diagnosed with ischemic colitis, and 3 patients diagnosed with other types of intestinal ischemia. In some patients, these adverse events have led to hospitalization, surgery, and even death.
As a result, FDA is announcing that the labeling of Zelnorm will be updated to include this important new risk information for doctors and patients. Although it has not been established that use of Zelnorm caused these adverse events, this new information will allow physicians and patients to better understand the potential risks and benefits of Zelnorm and make informed treatment decisions.
2. What is Zelnorm?
Zelnorm is a medicine used for the short-term treatment of women who have irritable bowel syndrome (IBS) with constipation (hard stools or difficulty passing stools) as their main bowel problem. IBS is a disorder that interferes with the normal functions of the large intestine (colon). Symptoms may include cramps, abdominal pain, bloating, constipation, and/or diarrhea. The cause of IBS is not known.
Zelnorm works by increasing the movement of stools through the bowels. For those patients who are helped, Zelnorm reduces pain and discomfort in the abdominal area, bloating, and constipation.
Zelnorm is not a cure for IBS and does not work for all women who use it. FDA does not have evidence that Zelnorm is effective in men with IBS.
3. What new changes are being made to the Zelnorm label?
The major changes to the Zelnorm label include a new warning about serious consequences of diarrhea, a new precaution about ischemic colitis and other forms of intestinal ischemia, and updated labeling for patients that includes information about these potential side effects and advises that patients should stop taking Zelnorm and contact their doctor.
4. What are serious consequences of diarrhea?
Serious consequences that can occur when patients experience large amounts of diarrhea include dehydration, low blood pressure, and fainting. In some of the reported cases in patients taking Zelnorm, these complications have required hospitalization for rehydration.
5. What is ischemic colitis?
Ischemic colitis is a condition resulting from reduced blood flow to the intestines, which in some cases can cause serious intestinal damage, and rarely death. Some of the signs and symptoms of ischemic colitis are new or worsening abdominal pain, fever, vomiting, bloody diarrhea, rectal bleeding, and low back pain.
Sometimes ischemic colitis is mild and may resolve by itself. However, other times ischemic colitis can lead to serious problems requiring surgery and in rare cases can lead to death.
FDA has received 20 reports of ischemic colitis in people taking Zelnorm, however, at this time we are not able to determine whether these events were caused by Zelnorm. It is possible that these events were not caused by Zelnorm, but rather by some other cause including other diseases that the patient may have or other drugs the patient was taking.
6. What is intestinal ischemia?
Intestinal ischemia is a condition resulting from reduced blood flow to the intestines that can lead to ischemic colitis or to more severe forms of intestinal damage that may require surgery or result in death.
7. Who should not use Zelnorm?
Patients should not start taking Zelnorm if they have:
diarrhea now or have diarrhea often
bad kidney or liver disease
ever had bowel obstruction (intestinal blockage), symptomatic gallbladder disease, or abdominal adhesions causing pain and/or intestinal blockage.
8. How should Zelnorm be taken?
The recommended dosage of Zelnorm is 6 mg taken twice daily orally before meals for 4 to 6 weeks. For those patients who respond to therapy at 4-6 weeks, an additional 4-6 week course can be considered.
9. Is Zelnorm safe to use?
Patients should understand that all drugs have risks and a determination by FDA that a drug is safe and effective does not mean that the drug is risk free. FDA will approve a drug if it determines that the benefits of the drug exceed the risks for the approved use as directed by the labeling. When FDA approves a drug, the labeling includes information on the benefits and risks and the appropriate dosing regimens so that doctors and patients can make informed individual treatment decisions.
Data from clinical trials and post-marketing reports have identified serious consequences of diarrhea in patients treated with Zelnorm and this potential adverse effect appears to be related to the effects of the drug. In addition, post-marketing reports have identified ischemic colitis and intestinal ischemia as potential adverse effects that may occur in patients receiving Zelnorm. While the available data do not allow FDA to determine whether the reports of ischemic colitis and intestinal ischemia are caused by Zelnorm, it is important that doctors and patients be aware of these potential risks as they assess the potential benefits of treatment with Zelnorm in individual patients.
Patients should ask their doctor whether Zelnorm is right for them. Patients should consult their doctor if they develop symptoms such as severe diarrhea, dizziness, fainting, new or worsening abdominal pain, or blood in the stools with or without abdominal pain.
10. Does Zelnorm cause serious consequences of diarrhea?
In some patients Zelnorm can cause severe diarrhea that can result in dehydration, low blood pressure, dizziness, fainting, or the need for hospitalization.
11. Does Zelnorm cause ischemic colitis and intestinal ischemia?
At this time we don’t know if Zelnorm is causing ischemic colitis or intestinal ischemia. We don’t know if these events are due to another reason such as an interaction with another medical condition or an added medication. However, because of the reports of ischemic colitis and intestinal ischemia in Zelnorm users, FDA would like the medical community and patients to be aware of the possible link. This will allow patients to seek prompt medical care should they get any of the signs or symptoms of ischemic colitis.
12. What are other side effects of Zelnorm?
The most common side effects of Zelnorm include:
Headache
Abdominal pain
Diarrhea
Nausea
Dizziness
These are not all the possible side effects of Zelnorm. Doctors or pharmacists can provide patients with additional information on the side effects of Zelnorm.
13. Are there other drugs used to treat IBS with constipation?
Patients are often treated with diet, exercise, fiber, and various medicines to help relieve constipation. There is no other FDA approved medication for IBS with constipation.
14. If a patient wants to discuss their treatment with Zelnorm what should they do?
Patients should discuss questions and concerns with their doctor.
If patients have further questions about Zelnorm, they may contact the Center for Drug's Division of Drug Information at: 888-INFO.FDA (888-463-6332), or email us at: druginfo@cder.fda.gov
Patients may also contact Novartis directly at 1-862-778-8300.
15. Is Zelnorm going to be taken off the market?
FDA is not thinking of taking Zelnorm off the market at this time. We are adding new information about potential risks of treatment with Zelnorm to the labeling so that doctors and patients can make informed individual treatment decisions. FDA is also encouraging doctors and patients to report any similar events to FDA so that we can further understand these events and their association with Zelnorm use.
