Why does medicine always check for bowel sounds?

[drmistga]

This is something I just do not get-as a third year early on I learned from surgery what I had already suspected which was listening for bowel sounds is completely useless and will give you no helpful info anyway-unless you are using it as a cover to test rebound or pain to touch.

Many people have no bowel sounds at any given time and many have loud, really active sounds at any given time. Thus hearing none or lots tells you jack. Location obviously tells you nothing since sound travels.

Just silly IMO yet every medicine person always includes it or asks about it-like give me one scenario where the bowel sounds effect any decision or thought about a patients problems? waste of time

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[lloyd braun]

High-pitched, tinkling sounds in SBO. In my opinion, the surgeons are just trying to come up with yet another excuse not to have to lay hands on a patient who might be able to speak.

 

[dr.op]

I think bowel sounds are quite useful, actually... I agree with the tinkling sounds as mentioned above, but even absent bowel sounds are useful. Their absence will raise the pre-test probability of an ileus, before confirming with a PFA or CT abdomen...

 

[Shah_Patel_PT]

High-pitched, tinkling sounds in SBO. In my opinion, the surgeons are just trying to come up with yet another excuse not to have to lay hands on a patient who might be able to speak.

Surgeons with a stethoscope??? I don't think the 2 go together....

 

[deleted87716]

As good an explanation as any...

What exactly are you listening for and what is its significance? Three things should be noted:

1. Are bowel sounds present?
2. If present, are they frequent or sparse (i.e. quantity)?
3. What is the nature of the sounds (i.e. quality)?

As food and liquid course through the intestines by means of peristalsis noise, referred to as bowel sounds, is generated. These sounds occur quite frequently, on the order of every 2 to 5 seconds, although there is a lot of variability. Bowel sounds in and of themselves do not carry great significance. That is, in the normal person who has no complaints and an otherwise normal exam, the presence or absence of bowel sounds is essentially irrelevant (i.e. whatever pattern they have will be normal for them). In fact, most physicians will omit abdominal auscultation unless there is a symptom or finding suggestive of abdominal pathology. However, you should still practice listening to all the patients that you examine so that you develop a sense of what constitutes the range of normal. Bowel sounds can, however, add important supporting information in the right clinical setting. In general, inflammatory processes of the serosa (i.e. any of the surfaces which cover the abdominal organs....as with peritonitis) will cause the abdomen to be quiet (i.e. bowel sounds will be infrequent or altogether absent). Inflammation of the intestinal mucosa (i.e. the insides of the intestine, as might occur with infections that cause diarrhea) will cause hyperactive bowel sounds. Processes which lead to intestinal obstruction initially cause frequent bowel sounds, referred to as "rushes." Think of this as the intestines trying to force their contents through a tight opening. This is followed by decreased sound, called "tinkles," and then silence. Alternatively, the reappearance of bowel sounds heralds the return of normal gut function following an injury. After abdominal surgery, for example, there is a period of several days when the intestines lie dormant. The appearance of bowel sounds marks the return of intestinal activity, an important phase of the patient's recovery. Bowel sounds, then, must be interpreted within the context of the particular clinical situation. They lend supporting information to other findings but are not in and of themselves pathognomonic for any particular process.

After you have finished noting bowel sounds, use the diaphragm of your stethoscope to check for renal artery bruits, a high pitched sound (analogous to a murmur) caused by turbulent blood flow through a vessel narrowed by atherosclerosis. The place to listen is a few cm above the umbilicus, along the lateral edge of either rectus muscles. Most providers will not routinely check for bruits. However, in the right clinical setting (e.g. a patient with some combination of renal insufficiency, difficult to control hypertension and known vascular disease), the presence of a bruit would lend supporting evidence for the existence of renal artery stenosis. When listening for bruits, you will need to press down quite firmly as the renal arteries are retroperitoneal structures. Atherosclerosis distal to the aorta (i.e. at the take off of the Iliac Arteries) can also generate bruits. Blood flow through the aorta itself does not generate any appreciable sound. Thus, auscultation over this structure is not a good screening test for the presence of aneurysmal dilatation.

Source: http://medicine.ucsd.edu/clinicalmed/abdomen.htm

 

[drmistga]

haha ok, for one your arguements are not even accurate, nevermind convincing. I am not knocking medicine-I hate surgery and most surgeons, I just think it was the only valuable piece of info I took away from surgery as I have not found ANY case where bowel sounds changed a treatment/diagnostic plan-tell me ONE scenario?

