Photo Attribution: Lamiot, CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/4.0, via Wikimedia Commons
I have two beautiful children, both born via cesarean section (C-section) (one was due to emergent reasons, the other due to hospital policy leading to no choice of mine).
A few months after my second C-section, I started experiencing severe bloating. I was stumped. This was not my usual irritable bowel type symptom (except for when I had severe flare-ups). No, this bloating happened every day, worsening as the day went on, and it was absolutely miserable.
At the time, I had no idea what was happening and neither did the many doctors that I desperately sought help from. After much research on my own, I learned that it was small intestinal bacterial overgrowth (SIBO)/intestinal methanogen overgrowth (IMO) that was the cause of the severe bloating. You can read more about my SIBO discovery journey here “How I ended 25 years of constipation.”
It was obvious that something changed after the second C-section. But what?
In June of 2016, I was attending the SIBO Symposium in Portland, OR. I listened to a presentation by Larry Wurn with Clear Passage Physical Therapy, with a catchy title “Are adhesions the missing link in unresolved SIBO?” You can watch a similar presentation by Larry Wurn Are adhesions the missing link? for more information.
Do you know when you have one of those “aha” moments? I had one then. Maybe there was a connection between my C-section and my unrelenting SIBO!
At the time, I didn’t want to admit it because, how was I going to test for this and if I do have adhesions, what am I going to do about it? There aren’t great ways to test for and treat adhesions, I’ll explain this later.
So I continued to put my head in the sand and rule out easier, more accessible causes. It wasn’t until 4 years later that I decided to seriously consider that, yes, adhesions are probably part of the cause of my SIBO (remember that the cause and treatment of SIBO are typically multi-factorial).
I Got to Ask the Famous SIBO Researcher a Question on a Webinar!
What helped me act on my suspicion is I had the good fortune to be able to directly ask Dr. Pimental, the famous gastroenterologist and main SIBO researcher at Cedars Sinai, a question during one of Dr. Weitz’s webinars. This is what I asked him “if SIBO relapses within a couple of months of resolution with antibiotics or the elemental diet, determined by a negative breath test and alleviation of symptoms, what do you feel is the underlying cause? I also mentioned that “the patient” (me) had a history of abdominal surgery.” He said, and I summarize “if a patient relapses that quickly, then it is most likely a structural problem and adhesions should be investigated.”
Adhesions, there I was again. I had circled back to where I should have started 4 years ago. Hearing Dr. Pimental say it was all of the confirmation that I needed.
What are Abdominal Adhesions?
Adhesions are fibrous bands of scar-like tissue that are formed after surgery (they can also form due to inflammation/infection) (Tabibian, Swehli, Boyd, Umbreen, & Tabibian, 2017).(1) Our organs should be slippery and smoothly guide to and fro as our body does the work of digestion, metabolism, and excretion. Adhesions can form weblike structures between neighboring organs or attach an organ to the abdominal wall, thus preventing proper movement and function.(2) Some people don’t even know they have adhesions while other people can have severe, debilitating symptoms from them.(1)
SIBO occurs when the body isn’t able to efficiently sweep the microorganisms out of the intestinal tract, resulting in a buildup of microorganisms in the small intestine. Adhesions can interfere with this process, depending upon where they are located. According to Sachdev and Pimentel,(3) one of the causes of SIBO is lack of motility (poor intestinal movement), which is seen in patients who have had previous gastrointestinal surgery.
One study found that of the 45 patients who tested positive for SIBO, 82% of them had a history of surgery.(4) It should be noted that 12 patients were negative for SIBO and 75% of the negative patients also had a history of surgery. So not everyone will develop SIBO from surgery, but for those who have SIBO, adhesions due to abdominal and pelvic surgery should be considered.
How do I Know if I Have Adhesions?
Your prior surgical history can be a big clue. The biggest factor in predicting adhesion formation was a previous history of abdominal surgery, ranging from 67%-93% of patients developing adhesions after surgery.(5) Adhesions can also be caused by trauma and infections.