Today’s announcement by FDA and Novartis is an effort to minimize risks and maximize benefits of Zelnorm by ensuring that patients and doctors fully understand these risks and benefits.
16. Is Zelnorm going to have restricted marketing like Lotronex?
FDA has not requested any restrictions on the marketing or distribution of Zelnorm. We will continue to carefully evaluate post-marketing reports in patients receiving Zelnorm and consider any additional changes to labeling or other risk management steps that may be necessary as we gain a better understanding of these events. We encourage doctors and patients to report possible adverse events to FDA’s MedWatch program at www.fda.gov/medwatch or call 1-800-FDA-1088.
17. What should patients do if they think they are having side effects from Zelnorm?
Patients should call their doctor right away if they think they are having side effects from Zelnorm.
FDA has received reports of Zelnorm users who have fainted because of low blood pressure due to severe diarrhea caused by Zelnorm. FDA is advising patients who faint while taking Zelnorm to stop the drug immediately and see their doctor at once.
If patients experience blood from the rectum, bloody diarrhea, and/or new or worse abdominal pain, they should stop taking Zelnorm immediately and see their doctor who may need to perform additional tests.
To gather more safety information about Zelnorm, FDA is asking that doctors and patients report cases of suspected adverse effects from Zelnorm to FDA’s MedWatch Program at: www.fda.gov/medwatch and click on "How to Report" or by calling 1-800-FDA-1088.
18. Does the current labeling for Zelnorm warn about diarrhea?
Yes, the first FDA approved labeling for Zelnorm described cases of diarrhea that were seen in clinical trials. Postmarketing surveillance has identified additional cases of diarrhea, some of which were serious enough to cause low blood pressure and fainting and the need for hospitalization for intravenous fluids. FDA has been working with the company to update its labeling to emphasize the serious nature of the diarrhea that some users might experience.
FDA/Center for Drug Evaluation and Research
http://www.fda.gov/cder/drug/infopage/zelnorm/zelnorm_QA.htm
Please visit www.adhesionrelateddisorder.com
Bev Doucette ask’s THE question when it come to prescribing "Zelnorm!"
Q. How does the prescribing physician KNOW if the patient has " abdominal adhesions causing pain and/or intestinal blockage.” (#7 below)
In my opinion, ZELNORM is a useless medication as there is no way the prescribing Dr. can diagnose "adhesions as the cause of pain or intestinal blockage" without a surgical procedure being done, and not all Dr.’s prescribing it are surgeons! In my opinion and based on what other persons who are afflicted with "Adhesion Related Disorder" have shared with me, that Dr.’s who prescribed "ZELNORM" to them told them that their symptoms were from IBS!
Once many of these patients had an adhesiolysis, pain and associated symptoms were resolved! So much for IBS! Of course, if a patient who presents with a history of abdominal/pelvic surgeries, and prior operatives that state "adhesions lysed" to a Dr. who is not up to date on his/her medicine, (antiquated medical practices) and has limited knowledge of "Adhesion Related Disorder," then it would be no surprise if the patient did in fact have some IBS! But that IBS would be the result of those office visits! (And whose bowels wouldn’t be "irritable" being all tethered by adhesions! Go figure, Doc!)
Check out the "NEW" discovery on:
"New guidelines given for severe or persistent constipation!"
American Journal of Gastroenterology [April, 2005].
AND
Check out 2/06 Bev’s Opinion on:
"Constipation & Adhesions"
Questions and Answers on Zelnorm (tegaserod maleate)1. What prompted FDA to work with Novartis to alert the public to new safety information about Zelnorm?
http://www.fda.gov/cder/drug/infopage/zelnorm/zelnorm_QA.htm
Since the time of Zelnorm’s initial marketing in the U.S. in August 2002 through March 2004, FDA’s postmarketing adverse event reporting system has received reports of patients taking Zelnorm who experienced serious adverse events. These reports include 21 patients taking Zelnorm who have experienced serious consequences of diarrhea, 20 patients who have been diagnosed with ischemic colitis, and 3 patients diagnosed with other types of intestinal ischemia. In some patients, these adverse events have led to hospitalization, surgery, and even death.
As a result, FDA is announcing that the labeling of Zelnorm will be updated to include this important new risk information for doctors and patients. Although it has not been established that use of Zelnorm caused these adverse events, this new information will allow physicians and patients to better understand the potential risks and benefits of Zelnorm and make informed treatment decisions.
2. What is Zelnorm?
Zelnorm is a medicine used for the short-term treatment of women who have irritable bowel syndrome (IBS) with constipation (hard stools or difficulty passing stools) as their main bowel problem. IBS is a disorder that interferes with the normal functions of the large intestine (colon). Symptoms may include cramps, abdominal pain, bloating, constipation, and/or diarrhea. The cause of IBS is not known.
Zelnorm works by increasing the movement of stools through the bowels. For those patients who are helped, Zelnorm reduces pain and discomfort in the abdominal area, bloating, and constipation.
Zelnorm is not a cure for IBS and does not work for all women who use it. FDA does not have evidence that Zelnorm is effective in men with IBS.
3. What new changes are being made to the Zelnorm label?
The major changes to the Zelnorm label include a new warning about serious consequences of diarrhea, a new precaution about ischemic colitis and other forms of intestinal ischemia, and updated labeling for patients that includes information about these potential side effects and advises that patients should stop taking Zelnorm and contact their doctor.
4. What are serious consequences of diarrhea?
Serious consequences that can occur when patients experience large amounts of diarrhea include dehydration, low blood pressure, and fainting. In some of the reported cases in patients taking Zelnorm, these complications have required hospitalization for rehydration.
5. What is ischemic colitis?
Ischemic colitis is a condition resulting from reduced blood flow to the intestines, which in some cases can cause serious intestinal damage, and rarely death. Some of the signs and symptoms of ischemic colitis are new or worsening abdominal pain, fever, vomiting, bloody diarrhea, rectal bleeding, and low back pain.
Sometimes ischemic colitis is mild and may resolve by itself. However, other times ischemic colitis can lead to serious problems requiring surgery and in rare cases can lead to death.
