The American Journal of Surgery 181 (2001) 512515

Effects of diphenhydramine HCl and methylprednisolone in the

prevention of abdominal adhesions
Fatih Mehmet Avsar, M.D.a,*, Mustafa Sahin, M.D.b, Faruk Aksoy, M.D.b,
A. Filiz Avsar, M.D.c,, Mehmet Akoz, M.D.d, Suleyman Hengirmen, M.D.a,
Sami Bilici, M.D.b
a
Ankara Numune Training Research and Hospital, Clinic of 1st Surgery, Ankara, Turkey
b
Department of General Surgery, Faculty of Medicine, Selcuk University, Konya, Turkey
c
Zekai Tahir Burak Maternity Hospital, Ankara, Turkey
d
Department of Biochemistry, Faculty of Medicine, Selcuk University, Konya, Turkey

Manuscript received August 11, 2000; revised manuscript January 2, 2001

Abstract
Objective: The purpose of this study was to determine the effects of diphenhydramine hydrochloride and methylprednisolone in peritoneal
adhesions.
Materials and methods: Forty-eight male rats were used in the study. The rats were anesthetized by 5 mg/kg ketamine hydrochloride. After
opening the abdomen, 10 longitudinal incisions of 2 to 3 cm in length were made on the right parietal peritoneum, and a 2 cm2 peritoneal
layer was excised from the left abdominal wall. The abdomen was closed with 3/0 silk suture. Group I was the control group, group II was
given 10 mg/kg diphenhydramine intravenously, group III was given 20 mg/kg methylprednisolone intravenously, and group IV was
administered both of the drugs in the above doses. A blood sample of 2 mL was taken from the rats on the 14th day after the operation.
The animals were then sacrificed. The abdomen was opened and abdominal adhesions were examined. A tissue sample of 1 g was taken
from the abdominal incision line. Albumin, zinc, and hemoglobin levels and leucocyte counts in the blood were determined as well as
hydroxyproline levels in the tissue.
Results: Numbers of adhesions were as follows: 9 in group I, 3 in group II, and 2 in group III. No adhesion was observed in group IV.
Albumin, zinc, and hemoglobin levels and leucocyte counts were found to be similar in all groups. Hydroxyproline levels in the tissue were
significantly lower in groups III and IV than in groups I and II (P 0.05).
Conclusions: Diphenhydramine and methylprednisolone reduced postoperative adhesions significantly in rats. Further investigations are
needed in order to use these drugs as antiadhesive agents in humans. 2001 Excerpta Medica, Inc. All rights reserved.

Keywords: Postoperative adhesion; Ileus; Infertility; Diphenhydramine hydrochloride; Methylprednisolone; Hydroxyprolone

Peritoneal adhesions develop in the majority of the patients
who have undergone an abdominal operation for various
reasons. Such adhesions are among important causes of
mechanic intestinal obstruction in clinics of general surgery,
and of infertility in clinics of gynecology and obstetrics
[13].
It was reported that 67% of the patients who had under-
gone an abdominal operation later developed adhesions [4],
* Corresponding author. Dr. Fatih Mehmet Avsar, Mesrutiyet Cad.
28/6, 06640 Kocatepe, Ankara, Turkey. Tel.: 90.312.4182410; fax:
90.312.4182760.
E-mail address: fatihmehmet@superonline.com, avsar59@hotmail.
com.
and 3% to 8% of the cases resulting from these adhesions
were operated on [5]. It is argued that among the causes of
ileus in various clinical series, peritoneal adhesions hold the
first rank, and that ileus occurs more frequently after pelvic
operations [1,6].
Injuries on peritoneal surfaces and existence of ischemic
lesions play an important role in abdominal adhesions. For-
eign bodies such as talc powder and suture materials, infec-
tions and intestinal leakage are also important [5,712].
Histamine, which is released by mast cells immediately
after injuries in peritoneal surfaces, causes vasodilatation
and an exudation enriched in protein [5,7,13]. This exudate
constitutes the base of adhesions. It has been argued that
blocking histamine release and preventing its effects by

