Chronic Intestinal Obstruction Research Articles

Inactivation of the basolateral Na‐K‐2Cl cotransporter, NKCC1, increases intestinal barrier permeability

Background Epithelial tight junctions are defective in gastrointestinal diseases. Conditions that causes epithelial barrier loss are often accompanied by dysregulation of tight junction protein expression and/or localization. Recently we have reported that patients with mutations in SLC12A2; the gene encoding the basolateral Na+-K+-2Cl- cotransporter (NKCC1), suffer from severe gastrointestinal deficit; including chronic gastrointestinal inflammation, gastrointestinal hemorrhage, intestinal obstruction, and constipation. NKCC1-KO mice develop spontaneous gastrointestinal inflammation with bleeding in the intestine. We therefore ask whether loss of NKCC1 function affect intestinal epithelial barrier function. Methods Wild-type HT29-MTX-E12 and CRISPR/Cas9 NKCC1-deleted HT29 clones were tested for tight junction protein expression and localization. Epithelial cell monolayers permeability to molecular tracers was assessed in transwell filters. Tight junction protein localization was assessed by immunofluorescence. Results Loss of NKCC1 expression strongly increases the expression of claudin-2, occluding, and ZO-1 in epithelial cell monolayers. Loss of NKCC1 significantly reduces the trans-epithelial electrical resistance (TER) indicating an increase in paracellular ions flux, which is consistent with upregulation of the cation-selective and channel-forming claudin-2. In addition, NKCC1-KO monolayers showed a significant increase in paracellular flux of small molecules, as the 0.33 kDa fluorescein permeability increases in the NKCC1-KO monolayers compared to wild-type, while the high molecular weight 4 kDa TRITC-Dextran and 70 kDa TRITC-Dextran permeability remained unchanged. In addition, Loss of NKCC1 causes mis-localization of occludin from the tight junction complex. Conclusions NKCC1 regulate tight junction protein expression and localization. Loss of NKCC1 function is a previously unknown mechanism that causes intestinal epithelial barrier loss.

Manejo del Síndrome de Arteria Mesentérica Superior

El síndrome de arteria mesentérica superior o también llamado síndrome de Wilkie, consiste en un diagnóstico de exclusión, una condición que causa un cuadro de obstrucción intestinal alta de forma crónica usualmente debido a un acortamiento del ángulo aorto mesentérico y la distancia aortomesentérica. Su clínica se basa en vómitos postprandiales, llenura postprandial, pérdida de peso y suele acompañarse de condiciones adicionales que causan un franco adelgazamiento del paciente. Su valoración y manejo es multidisciplinario e involucra múltiples especialidades médicas y quirúrgicas. El manejo inicial es médico y nutricional y se basa en lograr un claro aumento de peso, sin embargo, muchas veces es fallido y el paciente requiere de cirugía. Cuando esto sucede la técnica ideal con menos morbilidad asociada y mayor resolución de sintomatología consiste en la duodeno yeyunostomía laparoscópica.

Two Polyurethane Adhesives for PVDF Fixation Show Superior Biocompatibility in a Rat Model

Background The current standard for open and laparoscopic repair of incisional hernia consist of an abdominal wall augmentation by mesh implantation. However, the ideal fixation method of the prothesis material remains under discussion, due to potential complications of conventional fixation methods such as chronic abdominal pain or intestinal obstruction. As the use of adhesive based mesh fixation is an option of growing interest, the aim of this experimental study was to investigate the strength and biocompatibility of two newly developed polyurethane-based adhesives in comparison to a cyanoacrylatic adhesive, which is currently in clinical use. Methods Two experimental polyurethane/urea-based adhesives (Adhesive-A and Adhesive-B) were compared to a conventional cyanoacrylatic adhesive and an untreated control group. Biomechanical testing was carried out using a pull-out test in uniaxial tensile mode, while biocompatibility assessment was performed in a rat model with 40 Sprague-Dawley rats receiving a subcutaneous implanted PVDF mesh fixed by the corresponding adhesive. Histological and immunohistochemical analysis by a Tissue FAXS system examined the tissue integration of the mesh/adhesive combination and characterized the foreign body reaction. Results Biomechanical testing of the mesh/adhesive combinations showed a minimal strength of 15.08 N without a significant difference between the groups. Cellular penetration into the mesh/adhesive interface was significantly improved after application of polyurethane adhesives and Adhesive-A showed a significantly lower migration of CD68 positive cells to the adhesive sites compared to cyanoacrylate after 7 days. Conclusion The developed polyurethane-based adhesives are a promising alternative with sufficient adhesive strength and superior short-term biocompatibility to cyanoacrylate.

