I got quite good at that as a chief registrar in Johannesburg. We learned to listen for those differences that depict ileus from mechanical intestinal obstruction, an important distinction since the mechanical obstruction often needed an urgent operation while ileus did not we learned to distinguish propulsive sounds from ‘tinkling,’ non-propulsive ones. “When I trained, and did a lot of intestinal surgery, borborygmi really meant being able to hear loud bowel sounds without a stethoscope. In researching this issue lately, as I folded page corners of great medical tomes and drew boxes around pertinent information, I felt that I might do just as well turning those pages into something tangible, relevant and concrete something akin to the Japanese art of origami – a model of bird’s beak esophagus perhaps.Ī friend and colleague of mine who trained as a surgeon in South Africa in the 1970’s described to me his memories of learning the nuances of borborygmi. I also suspect that patients might push on their own bellies before a clinician ever enters the room or even in their presence to illustrate their pain: it hurts here! There’s little evidence to suggest that borborygmi triggered by palpation are any more or less pathological than those that are not. The thinking here is that palpation might disturb the intestines, trigger peristalsis, and thus alter the physical exam. My question is - so what? Reversing the procedure was considered unacceptable.
I was taught to listen in each quadrant for up to 30 seconds or until bowel sounds were heard. Schools in the United States teach students to listen prior to palpation whereas schools elsewhere teach students to auscultate after palpation. This complexity is further compounded by order of operations. 1 Additionally, some intestinal contractions are silent, so we cannot presume that a quiet bowel is a motionless bowel. This means that any analysis less than that time will be inadequate. Bowel sounds may cycle with peak-to-peak periods over 50-60 minutes. In reality, a healthy person may have no sounds for several minutes but then later have up to 30 a minute. Given that borborygmi may disseminate across the entire abdomen, and what you hear in one quadrant may reflect another part of the abdomen, the precise placement of your stethoscope seems irrelevant.Īlso controversial is the duration of auscultation. Educators (and texts) teach students to listen for bowel sounds for anything from 30 seconds to 7 minutes. Bates’ recommends listening in only one spot, Mosby’s in all four quadrants, and DeGowin’s suggests listening in all four quadrants and the midline. Some educators teach students that listening in one area is enough whereas others teach them to listen in all four quadrants. The technique learned depends on the school, the clinical gut of faculty and staff, and the physical exam text chosen. The noises produced by the movement of gas and fluids during peristalsis are bowel sounds. It appears to be more a reflection of tradition and anecdotal evidence. The relationship between bowel sounds and pathology is not evidence based. Despite these issues, bowel sounds are claimed to help us develop our differential and cinch our diagnosis. Yet firstly there’s little supporting evidence for this maneuver, and secondly there’s a lack of consensus about correct technique. Woe betide the student who fails to auscultate the abdomen of patients with these presentations. Medical programs teach us that listening to bowel sounds is an essential part of the physical examination of the abdomen, especially when the differential includes ileus, small bowel obstruction, diarrhea or constipation. Alexandra Godfrey, PA-C, practices emergency medicine in North Carolina.
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