As far as the pitch of the sounds. That is completely useless. Pitch is made from many acoustic factors and there are way too many variables in the guy/abdomen for it to tell you anything specific about the bowel sounds. Poeple often have low pitch and high pitch sounds off and on very often.

Poeple routinely have low bowel sounds depending on how active their inherent enteric is, how much they have ate, electrolyte counts blah blah-so there is no "normal" rate, sound, pitch etc to compare to-everyone has unique sounds that change from minute to minute so listening tells you jack.

So quantity tells you what? Nothing-we all have times of increased, decreased and none. Advancing diet for example is an argument someone used before and that is not true-tolerating diet and working your way up to food is how. Diagnosing any disease by quantity does not exist.

Quality-high pitch you say-if you can tell me one case where hearing high pitch bowel sounds added anything to your diagnosis or treatment than I will change my mind-but it will not happen since it is impossible.

Anyway I like medicine much more than surgery, but I am just saying sometimes medicine physicals are too exhaustive to the point of being useless at times. More time spent on the important things would be better. I am sure all you are aware of that JAMA study last year looking at house staff's ablity to pick up common heart murmurs-and it was embarrasingly low-well under 30 percent or so-and that IS something that is relevent and distinct and something worth listening to and only 30 percent of the time people picked it up-so how often do you think docs hear the right bowel sounds and relate it properly to disease? haha very few if any

 

[turkleton]

KentW provided a pretty solid explanation. The key in it- as 3rd year- is that it takes roughly 1-5 seconds, is completely meaningless on its own, but supplements a good history rather nicely. It will never make or break a diagnosis, but you'll find when you're in the position of responsibility deciding whether or not someone should get an ex-lap for a suspected obstruction you want to make as convincing of a case to yourself and to your colleagues- to send a patient, without substantive data, for a huge operation- or even to stick an uncomfortable NG tube down his throat for 3 days- should not be acceptable. While some practices seem arcane to a medical student, they will quickly find that there is a reason- not always of course- as to why residents follow them. Medicine physicals are exhaustive to a 3rd year for the purposes of teaching- no resident on call is going to spend 45 minutes examining a patient, but needs to know each part of the physical well so when he does his focused one in 1 minute, s/he knows what to look for.

 

[rat-tickler]

i'm already wearing my stethoscope.

 

[Mman]

Umm, surgeons regularly check bowel sounds on post-op patients to help determine when a patient can resume a po diet. Depending on what they have had done in their belly, sometimes bowel sounds are all you need to resume a diet of some kind. Sometimes they have to pass gas first. The presense or absense of bowel sounds comes up in the plan of many patients in relating to their NG tube and/or diet.

Sitting 4 days out from a large abdominal case with still no bowel sounds is not good.

 

[deleted87716]

I am just saying sometimes medicine physicals are too exhaustive

You're planning to go into psychiatry, right?

Good choice.

 

[drmistga]

Yes doing psych-I would hate to be in mediocre medicine which are a dime a dozen docs who refer out a headache these days-talk about dull-but I honroed all my medicine rotations and love medicine in theory-love learning about the pathology and treatment of it but do not want to do all that work for dismal pay as an IM doc-but none of you could give me an example so why get so mad-

the one example was starting PO diet after surgery bowel sounds do NEVER give the go ahead to begin diet bud-I guess you have not heard of residual or rebound bowel sounds-guess not-anyway was not trying to argue but you guys keep on checking those bowel sounds! Very enjoyable!

 

[deleted87716]

I would hate to be in mediocre medicine which are a dime a dozen docs who refer out a headache these days-talk about dull-but I honroed all my medicine rotations

The troll is strong in this one.

 

[chicamedica]

I dont agree with everything the OP is saying, but i do agree with the lack of utility of bowel sounds. This was a lesson I, too, took from my MS3 surgery rotation and i dont think it's the surgeons cutting corners--bowel sounds have really been useless to me. Granted, high pitched bowel sounds might tell you something, but lack thereof does not mean there is no bowel obstruction. Hypoactive bowel sounds. . .what is that anyway? Normal bowel sounds can be as far apart as a few minutes. How long do you need to listen for to call "hypoactive"? Like 10-15 min? And then what? If the patient is uncomfortable and has a distended belly, you'd do a flat plate or CT abd anyway--and you'd see the ileus. If the patient has no abd complaints, would you still work up for ileus if the bowel sounds seem sparse?

In my (albeit limited) experience, clinical picture and the rest of the abd exam has been more than enough to arouse suspicion of whatever might be causing an acute abdomen.