FDA has received 20 reports of ischemic colitis in people taking Zelnorm, however, at this time we are not able to determine whether these events were caused by Zelnorm. It is possible that these events were not caused by Zelnorm, but rather by some other cause including other diseases that the patient may have or other drugs the patient was taking.
6. What is intestinal ischemia?
Intestinal ischemia is a condition resulting from reduced blood flow to the intestines that can lead to ischemic colitis or to more severe forms of intestinal damage that may require surgery or result in death.
7. Who should not use Zelnorm?
Patients should not start taking Zelnorm if they have:
diarrhea now or have diarrhea often
bad kidney or liver disease
ever had bowel obstruction (intestinal blockage), symptomatic gallbladder disease, or abdominal adhesions causing pain and/or intestinal blockage.
8. How should Zelnorm be taken?
The recommended dosage of Zelnorm is 6 mg taken twice daily orally before meals for 4 to 6 weeks. For those patients who respond to therapy at 4-6 weeks, an additional 4-6 week course can be considered.
9. Is Zelnorm safe to use?
Patients should understand that all drugs have risks and a determination by FDA that a drug is safe and effective does not mean that the drug is risk free. FDA will approve a drug if it determines that the benefits of the drug exceed the risks for the approved use as directed by the labeling. When FDA approves a drug, the labeling includes information on the benefits and risks and the appropriate dosing regimens so that doctors and patients can make informed individual treatment decisions.
Data from clinical trials and post-marketing reports have identified serious consequences of diarrhea in patients treated with Zelnorm and this potential adverse effect appears to be related to the effects of the drug. In addition, post-marketing reports have identified ischemic colitis and intestinal ischemia as potential adverse effects that may occur in patients receiving Zelnorm. While the available data do not allow FDA to determine whether the reports of ischemic colitis and intestinal ischemia are caused by Zelnorm, it is important that doctors and patients be aware of these potential risks as they assess the potential benefits of treatment with Zelnorm in individual patients.
Patients should ask their doctor whether Zelnorm is right for them. Patients should consult their doctor if they develop symptoms such as severe diarrhea, dizziness, fainting, new or worsening abdominal pain, or blood in the stools with or without abdominal pain.
10. Does Zelnorm cause serious consequences of diarrhea?
In some patients Zelnorm can cause severe diarrhea that can result in dehydration, low blood pressure, dizziness, fainting, or the need for hospitalization.
11. Does Zelnorm cause ischemic colitis and intestinal ischemia?
At this time we don’t know if Zelnorm is causing ischemic colitis or intestinal ischemia. We don’t know if these events are due to another reason such as an interaction with another medical condition or an added medication. However, because of the reports of ischemic colitis and intestinal ischemia in Zelnorm users, FDA would like the medical community and patients to be aware of the possible link. This will allow patients to seek prompt medical care should they get any of the signs or symptoms of ischemic colitis.
12. What are other side effects of Zelnorm?
The most common side effects of Zelnorm include:
Headache
Abdominal pain
Diarrhea
Nausea
Dizziness
These are not all the possible side effects of Zelnorm. Doctors or pharmacists can provide patients with additional information on the side effects of Zelnorm.
13. Are there other drugs used to treat IBS with constipation?
Patients are often treated with diet, exercise, fiber, and various medicines to help relieve constipation. There is no other FDA approved medication for IBS with constipation.
14. If a patient wants to discuss their treatment with Zelnorm what should they do?
Patients should discuss questions and concerns with their doctor.
If patients have further questions about Zelnorm, they may contact the Center for Drug's Division of Drug Information at: 888-INFO.FDA (888-463-6332), or email us at: druginfo@cder.fda.gov
Patients may also contact Novartis directly at 1-862-778-8300.
15. Is Zelnorm going to be taken off the market?
FDA is not thinking of taking Zelnorm off the market at this time. We are adding new information about potential risks of treatment with Zelnorm to the labeling so that doctors and patients can make informed individual treatment decisions. FDA is also encouraging doctors and patients to report any similar events to FDA so that we can further understand these events and their association with Zelnorm use.
Today’s announcement by FDA and Novartis is an effort to minimize risks and maximize benefits of Zelnorm by ensuring that patients and doctors fully understand these risks and benefits.
16. Is Zelnorm going to have restricted marketing like Lotronex?
FDA has not requested any restrictions on the marketing or distribution of Zelnorm. We will continue to carefully evaluate post-marketing reports in patients receiving Zelnorm and consider any additional changes to labeling or other risk management steps that may be necessary as we gain a better understanding of these events. We encourage doctors and patients to report possible adverse events to FDA’s MedWatch program at www.fda.gov/medwatch or call 1-800-FDA-1088.
17. What should patients do if they think they are having side effects from Zelnorm?
Patients should call their doctor right away if they think they are having side effects from Zelnorm.
FDA has received reports of Zelnorm users who have fainted because of low blood pressure due to severe diarrhea caused by Zelnorm. FDA is advising patients who faint while taking Zelnorm to stop the drug immediately and see their doctor at once.
If patients experience blood from the rectum, bloody diarrhea, and/or new or worse abdominal pain, they should stop taking Zelnorm immediately and see their doctor who may need to perform additional tests.
To gather more safety information about Zelnorm, FDA is asking that doctors and patients report cases of suspected adverse effects from Zelnorm to FDA’s MedWatch Program at: www.fda.gov/medwatch and click on "How to Report" or by calling 1-800-FDA-1088.
18. Does the current labeling for Zelnorm warn about diarrhea?
Yes, the first FDA approved labeling for Zelnorm described cases of diarrhea that were seen in clinical trials. Postmarketing surveillance has identified additional cases of diarrhea, some of which were serious enough to cause low blood pressure and fainting and the need for hospitalization for intravenous fluids. FDA has been working with the company to update its labeling to emphasize the serious nature of the diarrhea that some users might experience.
FDA/Center for Drug Evaluation and Research
http://www.fda.gov/cder/drug/infopage/zelnorm/zelnorm_QA.htm
Please visit www.adhesionrelateddisorder.com
Abdominal wall lift versus positive-pressure capnoperitoneum for laparoscopic cholecystectomy
Ann Surg. 2004 Mar;239(3):388-94.