0002-9610/01/$ see front matter 2001 Excerpta Medica, Inc. All rights reserved.
PII: S 0 0 0 2 - 9 6 1 0 ( 0 1 ) 0 0 6 1 7 - 1
 F.M. Avsar et al. / The American Journal of Surgery 181 (2001) 512515
Table 1
Serological, hematological, and tissue parameters investigated in the study groups
Groups I II
Albumin, g/dL 1
3.83 0.30
Zinc, g/dL2 90.6 10.9
Hemoglobin, g/dL3 12.4 1.2
Leucocyte/mm4 6.01 0.82
Hydroxyproline, g/mg wet tissue5 3.23 0.27
1
P 0.799; 2
P 0.916; 3
P 0.949; 4
P 0.648;
using steroids reduces or eliminates peritoneal adhesions,
which still constitute serious surgical problems [11,13,14].
This study was carried out to investigate separate and
combined effects of diphenhydramine hydrochloride and
methylprednisolone on the prevention of peritoneal adhe-
sions.
Materials and methods
This study was performed in the Experimental Surgical
Research Center, Selcuk University, Konya, Turkey, with
the permission of the Ethics Committee of Selcuk Univer-
sity. Animal rights oversight rules provided by Turkish laws
were followed in the study.
Forty-eight male rats of the Wistar-Albino type were
used in the study. Their average weight was 215 20 g.
The animals were divided into 4 groups, each with 12 rats.
All the rats were fed standard rat diet, and were kept hungry
on the eve of the experiment.
The animals were anesthetized by administration of 5
mg/kg ketamine hydrochloride subcutaneously. The abdo-
men was opened by a midline incision of approximately 4
cm in length. Ten longitudinal incisions of 2 to 3 cm in
length were made on the peritoneal surface of the right
abdominal wall, and a peritoneal section of 2 cm2 was
excised from the inside of the left abdominal wall. The
abdomen was closed with 3/0 atraumatic continuous silk
sutures.
The groups were as follows: group I was the control
group; group II was given 10 mg/kg diphenhydramine hy-
drochloride; group III was given 20 mg/kg methylpred-
nisolone; and group IV was administered 10 mg/kg diphen-
hydramine plus 20 mg/kg methylprednisolone. The drugs
were administered just before the operation from the tail
vein.
After the operation, all rats were placed into their cages
and allowed tap water and rat pellets ad libitum for 14 days.
They were kept under controlled temperature (in 22C),
humidity and lighting (12-hour light-dark cycle) during this
period (following the Guide for the Care and Use of Lab-
oratory Animals, 1988).
The subjects were reanesthetized with 5 mg/kg ketamine
after 14 days of the operation. A blood sample of 2 mL was
taken by cardiac puncture from the rats for biologic and
513
III IV
3.88 0.28 3.95 0.41 3.92 0.27
88.5 13.8 90.8 15.8 87.6 11.4
12.4 1.6 12.1 1.2 12.2 1.4
6.02 0.91 6.39 0.85 6.10 0.86
3.24 0.25 2.58 0.37 2.50 0.30
5
P 0.000.
hemathologic analysis. The abdomen was opened from the
previous incision line. Right and left abdominal walls and
the incision line were investigated with regard to formation
of adhesions. The number of subjects having adhesions and
the grade of adhesions were assessed. The scoring method
developed by Granat et al [15] was used in the grading. In
order to determine tissue hydroxyproline levels, 1-g tissue
samples were taken from the incision line on the abdominal
wall. The samples were preserved in the deep freeze until
examination. We used the method described by Bergman
and Loxley [16,17] in the measurements of tissue hy-
droxyproline levels.
Statistical analysis of biochemical and hematologic pa-
rameters was made according to the Mann-Whitney U test.
The chi-square test was used in the comparison of grades of
adhesion. Values of P 0.05 were taken as significant in
statistical evaluations.
Results
Zinc and albumin levels studied in the sera, hemoglobin
levels and leukocyte counts found in blood, and hy-
droxyproline levels measured in tissue are given in Table 1.
No significant differences among the groups were found
with regard to zinc, albumin, and hemoglobin levels and
leucocyte counts. In the comparison of hydroxyproline lev-
els measured in the tissue among the groups, it was found
that the levels of group III and group IV, which were
administered methylprednisolone, were lower than that of
the control group and group II, which was administered
diphenhydramine HCl alone (P 0.05).
Number of formations and grades of abdominal adhe-
sions are presented in Table 2. Although adhesions were
observed in 9 rats in the control group, in 3 rats in group II,
and in 2 rats in group III, no adhesions were observed in
group IV. It was found that frequencies and grades of
adhesions in the groups that had been administered the
drugs decreased significantly in comparison with the control
group (P 0.05).
Comments
Abdominal adhesions occurring during the postoperative
period still constitute a serious problem in general surgery
514 F.M. Avsar et al. / The American Journal of Surgery 181 (2001) 512515
Table 2
Grading of the adhesions and the number of rats that had adhesion
Grade Group I Group II Group III Group IV
n 12 n 12 n 12 n 12
0 3 9 10 12
I 2 2 1 0 sible to prevent formation of adhesions completely. Agents
II 4 1 1 0
III 2 0 0 0
IV 1 0 0 0
Total 9 3 2 0
Grade 0 no adhesion; I thin, filamentous, easily separated adhe-
sions; II thick adhesions in a limited area; III widespread thick
adhesions; IV III plus adherence of visceral organs to the abdominal
wall [15].
and obstetrics and gynecology due to high morbidity and
mortality rates associated with them. Approximately 3% to
8% of patients who have undergone an abdominal operation
for various reasons are reoperated on for adhesive intestinal
obstruction at some point in their lives [5]. Repeating lap-
arotomies, pelvic operations, and inflammatory diseases
such as acute appendicitis, salpingitis, and intestinal perfo-
rations increase the risk of adhesion formation, and adhe-
sion ratio is reported to be very high among patients having
relaparotomy [6].