 

[chicamedica]

KentW provided a pretty solid explanation. The key in it- as 3rd year- is that it takes roughly 1-5 seconds, is completely meaningless on its own, but supplements a good history rather nicely. It will never make or break a diagnosis, but you'll find when you're in the position of responsibility deciding whether or not someone should get an ex-lap for a suspected obstruction you want to make as convincing of a case to yourself and to your colleagues- to send a patient, without substantive data, for a huge operation- or even to stick an uncomfortable NG tube down his throat for 3 days- should not be acceptable. While some practices seem arcane to a medical student, they will quickly find that there is a reason- not always of course- as to why residents follow them. Medicine physicals are exhaustive to a 3rd year for the purposes of teaching- no resident on call is going to spend 45 minutes examining a patient, but needs to know each part of the physical well so when he does his focused one in 1 minute, s/he knows what to look for.

If the patient is vomiting post-prandially & has abd pain, do you really need to hear the high-pitched bowel sounds to convince yourself they need an NG tube? Also, in deciding whether to send for an ex-lap, the patient should get an abd CT with an acute abdomen regardless, which would show the obstruction. Furthermore, if this is the clinical picture, imaging results and all, and the patient does not have the high pitched bowel sounds, will you then feel confident in saying there is no obstruction? Granted listening for bowel sounds takes only anywhere from 0.5 sec to a few minutes, and i still listen for them sometimes, but why do something that is so useless? I side with the surgeons on this one.

 

[drmistga]

If the patient is vomiting post-prandially & has abd pain, do you really need to hear the high-pitched bowel sounds to convince yourself they need an NG tube? Also, in deciding whether to send for an ex-lap, the patient should get an abd CT with an acute abdomen regardless, which would show the obstruction. Furthermore, if this is the clinical picture, imaging results and all, and the patient does not have the high pitched bowel sounds, will you then feel confident in saying there is no obstruction? Granted listening for bowel sounds takes only anywhere from 0.5 sec to a few minutes, and i still listen for them sometimes, but why do something that is so useless? I side with the surgeons on this one.

I like this one Shocking that there is only one person and sounds like a medical student as well who has enough common sense to recognize this-in medicine, especially these days you have to be efficient but not leave important things out-which means if ya dont need it and will not effect diagnosis or treatment than scrap it-it is something invented probably centuries ago before they knew much else

 

[tibor75]

Listening for bowel sounds is useless, except maybe in a post-surgical setting.

Even more useless is listening to them in all 4 quadrants since sounds in one area will be transmitted to another.

You can always tell a stupid intern as they'll write "BS X 4" or the equally stupid NC/AT.

 

[kungfufishing]

Listening for bowel activity can also be useful in the setting of an undifferentiated poisoning.

 

[ekydrd]

Yes doing psych-I would hate to be in mediocre medicine which are a dime a dozen docs who refer out a headache these days-talk about dull-but I honroed all my medicine rotations and love medicine in theory-love learning about the pathology and treatment of it but do not want to do all that work for dismal pay as an IM doc-but none of you could give me an example so why get so mad-

the one example was starting PO diet after surgery bowel sounds do NEVER give the go ahead to begin diet bud-I guess you have not heard of residual or rebound bowel sounds-guess not-anyway was not trying to argue but you guys keep on checking those bowel sounds! Very enjoyable!

You may have "honroed" all your medicine rotations... and you want a specific example of how certain bowel sounds heard by an internal medicine doctor changed the treatment plan... here's one for ya:

50ish man admitted in septic shock... no obvious source, vague reports of not feeling well for a few days, and an episode of dizziness. Has a very large ventral hernia with abdominal contents that has been there unchanged for 15 years, so not really a likely source. Bowel sounds (high pitched rushes) present epigastric region just above the superior part of the hernia. No bowel sounds within the hernia, that by CT was shown to have extensive loops of bowel in it. Surgery was called and took this guy to the OR twice. Found ischemic, necrotic bowel. Had it not been for us listening for bowel sounds and recognizing there were none where there should have been, we may have simply treated him with antibiotics, Xygris, pressors, and fluids to treat for the sepsis. Eventually he would have died and we would have missed the reason.

I listen for bowel sounds on nearly every exam... because abdominal complaints are often too vague to pinpoint the actual problem. You are right that sometimes patients get referred for what appear to be silly complaints (your example was headaches I believe), but do not second guess that internist who did the exam. He may have found something that concerned him enough to want a second opinion such as a defect in visual fields, weakness of occular or facial muscles, temporal tenderness, etc. Stay with psych. I would rather be examined by a doctor who did all those unnecessary parts of the physical exam than one who talked to me from the door.