Your symptoms might indicate the presence of adhesions, although many of these symptoms are non-specific. Here is a list of symptoms from the paper, “Abdominal adhesions: A practical review of an often-overlooked entity:(6)”
- Chronic (persistent or intermittent) bloating
- Abdominal cramping and borborygmi (rumbling sound)
- Altered bowel habits, including constipation or frequent loose stools (e.g. from development of small intestinal bacterial overgrowth)
- Nausea with or without early satiety
- Bowel obstruction, which may be transient, partial, or complete (and may cause the aforementioned symptoms)
- Female infertility and dyspareunia
- Rectal bleeding and dyschezia (i.e. painful defecation) during menses, which typically indicate colorectal involvement or endometriosis
Doctors can also recommend imaging studies (CT scans, X-rays, GI series tests), but according to the National Institutes of Health, they cannot show adhesions. These types of tests can only determine if you have a bowel obstruction caused by adhesions.
If you are like me and don’t have a bowel obstruction, but still want to know, you can follow Dr. Allison Siebecker’s advice. She said that you can do an imaging study to indirectly help diagnose adhesions if you know exactly what to tell the radiologist. Ask your practitioner to order a barium small bowel series/small bowel follow-through. Your practitioner should put this statement on the order form: “rule out adhesions with multiple spot films and positional changes to visualize each segment of bowel.”(SIBO SOS Masterclass Summit, 2020). The adhesions won’t be identified with this method, but if adhesions are causing problems, the radiologist might see 90-degree angles or areas of the bowel that have thinned and then dilated.
Some People have Multiple Abdominal Surgeries and They are Fine
I have a friend who has had 5 C-sections and she doesn’t seem to have any bowel problems or pain. Dr. Satish Rao said at a SIBO Summit that some people have a higher propensity toward developing adhesions than others.(SIBO SOS Masterclass Summit, 2020) This may explain why someone could have 5-C sections and be fine while someone else has one or two C-sections and ends up with chronic pain, or like me, with SIBO.
I had another reason to believe that adhesions were to blame for my SIBO, and that is family history.
Why are Some People More Susceptible to Forming Adhesions?
The tendency to create severe adhesions could be related to genetics. I explored this link because a close relative of mine had a hysterectomy and during her surgery, the doctors found webs of adhesions in her abdomen. These adhesions were probably formed from another abdominal surgery that she had years prior.
In 2018, researchers discovered a genetic link in mice that made the mice more susceptible to severe adhesion formation.(7) Upon surgical injury, a protein is expressed on the tissue that surrounds the organs (mesothelium). This protein signals the production of other proteins that form adhesions. The mice were given treatments to block this protein, which resulted in less severe adhesion formation. Do some people make more of this protein than others?
Two years later, researchers found several genetic variants in patients susceptible to adhesion formation, but it was indicated that more research needs to be done to help identify those at most risk.(8)
Treatment Options for Adhesions
In patients with severe symptoms, laparoscopic lysis has been reported as safe in the literature. However, having more surgery may contribute to relief but may increase the formation of more adhesions.(5)
Enzymes to Treat Adhesions?
After an injury, the body produces fibrin, an insoluble protein that acts like glue to seal the area, which begins the process of adhesion formation. The body produces enzymes that degrade fibrin, called fibrinolytic enzymes, to limit adhesion formation. In some cases, the activity of these enzymes are compromised, which allows other cells used to repair the injury to penetrate the adhesion and form a permanent matrix consisting of collagen and other materials.(9)
Serrapeptase or serratiopeptidase is an enzyme that degrades protein and I have seen blogs supporting its use to treat adhesions. This enzyme is fibrinolytic, meaning it breaks up fibrin, which is a protein found in adhesions. However, I couldn’t find any studies using this enzyme to treat adhesions. Visit the self-hacked website if you want to learn more about the benefits of serrapeptase, side effects, and dosages. I haven’t tried this on myself because there is more supporting evidence behind physical and massage therapy.