Abdominal wall lift versus positive-pressure capnoperitoneum for laparoscopic cholecystectomy: randomized controlled trial.
Alijani A, Hanna GB, Cuschieri A.Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee, Scotland.OBJECTIVE: To compare intraoperative cardiac function, postoperative cognitive recovery, and surgical performance of laparoscopic cholecystectomy with abdominal wall lift (AWL) versus positive-pressure capnoperitoneum (PPCpn).
SUMMARY BACKGROUND DATA: AWL has been proposed as an alternative approach to PPCpn to avoid adverse cardio-respiratory changes. However, the workspace obtained with the AWL is less optimal than PPCpn and previous studies documenting delayed postoperative recovery of consciousness following PPCpn have not assessed mental alertness despite its importance. METHODS: Forty operations were randomized into AWL and PPCpn. A standard anesthetic protocol was followed. Cardiac indices were measured with an esophageal Doppler machine. An auditory vigilance test was used to measure alertness level following extubation. All operations were videotaped and human reliability assessment techniques were used to identify surgical errors. RESULTS: There was a significant reduction in cardiac output during the first 20 minutes following CO2 insufflation in the PPCpn group, whereas in the AWL group it did not exhibit any significant change. Patients in AWL arm had better vigilance scores at 90 and 180 minutes following extubation compared with the PPn group (P < p =" 0.001).">Clinical Trial
Randomized Controlled Trial PMID: 15075657 [PubMed - indexed for MEDLINE]
Abdominal wall lift versus positive-pressure capnoperitoneum for laparoscopic cholecystectomy: randomized controlled trial.
Alijani A, Hanna GB, Cuschieri A.Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee, Scotland.OBJECTIVE: To compare intraoperative cardiac function, postoperative cognitive recovery, and surgical performance of laparoscopic cholecystectomy with abdominal wall lift (AWL) versus positive-pressure capnoperitoneum (PPCpn).
SUMMARY BACKGROUND DATA: AWL has been proposed as an alternative approach to PPCpn to avoid adverse cardio-respiratory changes. However, the workspace obtained with the AWL is less optimal than PPCpn and previous studies documenting delayed postoperative recovery of consciousness following PPCpn have not assessed mental alertness despite its importance. METHODS: Forty operations were randomized into AWL and PPCpn. A standard anesthetic protocol was followed. Cardiac indices were measured with an esophageal Doppler machine. An auditory vigilance test was used to measure alertness level following extubation. All operations were videotaped and human reliability assessment techniques were used to identify surgical errors. RESULTS: There was a significant reduction in cardiac output during the first 20 minutes following CO2 insufflation in the PPCpn group, whereas in the AWL group it did not exhibit any significant change. Patients in AWL arm had better vigilance scores at 90 and 180 minutes following extubation compared with the PPn group (P < p =" 0.001).">Clinical Trial
Randomized Controlled Trial PMID: 15075657 [PubMed - indexed for MEDLINE]
Tuesday, March 28, 2006
Medical Headlines ARDvark Blog
Loneliness linked to high blood pressure
CHICAGO (AP) - Loneliness in people over 50 greatly increases their risk of high blood pressure, researchers say in the latest study to underscore the health advantages of friends and family. The loneliest people studied had blood pressure readings as much as 30 points higher than those who weren't lonely, suggesting that loneliness can be as bad for the heart as being overweight or inactive, the researchers said.
Top health risks to mothers in poor nations
Hemorrhage and high blood pressure are the leading causes of maternal deaths in poor countries in Asia, Africa and Latin America, according to new research.
Drinkers, smokers need early colon cancer test
CHICAGO (Reuters) - People who smoke and drink should start screening for colon cancer earlier because they tend to contract the disease at a younger age than those who abstain from cigarettes and alcohol, a study said on Monday.
Antidepressants may cut colon cancer risk
NEW YORK (Reuters Health) - Confirming the findings from animal studies, treatment with SSRI type antidepressants, such as Zoloft and Prozac, is associated with a decreased risk of colorectal cancer, new research shows.
Heavy periods may warn of disease
A charity warns that prolonged heavy periods may warn of an undiagnosed disease.
Urinary Incontinence May Bring Depression
Women with the disorder face twice the risk, study finds
Record number of C-sections sparks concerns
Nearly three in 10 U.S. mothers are giving birth by Caesarean section — a record number — and more and more of them seem to be choosing a surgical birth even when there's no clear medical need.
Personalities Can Affect Sleep Woes
Some types are more prone to insomnia than others, explains Women's Health magazine's Beth Fenner. But she says there are steps you can take to counter the inability to get those Z's you need.
Birth pill 'may cut cancer risk'
Scientists are developing a contraceptive pill which carries a lower risk of breast cancer.
U.K. To Reduce Tax On Condoms, Contraceptive Products
Increased Response To Therapy With No Added Toxicity In Treatment Of Recurrent Ovarian Cancer, New Study Reports
Mass. Gov. Romney Does Not Sign Proclamation Recognizing Supreme Court Decision Legalizing Birth Control For Unmarried People
1.9M Additional Beneficiaries Signed Up For Drug Benefit In Last Month, According To New Enrollment Data
Six Patients Making Progress After Tragic Clinical Trial, London
Lyrica Approved For The Treatment Of Generalized Anxiety Disorder (GAD) In Europe
New Course That Aims To Make Tomorrow's Doctors More ‘Self-Aware'
Research Team Sweeps The Board With Intensive Care Innovations
Wasabi's Kick Linked To Single Pain Receptor
CHICAGO (AP) - Loneliness in people over 50 greatly increases their risk of high blood pressure, researchers say in the latest study to underscore the health advantages of friends and family. The loneliest people studied had blood pressure readings as much as 30 points higher than those who weren't lonely, suggesting that loneliness can be as bad for the heart as being overweight or inactive, the researchers said.
Top health risks to mothers in poor nations
Hemorrhage and high blood pressure are the leading causes of maternal deaths in poor countries in Asia, Africa and Latin America, according to new research.