GIST as a Lead Point in Adult Intussusception: Study in a Tertiary Hospital

Introduction: Intussusception is very common in childhood between the ages of 5 months to 1 year. In adults it is a rarity, in whom it commonly presents with a nonspecific, repeated, chronic or subacute intestinal obstruction. Ninety percent of them have a variable number of secondary pathological ‘lead point’- from benign lesion to malignant.5
 Objective: This study aims to find out the variations & the commonest ‘Lead points’ in rare adult intussusceptions.
 Methodology: Study period was from January 2015 to June 2019. All patients of adult intussusceptions, admitted in Shaheed Suhrawardy Medical college Hospital, were examined, investigated, & analysed peri-operative findings with post-operative histopathological results, in this prospective observational study.
 Result: In this study, among 15 patients, GIST found to be the commonest (46%) Lead point in adult intussusceptions. Others include Adenocarcinoma, Leiomyomatous polyp, Meckel’s Diverticulum, intestinal TB, etc. Male was mostly sufferer (67%). Ileoileal (II) variety was found more in male & Ileocecal (IC) variety in female.
 J Shaheed Suhrawardy Med Coll, December 2019, Vol.11(2); 138-141

Combination of Polypropylene Mesh and in Situ Injectable Mussel-Inspired Hydrogel in Laparoscopic Hernia Repair for Preventing Post-Surgical Adhesions in the Piglet Model.

Polypropylene (PP) mesh has been used successfully for a long time in clinical practice as an impressive prosthesis for ventral hernia repair. To utilize a physical barrier for separating mesh from viscera is a general approach for preventing adhesions in clinical practice. However, a serious abdominal adhesion between the mesh and viscera can possibly occur post-hernia, especially with the small intestine; this can lead to a series of complications, such as chronic pain, intestinal obstruction, and fistula. Thus, determining how to prevent abdominal adhesions between the mesh and viscera is still an urgent clinical problem. In this study, a dopamine-functionalized polysaccharide derivative (oxidized-carboxymethylcellulose-g-dopamine, OCMC-DA) was synthesized; this was blended with carboxymethylchitosan (CMCS) to form a hydrogel (OCMC-DA/CMCS) in situ at the appropriate time. The physical and chemical properties of the hydrogel were characterized successfully, and its excellent biocompatibility was presented by the in vitro cell test. The combination of this hydrogel and PP mesh was used in laparoscopic surgery for repairing the abdominal wall defect, where the hydrogel could become fixed in situ on the PP mesh to form an anti-adhesion gel-mesh. The results showed that the gel-mesh could prevent abdominal adhesions effectively in the piglet model. Moreover, the histology and immunohistochemical staining proved that the gel-mesh could effectively alleviate the inflammation reaction and deposition of collagen around the mesh, and it did not disturb the integration between mesh and abdominal wall. Thus, the gel-mesh has superior tissue compatibility.

Chinese expert consensus on the prevention of abdominal pelvic adhesions after gynecological tumor surgeries.

Adhesion is a postoperative complication that has plagued gynecologists for many years, as 60-90% of gynecological patients develop adhesions after abdominopelvic surgeries. Abdominopelvic adhesions could lead to chronic pelvic pain, infertility, intestinal obstruction, and complicated reoperations. Adhesions might also increase the risk of postoperative chemoradiotherapy failure and endanger patients' lives, especially after surgeries for gynecological malignant tumors. The aim of this consensus was to review the pathogenesis and clinical consequences of adhesions and to summarize various surgical procedures and preventive measures that can reduce the occurrence of adhesions after gynecological tumor surgeries based on a discussion among well-known domestic gynecology specialists.