 

[Chinnychin]

You may have "honroed" all your medicine rotations... and you want a specific example of how certain bowel sounds heard by an internal medicine doctor changed the treatment plan... here's one for ya:

50ish man admitted in septic shock... no obvious source, vague reports of not feeling well for a few days, and an episode of dizziness. Has a very large ventral hernia with abdominal contents that has been there unchanged for 15 years, so not really a likely source. Bowel sounds (high pitched rushes) present epigastric region just above the superior part of the hernia. No bowel sounds within the hernia, that by CT was shown to have extensive loops of bowel in it. Surgery was called and took this guy to the OR twice. Found ischemic, necrotic bowel. Had it not been for us listening for bowel sounds and recognizing there were none where there should have been, we may have simply treated him with antibiotics, Xygris, pressors, and fluids to treat for the sepsis. Eventually he would have died and we would have missed the reason.

I listen for bowel sounds on nearly every exam... because abdominal complaints are often too vague to pinpoint the actual problem. You are right that sometimes patients get referred for what appear to be silly complaints (your example was headaches I believe), but do not second guess that internist who did the exam. He may have found something that concerned him enough to want a second opinion such as a defect in visual fields, weakness of occular or facial muscles, temporal tenderness, etc. Stay with psych. I would rather be examined by a doctor who did all those unnecessary parts of the physical exam than one who talked to me from the door.

That is a ridiculous example-if you or your team cannot automatically put necrotic loop of bowel at the top of your list in a guy with a hernia KNOWN to contain bowel per CT or history than you need to work on ddx. I do not know any doc that would not have known this right away and got a surgery consult-and no surgeon would not have thought of this especially with no other causes.

Also you cannot tell there are no bowel sounds specifically in a loop of bowel stuck in a hernia-you obviously did not do well at physics or you would understand the principle of sound waves-there is NO way to isolate sound in a belly by listening-its either there or not but never can be located-

glad you are not near me-scary who they let be docs these days.

 

[ekydrd]

That is a ridiculous example-if you or your team cannot automatically put necrotic loop of bowel at the top of your list in a guy with a hernia KNOWN to contain bowel per CT or history than you need to work on ddx. I do not know any doc that would not have known this right away and got a surgery consult-and no surgeon would not have thought of this especially with no other causes.

Also you cannot tell there are no bowel sounds specifically in a loop of bowel stuck in a hernia-you obviously did not do well at physics or you would understand the principle of sound waves-there is NO way to isolate sound in a belly by listening-its either there or not but never can be located-

glad you are not near me-scary who they let be docs these days.

So you think it's a ridiculous example? Why is it ridiculous? He had a known hernia with a large abdominal wall defect. As you (should) know large defects usually do not lead to incarceration and thus ischemia, so no, necrotic bowel was not initially at the top of the DDx, and should NOT automatically be at the TOP of your list, but at least on it. In a 50ish yo male there are other more likely things that can lead to sepsis. Can you say urosepsis? How 'bout pneumonia? Besides, you CAN localize bowel sounds to a point, as well as whether there are sounds or not. But of course, you have to know how to use your stethoscope. In this case it was not a single loop of bowel stuck in the hernia as you suggest, but rather nearly the entire small bowel, so no sounds in the hernia was very significant.

Oh, and by the way... I'd be careful who you make assumtions about. I did very well in physics, chemistry, biology, microbiology, neurology, calculus, anthropology, psychology, english, the required foreign language, and any other course you'd care to mention. I fully understand the principle behind transferred sound and how different materials transmit sound differently. Before you cast another stone at my credibility go look in a mirror and be sure you are perfect first.

 

[Chinnychin]

So you think it's a ridiculous example? Why is it ridiculous? He had a known hernia with a large abdominal wall defect. As you (should) know large defects usually do not lead to incarceration and thus ischemia, so no, necrotic bowel was not initially at the top of the DDx, and should NOT automatically be at the TOP of your list, but at least on it. In a 50ish yo male there are other more likely things that can lead to sepsis. Can you say urosepsis? How 'bout pneumonia? Besides, you CAN localize bowel sounds to a point, as well as whether there are sounds or not. But of course, you have to know how to use your stethoscope. In this case it was not a single loop of bowel stuck in the hernia as you suggest, but rather nearly the entire small bowel, so no sounds in the hernia was very significant.