Drinkers, smokers need early colon cancer test
CHICAGO (Reuters) - People who smoke and drink should start screening for colon cancer earlier because they tend to contract the disease at a younger age than those who abstain from cigarettes and alcohol, a study said on Monday.
Antidepressants may cut colon cancer risk
NEW YORK (Reuters Health) - Confirming the findings from animal studies, treatment with SSRI type antidepressants, such as Zoloft and Prozac, is associated with a decreased risk of colorectal cancer, new research shows.
Heavy periods may warn of disease
A charity warns that prolonged heavy periods may warn of an undiagnosed disease.
Urinary Incontinence May Bring Depression
Women with the disorder face twice the risk, study finds
Record number of C-sections sparks concerns
Nearly three in 10 U.S. mothers are giving birth by Caesarean section — a record number — and more and more of them seem to be choosing a surgical birth even when there's no clear medical need.
Personalities Can Affect Sleep Woes
Some types are more prone to insomnia than others, explains Women's Health magazine's Beth Fenner. But she says there are steps you can take to counter the inability to get those Z's you need.
Birth pill 'may cut cancer risk'
Scientists are developing a contraceptive pill which carries a lower risk of breast cancer.
U.K. To Reduce Tax On Condoms, Contraceptive Products
Increased Response To Therapy With No Added Toxicity In Treatment Of Recurrent Ovarian Cancer, New Study Reports
Mass. Gov. Romney Does Not Sign Proclamation Recognizing Supreme Court Decision Legalizing Birth Control For Unmarried People
1.9M Additional Beneficiaries Signed Up For Drug Benefit In Last Month, According To New Enrollment Data
Six Patients Making Progress After Tragic Clinical Trial, London
Lyrica Approved For The Treatment Of Generalized Anxiety Disorder (GAD) In Europe
New Course That Aims To Make Tomorrow's Doctors More ‘Self-Aware'
Research Team Sweeps The Board With Intensive Care Innovations
Wasabi's Kick Linked To Single Pain Receptor
Securing Your Medical Records
From: Beverly J, Doucette Sat, 6 Nov 1999 13:01:21 -0600 (CST)
On Thu, 4 Nov 1999, Gina wrote:
I read with interest and sadness about your discovery at having had an adhesiolysis without your knowledge. This is very unfortunate but far from uncommon, Gina! I too discovered that I did indeed have adhesions the same way. I cannot count on both hands how many times I have heard that same story repeated from adhesion sufferers. Far too often a happening.
If you have presented to a Dr. with pain and symptoms that occurred following an invasive medical procedure -- even years after it -- and have undergone diagnostic testing that resulted in no abnormal pathology being the cause of your symptoms, you must secure your operative reports! Many a surgical procedure that is done for pain unassociated with any abnormal pathology detected results in a removal of the " offending " organ, and then that organ is found in pathology as NOT being the cause of your symptoms! You'll never know that. You may be told that the organ was removed, or that the organ is the cause of your symptoms, only to present again in a year or so, or less with the very same symptoms as before..and you wonder why? ...
I have stated before the importance of finding out as much as you can about your medical condition, to educate yourself as to reasons for your symptoms and suffering, to take responsibility for your medical care...ultimately it is your responsibility to know what, when and how your medical provider is handling your case.
By securing your own operative reports, and ALL associated pathology and any cytology reports, you are beginning to take on the responsibility of educating yourself. You will be able to understand if you had adhesions for a fact, you will be able to understand just what organs have been affected by adhesions, and you will better understand why you feel the symptoms that you present to your Dr. with! You can also bet that you are more involved with adhesions than you
Reading in the report -- as denovo ( new ) adhesions as well as reformed adhesions are present as a result of the surgery.
If you saw that you had adhesions attached to your bladder -- and you're presenting with frequent urination or pressure -- then you know that there is a high probability that the adhesions that were lysed around or on your bladder have reformed. This is as long as you have NOT been diagnosed with any other means of a cause for the symptom! You will be able to recognize what to discuss with your Dr. as possibilities for your symptoms by securing and reading your operative reports.
You can secure your reports by signing a release form at the medical facility the surgery was performed at. You should NOT be charged for these records as you are entitled to have them for a second opinion. And who isn't getting a second opinion, right? One never knows when they will be looking for a new care provider; so you actually ARE securing the records for that purpose! And in the event you will be taking them to another Dr...make copies!
Please do this now, be sure to request ALL associated pathology, cytology, post surgical reports. And all pre- surgical ultra sounds or any other diagnostic tests that you had prior to the surgery.
If you have any questions as to your reports, ask for assistance in understanding them...ask on this blog, look up the question on the net, or post on this site .
Whatever you do, secure your records! This should be done NOT as a reflection on your surgeon or Dr., but as part of your overall responsibility of knowing what is going on with YOUR health care!
Adhesion related disorder is NOT so elusive that surgeons and Drs. don't know it's there at all...it is just difficult to diagnose for a fact without an invasive procedure. And if all else proves negative as to the cause of your symptoms -- and especially if you have had prior adhesiolysis and the symptoms are much the same -- you can bet that you probably have them back! YOU can bet that...but a Dr. cannot! But be sure to at least know for a fact that you did indeed have adhesions at one time! Don't wait for your surgeon or Dr. to tell you that..as you may just wait forever!
My best regards to all of you and I pray for an answer for each of you in your suffering...peace within your pain can be found if you take responsibility for understanding it as much as you can!
On Thu, 4 Nov 1999, Gina wrote:
I read with interest and sadness about your discovery at having had an adhesiolysis without your knowledge. This is very unfortunate but far from uncommon, Gina! I too discovered that I did indeed have adhesions the same way. I cannot count on both hands how many times I have heard that same story repeated from adhesion sufferers. Far too often a happening.
If you have presented to a Dr. with pain and symptoms that occurred following an invasive medical procedure -- even years after it -- and have undergone diagnostic testing that resulted in no abnormal pathology being the cause of your symptoms, you must secure your operative reports! Many a surgical procedure that is done for pain unassociated with any abnormal pathology detected results in a removal of the " offending " organ, and then that organ is found in pathology as NOT being the cause of your symptoms! You'll never know that. You may be told that the organ was removed, or that the organ is the cause of your symptoms, only to present again in a year or so, or less with the very same symptoms as before..and you wonder why? ...