Superior mesenteric artery syndrome following spinal deformity correction

Background. Superior mesenteric artery syndrome is a rare pathological condition caused by an abnormal transposition of the superior mesenteric artery from the abdominal part of the aorta. It results in compression of the distal part of the duodenum between the aorta and the superior mesenteric artery. It is clinically manifested by signs of acute intestinal obstruction, including pain in the epigastric region, nausea, and profuse vomiting. In the absence of timely treatment, patients may experience electrolyte disturbance, severe nutritional deficiency, the risk of perforation of the stomach, aspiration pneumonia, bezoar formation, thromboembolism, and the development of other life-threatening complications that can lead to death.
 Case study. In the presented case study, superior mesenteric artery syndrome developed in a 17-year-old girl after surgical correction of a spinal deformity in the treatment of idiopathic scoliosis. This was due to postoperative loss of body weight, as well as a rapid change in the patients ratio of growth to body weight.
 Discussion. Significant clinical improvement was achieved as a result of an integrated approach to the treatment of this complication. However, despite the successful result from conservative therapy, the patient remains at risk of developing chronic duodenal obstruction of varying severity, which may require surgical treatment.
 Conclusion. With the untimely and incomplete treatment of superior mesenteric artery syndrome, the risk of developing chronic intestinal obstruction increases. Treatment of this complication begins with conservative therapy. In the absence of the effect of conservative therapy, and in the case of disease progression, the development of life-threatening conditions (such as bleeding and perforation) requires surgical treatment.

Morphological changes of a great omentum at implantation of polypropylene and composite prostheses at allohernioplasty

To date, allohernioplasty of giant postoperative ventral hernias retains high postoperative mortality and a significant number of postoperative complications. The purpose of the study is to investigate the possibility of intraperitoneal use of polypropylene and composite implants in allohernioplasty of postoperative giant ventral hernias by studying the morphological changes of the great omentum. The results of surgical treatment of 146 patients with postoperative giant ventral hernias were investigated. To this group of patients with allohernioplasty by the method onlay was performed 22 (15.1%) patients, by the method sublay – 46 (31.5%), by the method inlay – 52 (35.6%), with intra-abdominal placement of the mesh by the method onlay (intraperitoneal onlay mesh) – 26 (17.8%). 32 (21.9%) patients who underwent surgery using the sublay method polypropylene implant was fenced off from the abdominal organs with a great omentum, 22 (15.1%) patients operated on by the intraperitoneal onlay mesh method composite implant was also fenced off from the abdominal organs by a great omentum. In 8 (5.5%) patients from the group of patients who were operated on by the sublay method and in 6 (4.1%) – operated by the intraperitoneal onlay mesh method for 14-18 days patients developed signs of chronic intestinal obstruction, where the cause was postoperative adhesive illness. The study of the effect of polypropylene prosthesis on a great omentum was performed on 8 outbred dogs and 6 outbred mature dogs, who were implanted with a composite mesh unilaterally covered with oxycellulose. The polypropylene implant has been shown to have a greater capacity for the development of adhesive processes. However, if a great omentum to protect this prosthesis from the abdominal cavity then the first zone (active inflammation) spread in 155 microns (increase in the number of blood capillaries of the microcirculatory bed, thickening of the arterioles wall, venous full blood flow, diapedesis of leukocytes through the wall of the blood cells), the second zone (sclerosis) – up to 40 microns (increase in the number of macrophages and lymphocytes. proliferation of fibroblasts). In the future, the structure of the omentum was almost indistinguishable, so with allohernioplasty by the developed method, it was possible to prevent the development of adhesive disease on the intestine. This study confirmed the limited spread of the inflammatory response, which allows the implant of a polypropylene mesh on a great omentum. In the composite mesh, the composite mesh was spliced with surrounding tissues from the side where there was no gel coating, and from the side of the salivary coating, the “readiness” to spread the inflammatory process (vasculitis with pronounced lympho-plasmocytic infiltration of the vessel walls and perivascular ductus), therefore, left it is also necessary to enclose it with a large omentum from intestium.

NPPB prevents postoperative peritoneal adhesion formation by blocking volume-activated Cl- current.