Oh, and by the way... I'd be careful who you make assumtions about. I did very well in physics, chemistry, biology, microbiology, neurology, calculus, anthropology, psychology, english, the required foreign language, and any other course you'd care to mention. I fully understand the principle behind transferred sound and how different materials transmit sound differently. Before you cast another stone at my credibility go look in a mirror and be sure you are perfect first.

Dude you said in your initial post there was "no obvious causes"-so unless you are completely dumb you would probably recognize pneumonia, urosepsis from the basic work up.

ANY time someone presents with a hernia-no matter if they tell you they have had it for 50 years-you treat it like a new hernia as far as most severe complications. Do you take the word of your patient on everything? Or go by old records and never work up a patient? Docs always assess a patient completely using collateral as just that-collateral to their own work up.

50 year old presents with NO obvious cause and the only thing found is a hernia. the ddx is not huge. Like you said pneumonia and uro-already ruled out because those are easy to catch. Perfd bowel/appendix/gastric ulcer something like that-should be up there but likely can rule in or out by pain-so I am assuming this guy was a 50 year old without a painful belly and a giant hernia-pretty obviously to me. And large hernias often do not have loops of bowel-all that means is there is less of a chance. You cannot work it up based on it having a lower chance so you can forget about it-

Not trying to argue but your example is pretty weak you have to admit-I mean if bowel sounds was the dealbreaker in that case-you had some weak docs there.

 

[Onco]

Listening for bowel sounds is useless, except maybe in a post-surgical setting.

Even more useless is listening to them in all 4 quadrants since sounds in one area will be transmitted to another.

You can always tell a stupid intern as they'll write "BS X 4" or the equally stupid NC/AT.

Dude, you really need intern experience...

You check bowel sounds not to diagnose an abnormality but to confirm that your patient has 'positive bowel sounds'. Period. You need to confirm that regardless of whether its useless or not useless.

If there are NO bowel sounds and the patient is in no distress and is a healthy, normal adult.. dont panic. Jot it down.

 

[Chinnychin]

Dude, you really need intern experience...

You check bowel sounds not to diagnose an abnormality but to confirm that your patient has 'positive bowel sounds'. Period. You need to confirm that regardless of whether its useless or not useless.

If there are NO bowel sounds and the patient is in no distress and is a healthy, normal adult.. dont panic. Jot it down.

The guys not saying someones stupid for putting positive bowel sounds-rather stupid when you say BS times 4-considering there is not possible way to determine that nor is it relevent.

 

[Onco]

Its plain wrong to say 'listening to BS is useless'.. Period.

 

[megacolon]

All I know is that when we had a 6 month old come in crying and not looking so well...and when I listened to his belly and it was silent...intussusception went a lot higher up on my list since I couldn't really tell if he was having rebound tenderness when he can't talk. If I had heard normal bowel sounds on my exam, I would have been much more likely to think he had another cause of not feeling well. The absent bowel sounds on top of the rest of the exam prompted us to call the surgeons right after the exam and get the kid down for his air contrast enema. Since we were able to diagnose it quickly, he only had 6" of bowel removed instead of a lot more.

I'm sure someone who knows more than me will say a real doctor should have known what the Dx was without the bowel sound exam, or how obvious the Dx was. But since you weren't there, I'd just tell you to shove it since we all know that presentations of illness can vary dramatically and sometimes subtle differences are the key pieces of information that lead to the correct diagnosis or treamtent decision.

 

[Chinnychin]

All I know is that when we had a 6 month old come in crying and not looking so well...and when I listened to his belly and it was silent...intussusception went a lot higher up on my list since I couldn't really tell if he was having rebound tenderness when he can't talk. If I had heard normal bowel sounds on my exam, I would have been much more likely to think he had another cause of not feeling well. The absent bowel sounds on top of the rest of the exam prompted us to call the surgeons right after the exam and get the kid down for his air contrast enema. Since we were able to diagnose it quickly, he only had 6" of bowel removed instead of a lot more.

I'm sure someone who knows more than me will say a real doctor should have known what the Dx was without the bowel sound exam, or how obvious the Dx was. But since you weren't there, I'd just tell you to shove it since we all know that presentations of illness can vary dramatically and sometimes subtle differences are the key pieces of information that lead to the correct diagnosis or treamtent decision.