Peritoneal adhesions are classified into three catego-
ries congenital, inflammatory, and postoperative adhe-
sionsaccording to their mechanisms of formation. Con-
genital adhesions have not been covered by our study.
Several mechanisms have been proposed for the develop-
ment of inflammatory and postoperative adhesions, and
many factors have been described. Of these factors, the
most important ones are peritoneal injuries, infections, and
foreign bodies left within the abdominal cavity [5,7,10,18].
Also, ischemic lesions formed on peritoneal surfaces are
accepted as one of the most important factors in adhesion
formation [5,8,12]. In this study, induced peritoneal injury
was taken as a model, and treatment of pathophysiologic
events developing upon peritoneal injury was planned.
Clinical and experimental studies show that the fre-
quency of adhesion development after abdominal operations
is very high. A most definitive work made on postoperative
adhesion frequency is the postmortem study carried out by
Weibel et al [4] on a large cadaver series. Frequency of
adhesion in the cadavers, which had undergone previous
abdominal operation for various reasons, was determined to
be 67% in their work. In our study, this figure was found to
be similar, at 75%, in the control group.
Most of the studies associated with adhesion have been
performed with animal models. Nevertheless, the literature
contains a few clinical studies. Jansens work [2] could be
taken as an outstanding example in this respect. In that
study, mechanical barriers were used in order to prevent
adhesion formation in young women undergoing gyneco-
logic surgery, and their effects were examined at regular
intervals laparoscopically. The type of the study rather than
its results seems most interesting.
Several treatment modalities and agents have been pro-
posed along with protective measures to prevent postoper-
ative abdominal adhesions [5,9,11]. However, it is not pos-
used for this purpose may be divided mainly into two
groups as having local and systemic effects [9]. Locally
applied agents prevent formation of adhesion by blocking
the contact between peritoneal surfaces or by their fibrino-
lytic effects. Systemic agents have more complex effects in
the prevention of adhesions. Because locally applied agents
have limited effects and cause complications, their use is
restricted [9]. That the size of peritoneal surface is too large
and that such agents are removed from the peritoneum
quickly constitute their most serious disadvantages.
Injuries occurring in on peritoneum surface play an im-
portant role in the development of postoperative adhesions.
Histamine released from mast cells after the injury causes
vasodilatation and increases vascular permeability. As a
result of such changes, a liquid rich in protein passes to the
peritoneal cavity. The coagulum formed in this liquid
causes adhesion of peritoneal surfaces to each other [7].
Fibroblasts, starting from the first day, by synthesizing col-
lagen cause the adhesions to mature [18].
Antihistamines applied by the systemic route have been
reported to prevent development of adhesion by reducing
vasodilatation and vascular permeability, and corticoste-
roids have also been reported to have the same effect by
decreasing vascular permeability by their antiinflammatory
effects and by stopping cell proliferation and collagen syn-
thesis [13,18,19]. It was also found in our study that di-
phenhydramine, an antihistaminic agent, and methylpred-
nisolone prevented peritoneal adhesions significantly. When
the two agents were used together, their effects increased
even more.
Kappas et al [19] have investigated the effects of sys-
temic and local corticosteroids on the development of ad-
hesions and have found that steroids administered system-
ically decreased formation of adhesion significantly. While
there are other works indicating corticosteroids may be
applied as antiadhesive agents, side effects of these drugs
have also been emphasized [9,11,15]. Although it has been
proposed that antihistaminics may be used as antiadhesives
[9,13,15], the literature does not contain a sufficient number
of studies on the subject.
When the chain of pathologic events occurring after
peritoneal injury is taken into account, it is understood that
histamine plays an important role in the formation of adhe-
sion [7]. Blocking this substance with antihistamines and
thus preventing formation of adhesion seems to be very
reasonable. Very similar results were obtained in the anti-
histaminic group and in the corticosteroid group in our
study. In addition, antihistamines have the advantage in that
they have no side effects, they do not have the immune
suppressive effects that steroids have, and they do not im-
 F.M. Avsar et al. / The American Journal of Surgery 181 (2001) 512515
pair injury healing. The decreased hydroxyproline levels in
the groups given steroids show that healing is adversely
affected by steroids. Hydroxyproline is a product formed
from destruction of collagen, and it is a sign of injury
healing [14,18]. In our study, the levels of hydroxyproline in
the antihistamine-treated group were found to be unaf-
fected. Gazzaniga et al [13] have shown in their experimen-
tal work carried out on rats that antihistaminics have pre-
vented formation of adhesions more efficiently than steroids
have done. In addition, they have obtained better results in
the groups with combined antihistamines and steroids,
which is similar to our results.
We conclude that the use of antihistamines and steroids
separately or in combination in abdominal, abdominopelvic,
and gynecologic operations will reduce the rate of postop-
erative adhesions and related complications. We believe
that these drugs will have an important role in the preven-
tion of peritoneal adhesions, especially among patients at
high risk for peritoneal adhesion.
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