5-Nitro-2-(3-phenylpropylamino)-benzoic acid (NPPB) is a non-specific chloride channel blocker. Peritoneal adhesion is an inevitable complication of abdominal surgery and remains an important clinical problem, leading to chronic pain, intestinal obstruction, and female infertility. The aim of this study is to observe the effects of NPPB on peritoneal adhesions and uncover the underlying mechanism. The formation of postoperative peritoneal adhesions was induced by mechanical injury to the peritoneum of rats. MTT assay and wound-healing assay were used to evaluate proliferation and migration of primary cultured adhesion fibroblasts (AFB) respectively. Whole-cell chloride currents were measured using a fully automated patch-clamp workstation. Cell volume changes were monitored by light microscopy and video imaging. Our results demonstrated that NPPB could significantly prevent the formation of peritoneal adhesion in rats and inhibit the proliferation of AFB in a concentration-dependent manner. NPPB also reduced the migration of AFB cells with an IC50 of 53.09 μM. A 47% hypotonic solution successfully activated the ICl,vol in AFB cells. The current could be blocked by extracellular treatment with NPPB. Moreover, 100 μM NPPB almost completely eliminated the capacity of regulatory volume decrease (RVD) in these cells. These data indicate that NPPB could prevent the formation of postoperative peritoneal adhesions. The possible mechanism may be through the inhibition of the proliferation and migration of AFB cells by modulating ICl,vol and cell volume. These results suggest a potential clinical use of NPPB for preventing the formation of peritoneal adhesions.

Similarities between Preexplorative Diagnosis and Perexplorative Findings of Intestinal Obstruction Patients in Two Tertiary Care Hospitals in Bangladesh

Background: Intestinal obstruction is a common surgical problem that surgeons face in clinical practice. Still intestinal obstruction is a major problem in medical college hospitals in Bangladesh. Causes of intestinal obstruction remain same as earlier. There is lack of statistical data in our country. So, this study will be helpful in various aspect of management of intestinal obstruction patients by providing data.
 Objective: To find out similarities between preoperative diagnosis with actual peroperative findings of intestinal obstruction.
 Materials and Methods: This cross-sectional study was conducted from April 2013 to April 2014 at Enam Medical College Hospital and Dhaka Medical College Hospital. Two hundred patients were selected by purposive sampling of diagnosed cases of intestinal obstruction.
 Results: Among the subjects male were 124 (62%) and female were 76 (38%). Mean age was 34.56 ± 9.13 years. The maximum respondents were from 21–30 years age group (54%) followed by 31–40 years (18%) age group. Chronic intestinal obstruction was present in 53% cases and acute intestinal obstruction in 47% cases. The clinical profile showed that all patients had abdominal pain followed by vomiting (78%). The preoperative diagnosis of intestinal obstruction was neoplastic obstruction (24%) followed by obstructed hernia (22.5%). The highest similarities (100%) were observed in case of volvulus and ileosigmoid knotting. Obstructed hernia had the highest accuracy (97.7%) followed by neoplastic obstruction (91.66%). Maximum patients (13.5%) suffered from wound infection followed by burst abdomen (3%).
 Conclusion: The preoperative diagnoses are very much similar to peroperative findings. The clinical parameters and other mandatory diagnostic tools commonly used in tertiary level hospitals in our country showed diagnostic accuracy in diagnosis of intestinal obstruction.
 J Enam Med Col 2019; 9(3): 155-159

Laparoscopic management for Wilkie´s syndrome.

Wilkie's syndrome is a rare entity that presents as a chronic intestinal obstruction secondary to mechanical compression of the third portion of the duodenum due to a decreased aorto-mesenteric angle. This entity has a reported incidence of 0.012 to 2.4% and can lead to high morbidity and mortality; In addition, there are major controversies regarding its diagnosis and treatment, which is why the authors present a case report of a patient with a diagnosis of Wilkie's syndrome and its surgical management via laparoscopy. A case of a patient with clinical and imaging manifestations of superior mesenteric artery syndrome is presented, along with acritical review of the literature, taking into account articles published in the PubMed and ScienceDirect databases during the past 8 years. A 27-year-old patient with 20 years of abdominal pain that exacerbated one week before admission, with a clinical and imaging manifestations of Wilkie's syndrome. Patient presents refractoriness to medical management, which led to a surgical approach with laparoscopic duodenum-jejunostomy that was carried out without perioperative complications and satisfactory results. The superior mesenteric artery syndrome is a rare entity that in some scenarios requires surgical management. The laparoscopic duodeno-jejunostomy is the procedure of choice to manage this entity as evidenced in our case, which is also consistent with what is reported in the world medical literature.

Ultrasonographic and histopathological features in 8 cats with fibrotic small intestinal stricture.