I have stated before the importance of finding out as much as you can about your medical condition, to educate yourself as to reasons for your symptoms and suffering, to take responsibility for your medical care...ultimately it is your responsibility to know what, when and how your medical provider is handling your case.
By securing your own operative reports, and ALL associated pathology and any cytology reports, you are beginning to take on the responsibility of educating yourself. You will be able to understand if you had adhesions for a fact, you will be able to understand just what organs have been affected by adhesions, and you will better understand why you feel the symptoms that you present to your Dr. with! You can also bet that you are more involved with adhesions than you
Reading in the report -- as denovo ( new ) adhesions as well as reformed adhesions are present as a result of the surgery.
If you saw that you had adhesions attached to your bladder -- and you're presenting with frequent urination or pressure -- then you know that there is a high probability that the adhesions that were lysed around or on your bladder have reformed. This is as long as you have NOT been diagnosed with any other means of a cause for the symptom! You will be able to recognize what to discuss with your Dr. as possibilities for your symptoms by securing and reading your operative reports.
You can secure your reports by signing a release form at the medical facility the surgery was performed at. You should NOT be charged for these records as you are entitled to have them for a second opinion. And who isn't getting a second opinion, right? One never knows when they will be looking for a new care provider; so you actually ARE securing the records for that purpose! And in the event you will be taking them to another Dr...make copies!
Please do this now, be sure to request ALL associated pathology, cytology, post surgical reports. And all pre- surgical ultra sounds or any other diagnostic tests that you had prior to the surgery.
If you have any questions as to your reports, ask for assistance in understanding them...ask on this blog, look up the question on the net, or post on this site .
Whatever you do, secure your records! This should be done NOT as a reflection on your surgeon or Dr., but as part of your overall responsibility of knowing what is going on with YOUR health care!
Adhesion related disorder is NOT so elusive that surgeons and Drs. don't know it's there at all...it is just difficult to diagnose for a fact without an invasive procedure. And if all else proves negative as to the cause of your symptoms -- and especially if you have had prior adhesiolysis and the symptoms are much the same -- you can bet that you probably have them back! YOU can bet that...but a Dr. cannot! But be sure to at least know for a fact that you did indeed have adhesions at one time! Don't wait for your surgeon or Dr. to tell you that..as you may just wait forever!
My best regards to all of you and I pray for an answer for each of you in your suffering...peace within your pain can be found if you take responsibility for understanding it as much as you can!
Chronic Intermittent Intestinal Obstruction From a Seat Belt Injury
Southern Medical Journal 2001
Chronic Intermittent Intestinal Obstruction From a Seat Belt Injury
Janet R. Harrison, MD, Michael O. Blackstone, MD, Thomas Vargish, MD, Arunas Gasparaitis, MD, Division of Gastroenterology, University of Chicago Hospitals, Chicago, Ill
Abstract
Most patients with intestinal obstruction have had previous surgery. Rarely, the development of adhesions and resulting small bowel obstruction is attributed to previous intra-abdominal trauma. We present the case of a young man, without a history of surgery, who had been a restrained driver in a motor vehicle crash. Seven years later, the patient had an intermittent partial small bowel obstruction that recurred over the next 5 years. We review the pathophysiology and epidemiology of similar occurrences, as well as diagnostic options. [South Med J 94(5):499-501, 2001. © 2001 Southern Medical Association]
Introduction
Intra-abdominal adhesions cause most mechanical small bowel obstructions.[1,2] Most adhesions are due to previous intra-abdominal surgery.[2,3] In patients without a surgical history, intra-abdominal adhesions have rarely been attributed to blunt abdominal trauma.[1,2,4,5]
We report a case of a young man who was the restrained driver in a car crash. He had no history of laparotomy or intra-abdominal disease. After a protracted course of recurrent pain, adhesional intermittent partial small bowel obstructions were diagnosed. Abdominal trauma may be an under-recognized cause of obstructing intestinal adhesions.
Case Report
This 33-year-old man had had intermittent abdominal pain for 5 years. Approximately once a year, he had an episode of lower abdominal "tightening" and "spasm." The symptoms lasted 10 to 24 hours and were associated with nausea and vomiting. He limited his diet to clear liquids, toast, and crackers until the pain remitted. Between these episodes, he had no gastrointestinal symptoms.
Twelve years before this presentation, he had been the restrained driver in a motor vehicle crash, which had caused abdominal wall contusions, transient microscopic hematuria, a clavicular fracture, and a pneumothorax. He had not required surgery, and computed tomography had not been done. He had no other medical history; he denied surgery, abdominal radiation, intra-abdominal infection, and inflammatory diseases of the bowel.
Previous studies included small bowel radiography, barium enema, magnetic resonance imaging (MRI) of the abdomen, colonoscopy, urine porphyrin testing, and stool studies for ova and parasites. These were all unremarkable. The patient was intermittently treated with famotidine, dicyclomine, hyoscyamine, and omeprazole. There was no change in frequency, duration, or severity of symptoms. Family history and social history were unremarkable.
The patient was a well-appearing tall, thin man. He was afebrile and normotensive, and findings on physical examination, including the abdominal and rectal examinations, were normal.
To further investigate the source of pain, an enteroclysis and a Meckel's scan were done (while the patient was asymptomatic). Results of both were normal.
Four months after these tests, the abdominal pain recurred. While he was still symptomatic, another enteroclysis was done, which showed kinking of the small bowel at an acute angle. The contrast material moved slowly and pooled. This was diagnostic of an adhesional small bowel obstruction
At laparoscopy
Extensive small bowel adhesions were found, and several discrete bands were causing kinking in the distal jejunum (Fig 2). Lysis of adhesions was done during the laparoscopy. The bowel was normal in appearance, without stenosis, stricture, or inflammation. After 1 year of follow-up, the patient is well and has had no further episodes of abdominal pain.