Physical and Massage Therapy
The Wurn Technique is a form of physical therapy that is the most well-researched technique to treat adhesions. I mentioned at the beginning of this post that I saw Larry Wurn speak about adhesions at a conference. He is a licensed massage therapist and together with his wife, who is a physical therapist, developed the Wurn technique to break up adhesions. His wife, Belinda was also a patient and like many of us, had to take matters into her own hands to help heal herself. She developed severe abdominal symptoms after an appendectomy and bowel resection. She developed SIBO and lost over 20 pounds because of her symptoms. It was her illness that was the impetus for the couple to develop their technique. Their website clearpassage.com has a large amount of research, resources, and other information about adhesions. They have clinics scattered throughout North America and the cost of therapy is between $6500-$8500 for 20 hours. Insurance reimbursement varies between 0-100%.
Visceral manipulation is the gentle movement of the internal organs, especially in the abdominal region. There are therapists with backgrounds in physical therapy, massage therapy, and myofascial relief therapy (rolfing) who have conducted specialized training in visceral manipulation through organizations such as the Barral Institute. To find a practitioner, go to the International Association of Healthcare Practitioners, where you can search for therapists with specific training in visceral manipulation.
Dr. Ruscio interviewed Dr. Jason Wysocki, a naturopathic physician who also specializes in visceral therapy. Dr. Wysocki gives an excellent overview of the definition of visceral manipulation, the different therapies, how to know if you need visceral manipulation, and addressing ileocecal valve issues. You can review the transcript or listen to the episode here.
Dr. Pimental’s word of caution is to make sure that the person is very knowledgeable about adhesion therapy, or they could cause the adhesions to tear, rebuild, and form larger adhesions.(SIBO SOS Masterclass Summit, 2020)
Adhesions and C-section Surgery
While reviewing the Clear Passage’s website, I learned that over 90% of patients form adhesions after a C-section and that 35% of people are readmitted to the hospital after all types of pelvic surgery due to adhesions. They have a really good article on their website titled “How to tell if you have adhesions after a C-section.” There is a picture of a C-section scar that is indented that looks just like mine. So even though there are no biomarkers for adhesions and I’m not getting exploratory surgery to find out if I have them, I had 4 strong indicators to suspect that adhesions were at least part of my problem: 1) Symptoms occurring after C-section surgery; 2) family history of adhesions; 3) indented C-section scar; and 4) Dr. Pimental’s advice to seek treatment due to my history of quick relapses after successful clearing of SIBO.
What Have I Done About My Adhesions?
I have had great success with pharmaceutical antibiotics, the elemental diet, and herbal antimicrobials in eliminating my SIBO symptoms. To manage and prevent relapse, I have learned to rotate low doses of antimicrobials and antifungals. I utilize a whole foods diet high in non-starchy vegetables, exercise, practice relaxation, and breathing techniques, and include probiotics, prebiotics, and properly fermented vegetables in my daily diet. I utilize fasting (up to 3 days in length) if I run into major symptoms.
In addition to all of that, I saw a massage therapist in my area who was trained in myofascial release (for about 10 visits). My mom, who is also a massage therapist (but lives too far away for me to visit regularly enough to get therapy), taught me how to use a percussor at home. This is a handheld device that emits “Galvanic Wave” action that is purported to release the fascia (fascia is connective tissue that can have adhesions attached to it). She is very knowledgeable about how tissue in the abdomen can be connected to other areas in the body. So working with adhesions shouldn’t just be directed in the abdomen alone. I use the percussor 3 times per week according to my mom’s instructions.
At this point in time, Clear Passages was not an option for me, since there is not an office located anywhere near where I live. It would necessitate taking weeks off of work to get there and a large amount of money with no guarantee that it would work. I think this is a great option for those who are experiencing debilitating pain from adhesions or have a history of bowel obstructions. There are some testimonials on Facebook that you can look at from people who have used Clear Passages.
Adhesion Support Groups
If you feel that you have adhesions, there are some very supportive Facebook groups that you can join, with testimonials from people who have used Clear Passages and other techniques. These groups include “Adhesions and Scar Tissue…there is hope….and help” and “International Adhesions Society.” There are more groups as well, just search on Facebook using “adhesions.”
Don’t give up investigating your underlying causes to SIBO. From experience with myself and working with clients, there is no one magic bullet. If you feel adhesions are a problem for you, talk to your healthcare providers and research the therapies discussed in this post, then take action!