Benign stricture is an uncommon cause of chronic small intestinal obstruction in the cat. The purpose of this retrospective case series was to describe the ultrasonographic features, histopathological findings, and clinical presentation in a group of cats with benign small intestinal stricture. Inclusion criteria were cats presenting during the period 2010-2017, and that had ultrasonography and small intestinal stricture confirmed at surgery. For each cat, clinical data and ultrasonographic findings were retrieved from the medical record, and histopathology, where available, was reviewed. Eight cats met the inclusion criteria. The location of strictures was duodenum (1/8), mid- to distal jejunum (4/8), and ileum (3/8). Ultrasonographic findings included gastric distension (8/8) and generalized (3/8) or segmental (5/8) intestinal dilation consistent with mechanical obstruction. Ingesta did not propagate beyond the strictured segment. Wall thickening was mild to moderate (3-6mm). Normal wall layering was disrupted in all cats. Strictures were predominantly hypoechoic (7/8) and associated with hyperechoic peri-intestinal mesentery (6/8). Annular strictures (5/8) were less than 15mm in length whereas long-segment strictures (3/8) were greater than 15mm in length. Histopathology showed transmural disease with fibrosis and inflammation (8/8), often (6/8) extending into the bordering mesentery. The mucosa was the most severely affected layer and epithelial injury accompanied the mucosal fibrosis/inflammation. Clinical presentation reflected delayed diagnosis of chronic bowel obstruction with debilitation (8/8), marked weight loss (8/8), and prerenal azotemia (5/8). Benign fibrostenotic stricture should be considered a differential diagnosis in debilitated young cats presenting with chronic bowel disease and ultrasonographic features of intestinal obstruction.

Hirschsprung disease in an adult with intestinal malrotation and volvulus: an exceptional association

BackgroundHirschsprung disease is a neonatal discovery in almost all cases, and the association of Hirschsprung disease in adults with symptomatic intestinal malrotation is unusual. This combination delays diagnosis and can lead to mistake in surgical strategy.Case presentationA 43-year-old patient with a history of colectomy for colonic inertia and megadolichocolon was admitted to the Carcassonne Hospital emergency room for a volvulus of small bowel obstruction in a chronic intestinal obstruction context with episodes of acute, variable-looking occlusive syndromes. Intestinal malrotation was discovered during surgical small bowel detorsion. The acute occlusion syndrome recurred after the procedure. In view of the unfavorable evolution, an emptying of the dilated small bowel and a discharge ileostomy upstream of the rectum were performed. In the face of postoperative improvement, rectal manometry and deep full parietal rectal biopsies made it possible to highlight the diagnosis of Hirschsprung disease. The patient thus had functional acute occlusive syndromes and chronic occlusion due to Hirschsprung disease of attenuated form and acute organic occlusive syndromes related to her incomplete common mesentery.ConclusionsThis rare association, which may be responsible for delayed diagnostic and therapeutic wandering, highlights the importance of performing manometry and deep full parietal biopsies before a colectomy for colonic inertia, as well as the possibility of suggesting a common Hirschsprung disease and/or mesentery in an adult with multiple occlusive syndromes of variable appearance.

Portal vein recanalization failed to improve chronic intestinal obstruction due to extrahepatic portal vein obstruction

Extrahepatic portal vein obstruction (EHPVO) refers to obstruction of the extrahepatic portal vein that is characterized by cavernous transformation, portal hypertension, and intestinal dysfunction. Radiological interventions on EHPVO are an extraordinary challenge, although being reported to be safe and effective in selected patients by pertinent experts. Chronic intestinal dysfunction is a rare complication of EHPVO; it is unknown whether portal vein re-canalization by radiological interventions can improve chronic intestinal dysfunction. We describe a 22-year-old male patient with chronic intestinal dysfunction due to EHPVO, which was not improved by portal vein re-canalization. The patient presented with acute abdominal pain and dyspepsia for 2 weeks without hematochezia in August 2016 and was diagnosed with EHPVO. Due to cavernous transformation, systemic anticoagulation therapy was administered, and although his abdominal pain was relieved, the patient still had dyspepsia and partial jejunum dysfunction. Intestinal segmentectomy was suggested but was refused, and the patient received catheter-directed thrombolysis in another hospital. Although the portal vein was partly recanalized, the intestinal obstruction was not alleviated. Four months after onset, an emergent enterectomy was performed due to severe hematochezia with pathological examination findings of necrosis, ulcer, and granulation formation. Unfortunately, the patient developed a serious systemic infection, severe thrombocytopenia and disseminated intravascular coagulation, which was assumed to be caused by intestinal bacterial translocation and serious malnutrition. The infection was subsequently controlled. In conclusion, in patients with chronic intestinal dysfunction due to EHPVO, portal vein re-canalization may not improve intestinal function. Timely enterectomy may prevent intestinal bacterial translocation and serious malnutrition.