Discussion
Adhesions from previous surgery cause most small bowel obstructions.[2,3] Combining the data from three published studies yielded a total of 1,730 patients with adhesional small bowel obstructions.[2,6,7] The vast majority of patients had a history of previous surgery, and only 218 patients (12.6%) had no surgical history. In 129 (60%) of the nonsurgical patients, an etiology was identified -- most often tuberculous peritonitis, a history of intra-abdominal inflammation, or a history of pelvic inflammatory disease. In one patient, the adhesions were attributed to abdominal trauma, occurring 3 weeks before the development of obstruction. In 89 (40%) of the nonsurgical patients, there was no identifiable cause for the adhesions.[2,6,7]
In our case, a restrained driver in a motor vehicle crash had significant abdominal trauma, causing abdominal wall ecchymoses and microscopic hematuria at the time of the crash. Seven years later, intra-abdominal adhesions caused intermittent small bowel obstructions with associated abdominal pain. Although the motor vehicle crash and adhesional small bowel obstruction may be coincidental in our patient, there is no other explanation for the development of adhesions. Our case, therefore, suggests that the intra-abdominal trauma may have caused the development of adhesions and subsequent small bowel obstruction. A subset of patients with "idiopathic" adhesions may have had a history of remote abdominal trauma.
In 1962, Garrett and Braunstein first described the "seat belt syndrome," which encompassed a spectrum of intra-abdominal injuries caused by the seat belt during impact. In one study, 5% to 15% of patients sustaining blunt abdominal trauma had intestinal injury occurred. The intestine is, in fact, the third most commonly injured intra-abdominal organ in the seat belt syndrome. Relatively fixed portions of bowel, such as the proximal jejunum and distal ileum, are more susceptible to injury.[5,10,11] The mobile portions are able to escape the highest pressure and the resultant damage.[11]
Motor vehicle crashes cause intestinal injury by several mechanisms. As an individual is propelled forward upon impact, the seat belt or buckle inflicts pressure -- throwing the intestine against the vertebral column and causing a contusion.[4,12-14] Also, rapid deceleration may shear fixed ligaments and mesenteric attachments.[12-16]
Surgery and trauma result in peritoneal injury, the impetus for the development of adhesions. After surgery, the peritoneal surface is denuded and the microvasculature is disrupted, releasing a serosanguineous exudate that is followed by the formation of a fibrinous bridge.[3,17,18] Since fibrinolysis requires an adequate blood supply, tissue injury in an avascular milieu is associated with diminished fibrinolysis and a persistent fibrinous bridge.[3,17] Collagen is deposited 4 to 5 days later, and permanent adhesions result.[18] Since abdominal trauma is another cause of peritoneal injury, it is a logical supposition that adhesions could form in this scenario.
The seat belt syndrome includes acute intestinal injury, as well as the less common delayed small bowel obstruction.[5,12-16,19,20] Most patients have symptoms 2 to 3 weeks after a crash and go to their physician 4 to 18 weeks after the trauma, though presentation has been delayed as long as 18 years.[12,15] The common symptoms of abdominal distention, pain, and vomiting mimic postoperative obstruction.[16] At the time of surgical exploration, strictures, previous perforations, and adhesions have been identified as the cause of obstruction in patients with posttraumatic small bowel obstructions.[4,14-16,20] In one case report, a motor vehicle crash caused abdominal pain and an adhesional small bowel obstruction without structural abnormalities of the intestine.
In our case, a motor vehicle crash presumably caused an intestinal contusion, eventually resulting in adhesion formation and intermittent obstruction. Any source of severe blunt abdominal trauma, such as contact sports or biking accidents with resultant peritoneal injury, could cause adhesions by the same mechanism; peritoneal contusion associated with a decrease in fibrinolysis can result in the development of adhesions. Perhaps unrecognized "trauma" accounts for a portion of unexplained adhesional obstructions.[2,6,7] Recurrent obstructive symptoms should therefore prompt the clinician to take a thorough history of abdominal trauma.[5,21]
This case also portrays the difficulty of diagnosing an intermittent partial small bowel obstruction. Enteroclysis correctly diagnoses an adhesive small bowel obstruction in as many as 87.8% of patients.[22] False-negative studies occur and are more likely if the enteroclysis is done when the patient is asymptomatic.[22] Johnson et al[22] advocated the use of radiopaque markers, which collect proximal to the obstruction, to unmask adhesive obstructions. Results of our patient's initial enteroclysis were entirely normal, even on subsequent review. In comparison, when he was symptomatic, the study revealed a high density of contrast material proximal to an obstructing band, and the diagnosis of partial small bowel obstruction was made.
Chronic Intermittent Intestinal Obstruction From a Seat Belt Injury
Janet R. Harrison, MD, Michael O. Blackstone, MD, Thomas Vargish, MD, Arunas Gasparaitis, MD, Division of Gastroenterology, University of Chicago Hospitals, Chicago, Ill
Abstract
Most patients with intestinal obstruction have had previous surgery. Rarely, the development of adhesions and resulting small bowel obstruction is attributed to previous intra-abdominal trauma. We present the case of a young man, without a history of surgery, who had been a restrained driver in a motor vehicle crash. Seven years later, the patient had an intermittent partial small bowel obstruction that recurred over the next 5 years. We review the pathophysiology and epidemiology of similar occurrences, as well as diagnostic options. [South Med J 94(5):499-501, 2001. © 2001 Southern Medical Association]
Introduction
Intra-abdominal adhesions cause most mechanical small bowel obstructions.[1,2] Most adhesions are due to previous intra-abdominal surgery.[2,3] In patients without a surgical history, intra-abdominal adhesions have rarely been attributed to blunt abdominal trauma.[1,2,4,5]
We report a case of a young man who was the restrained driver in a car crash. He had no history of laparotomy or intra-abdominal disease. After a protracted course of recurrent pain, adhesional intermittent partial small bowel obstructions were diagnosed. Abdominal trauma may be an under-recognized cause of obstructing intestinal adhesions.
Case Report
This 33-year-old man had had intermittent abdominal pain for 5 years. Approximately once a year, he had an episode of lower abdominal "tightening" and "spasm." The symptoms lasted 10 to 24 hours and were associated with nausea and vomiting. He limited his diet to clear liquids, toast, and crackers until the pain remitted. Between these episodes, he had no gastrointestinal symptoms.