Pseudo-obstrução intestinal crônica pediátrica - uma revisão de literatura

Pseudo-obstrução intestinal crônica pediátrica - uma revisão de literatura

Liposarcoma of mesorectum presenting as chronic intestinal obstruction: a rare case

The term ‘liposarcoma’ refers to a spectrum of neoplastic lesions that can be benign to malignant and likely to recur or metastasize. Liposarcoma is a common soft tissue sarcoma found in adults and occurs mostly in extremities especially thigh followed by retroperitoneum. Here we present a case of spindle cell variant of well differentiated liposarcoma of mesorectum and underwent Anterior resection for the same. The treatment of choice for liposarcomas of retroperitoneum remains debatable and there are no clear-cut guidelines available regarding the same. However, considering the higher rates of local recurrence we advise a complete surgical excision following anatomical principles.

Colonic lymphoma causing colo-colonic intussusception and chronic intestinal obstruction in a four-year-old German shepherd dog

Gastrointestinal lymphoma accounts for approximately 7 per cent of all canine lymphomas. It is typically associated with a poor prognosis when localised to the gastrointestinal tract. This case report describes...

Strangulated Femoral Hernia With Perforated Jejunal Pseudodiverticula : a Case Report

Introduction: Sixty percent of femoral hernias are characterized by incarceration and strangulation. Jejunal pseudo diverticulum are rare and usually asymptomatic. It may cause chronic obstruction of small bowel and can lead to an acute perforation.Case presentation: An 85 – year – old woman presenting with 1 week history of generalized abdominal pain, with episodes of vomiting, fever, and history of 6 months of reponible femoral hernia and 2 weeks strangulated of femoral hernia. An abdominal X-ray displayed multiple dilated loops of the small bowel, coil spring sign and intra peritoneal free air. This patient underwent a laparotomy and hernioraphy, which identified single perforated jejunal pseudo diverticulum 50 cm from ligamentum of treitz orally from strangulated of ileal on femoral hernia site, and associated fecal contamination. The management for this case was perforation repaired with diverticulectomy, simple closure, and extensive washout of intraperitoneal cavity. The non tension femoral hernia repair was performed with monofilament, macroporous MESH.Conclusion: chronic intestinal obstruction caused by femoral hernia in the elderly can lead a performed of intestinal pseudo diverticulum and lead to significant morbidity and mortality. This could be suspected in those presenting with cramping abdominal pain and altered bowel habits.Keywords: hernia, femoral, strangulated, pseudo diverticulum, perforated, management

Abdominal cocoon with early postoperative small bowel obstruction

Rationale:Abdominal cocoon is a condition in which intestinal obstruction results from the encasement of part or whole of the small bowel by a thick fibrous membrane, giving the appearance of a cocoon. The preoperative diagnosis is difficult to be made and the treatment is still controversial.Patient concerns:Here we describe the case of a 62-year-old male presented with a 24-h history of continual colicky abdominal pain, which was accompanied with nausea and vomiting.Diagnosis:Accurate diagnosis of abdominal cocoon was made intraoperatively.Interventions:Membrane excision and adhesiolysis were performed and the patient experienced early postoperative small bowel obstruction. Nasointestinal obstruction tube was then installed and bowel function was gradually recovered by the 20th postoperative day.Outcomes:The patient recovered well and was discharged from the hospital on the 30th postoperative dayLessons:Abdominal cocoon can occur at any age. The possibility of abdominal cocoon should also be considered in infertile patients. Imaging studies may be helpful to make the correct diagnosis, and surgery should be performed for patients with recurrent acute or chronic intestinal obstruction.

Assessment of Laparoscopy in diagnosis and Management of adhesive intestinal obstruction

Adhesions are a common sequela after abdominal surgery. Adhesions are an important etiology of acute or chronic intestinal obstruction or even chronic pain, and must be suspected as a leading cause of abdominal pain whenever the patient as undergone previous abdominal surgery.