Twelve years before this presentation, he had been the restrained driver in a motor vehicle crash, which had caused abdominal wall contusions, transient microscopic hematuria, a clavicular fracture, and a pneumothorax. He had not required surgery, and computed tomography had not been done. He had no other medical history; he denied surgery, abdominal radiation, intra-abdominal infection, and inflammatory diseases of the bowel.
Previous studies included small bowel radiography, barium enema, magnetic resonance imaging (MRI) of the abdomen, colonoscopy, urine porphyrin testing, and stool studies for ova and parasites. These were all unremarkable. The patient was intermittently treated with famotidine, dicyclomine, hyoscyamine, and omeprazole. There was no change in frequency, duration, or severity of symptoms. Family history and social history were unremarkable.
The patient was a well-appearing tall, thin man. He was afebrile and normotensive, and findings on physical examination, including the abdominal and rectal examinations, were normal.
To further investigate the source of pain, an enteroclysis and a Meckel's scan were done (while the patient was asymptomatic). Results of both were normal.
Four months after these tests, the abdominal pain recurred. While he was still symptomatic, another enteroclysis was done, which showed kinking of the small bowel at an acute angle. The contrast material moved slowly and pooled. This was diagnostic of an adhesional small bowel obstruction
At laparoscopy
Extensive small bowel adhesions were found, and several discrete bands were causing kinking in the distal jejunum (Fig 2). Lysis of adhesions was done during the laparoscopy. The bowel was normal in appearance, without stenosis, stricture, or inflammation. After 1 year of follow-up, the patient is well and has had no further episodes of abdominal pain.
Discussion
Adhesions from previous surgery cause most small bowel obstructions.[2,3] Combining the data from three published studies yielded a total of 1,730 patients with adhesional small bowel obstructions.[2,6,7] The vast majority of patients had a history of previous surgery, and only 218 patients (12.6%) had no surgical history. In 129 (60%) of the nonsurgical patients, an etiology was identified -- most often tuberculous peritonitis, a history of intra-abdominal inflammation, or a history of pelvic inflammatory disease. In one patient, the adhesions were attributed to abdominal trauma, occurring 3 weeks before the development of obstruction. In 89 (40%) of the nonsurgical patients, there was no identifiable cause for the adhesions.[2,6,7]
In our case, a restrained driver in a motor vehicle crash had significant abdominal trauma, causing abdominal wall ecchymoses and microscopic hematuria at the time of the crash. Seven years later, intra-abdominal adhesions caused intermittent small bowel obstructions with associated abdominal pain. Although the motor vehicle crash and adhesional small bowel obstruction may be coincidental in our patient, there is no other explanation for the development of adhesions. Our case, therefore, suggests that the intra-abdominal trauma may have caused the development of adhesions and subsequent small bowel obstruction. A subset of patients with "idiopathic" adhesions may have had a history of remote abdominal trauma.
In 1962, Garrett and Braunstein first described the "seat belt syndrome," which encompassed a spectrum of intra-abdominal injuries caused by the seat belt during impact. In one study, 5% to 15% of patients sustaining blunt abdominal trauma had intestinal injury occurred. The intestine is, in fact, the third most commonly injured intra-abdominal organ in the seat belt syndrome. Relatively fixed portions of bowel, such as the proximal jejunum and distal ileum, are more susceptible to injury.[5,10,11] The mobile portions are able to escape the highest pressure and the resultant damage.[11]
Motor vehicle crashes cause intestinal injury by several mechanisms. As an individual is propelled forward upon impact, the seat belt or buckle inflicts pressure -- throwing the intestine against the vertebral column and causing a contusion.[4,12-14] Also, rapid deceleration may shear fixed ligaments and mesenteric attachments.[12-16]
Surgery and trauma result in peritoneal injury, the impetus for the development of adhesions. After surgery, the peritoneal surface is denuded and the microvasculature is disrupted, releasing a serosanguineous exudate that is followed by the formation of a fibrinous bridge.[3,17,18] Since fibrinolysis requires an adequate blood supply, tissue injury in an avascular milieu is associated with diminished fibrinolysis and a persistent fibrinous bridge.[3,17] Collagen is deposited 4 to 5 days later, and permanent adhesions result.[18] Since abdominal trauma is another cause of peritoneal injury, it is a logical supposition that adhesions could form in this scenario.
The seat belt syndrome includes acute intestinal injury, as well as the less common delayed small bowel obstruction.[5,12-16,19,20] Most patients have symptoms 2 to 3 weeks after a crash and go to their physician 4 to 18 weeks after the trauma, though presentation has been delayed as long as 18 years.[12,15] The common symptoms of abdominal distention, pain, and vomiting mimic postoperative obstruction.[16] At the time of surgical exploration, strictures, previous perforations, and adhesions have been identified as the cause of obstruction in patients with posttraumatic small bowel obstructions.[4,14-16,20] In one case report, a motor vehicle crash caused abdominal pain and an adhesional small bowel obstruction without structural abnormalities of the intestine.
In our case, a motor vehicle crash presumably caused an intestinal contusion, eventually resulting in adhesion formation and intermittent obstruction. Any source of severe blunt abdominal trauma, such as contact sports or biking accidents with resultant peritoneal injury, could cause adhesions by the same mechanism; peritoneal contusion associated with a decrease in fibrinolysis can result in the development of adhesions. Perhaps unrecognized "trauma" accounts for a portion of unexplained adhesional obstructions.[2,6,7] Recurrent obstructive symptoms should therefore prompt the clinician to take a thorough history of abdominal trauma.[5,21]
This case also portrays the difficulty of diagnosing an intermittent partial small bowel obstruction. Enteroclysis correctly diagnoses an adhesive small bowel obstruction in as many as 87.8% of patients.[22] False-negative studies occur and are more likely if the enteroclysis is done when the patient is asymptomatic.[22] Johnson et al[22] advocated the use of radiopaque markers, which collect proximal to the obstruction, to unmask adhesive obstructions. Results of our patient's initial enteroclysis were entirely normal, even on subsequent review. In comparison, when he was symptomatic, the study revealed a high density of contrast material proximal to an obstructing band, and the diagnosis of partial small bowel obstruction was made.
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