Wow you sound useless-you cannot tell rebound pain without talking? haha you actually ask the patient if they feel pain on rebound in adults? Maybe you have not seen an acute belly but there is no need to ask someone-just shake the bed a bit with your knee or do the exam and they will jump, sometimes literally-babies, kids and adults. I have to say the only time "listening for bowel sounds" is useful is when you are really testing for rebound with your bell by pressing down and releasing

Gosh it some of you are ridiculous-so you heard no bowel sounds in a sick baby-shocker-I am sure he was just packing in the food the last couple days being so sick and that huge GI system of a baby really makes a lot of noise. Unless you sat there and listened for 30 minutes than you cannot say silent bowel sounds meant anything-listen to your own damn gut-its easy stick the steth on throughout the day and you will see there are times there are sounds and time there are not-prove it to yourself since you cannot seem to grasp the concept.

Again-how did that change your treatment or plan? If you would have ruled out intuss. if you did hear bowel sounds then you need to read up on the disease. your entire bowel is not shut down nor is it non-functional-rather its basically jumbled up for lack of a better term-plent of bowel sounds from the contractions in the rest of the bowel. Either way bowel sounds did nothing for your plan.

Maybe hearing no sound helped you think of intuss just because randomly you associate the two even though it is wrong to but that does not mean the sounds were useful if you had a grasp. Either way they made no difference-the big 5-6 common bad things in kids should be on the ddx and surgical candidate is always ruled out when there is a question of belly tenderness-or atleast scanned, enema something unless you can be sure its not the belly.

oh well last post I will make-does not matter to me. You guys spend all the time listening to sounds of the gut and using them to construct a ddx-have fun!

 

[megacolon]

I saw that response coming, as I listed in last paragraph of my post. It seems while you seem to be "not caring" at all, you sure get pretty nasty, condescending, and sarcastic responding to something you don't seem to care anything about at all. Most of your other posts seem to suggest you want to come across as the person who doesn't have to exert any effort but simultaneously seems to know more than anyone else ever could.

I hope you're bedside manner is better than the respect you show to colleagues on here, not for our sake, but for your patients.

And by the way...if you reread my post maybe once, or as many times as it would take you to 'get it' I did mention that the absent bowel sounds COMBINED with other things I found on the exam raised my suspicion high enough to not rule it out, but to begin treating it after my exam. And I did listen to the bowel for a couple minutes to develop my feeling that the bowel sounds were absent, especially compared to the thousand other bellies I can in my experience compare it to. Furthermore, the difference in a baby between normal abdominal tenderness and rebound tenderness actually does take a lot of clinical judgment to determine, so I'm guessing you're either A) not a pediatrician or B) a pretentious student. Looking at your other posts it seems to be the latter. I'm also guessing that the majority, though not all, of your experience with intussusception comes from your studying for your Peds shelf and STEP2, since you're interviewing for psych. Just know that intussusception presents with more than the classic buzzwords and findings that you're tested on for the USMLE. Hopefully you did see it on your peds rotation to learn that...but rest assured you won't need many physical exam skills on psych and no you probably won't get much benefit from listening to a schizos belly. I get calls from psych residents concerned that someone's BP is 150/90 when they're being transferred to the inpt. floor and aren't sure quite how to manage it.

And I do care about it, because I think physical exam skills are important to develop and know how to use, because although the overall physical exam may not be sensitive to detecting a lot of things, it can save you when you need it. But then again, you don't care, so I won't expect another nasty response in 15 min from ya. Spend a little time thinking and not speaking before you reply back again.

 

[msu_scutmonkey]

Please do not feed the psychiatry trolls Chinnychin and drmistga. No amount of explaining how clinical decision making works will make them listen to bowel sounds. The only thing they will be using their stethoscopes for is to listen to the voices inside their patients head.

 

[megacolon]

true man, good call. I fell into the trap of yet again trying to educate another branch of the health care system that doesn't know what it's doing.

Hopefully where ever they match, it will have a VA. They should fit right in.

 

[chicamedica]

I like this one Shocking that there is only one person and sounds like a medical student as well who has enough common sense to recognize this-in medicine, especially these days you have to be efficient but not leave important things out-which means if ya dont need it and will not effect diagnosis or treatment than scrap it-it is something invented probably centuries ago before they knew much else

I'm actually halfway through intern year (IM), but close enough . . . I felt this way about bowel sounds as a med student too, since my MS3 surg rotation!

 

[chicamedica]

All I know is that when we had a 6 month old come in crying and not looking so well...and when I listened to his belly and it was silent...intussusception went a lot higher up on my list since I couldn't really tell if he was having rebound tenderness when he can't talk. If I had heard normal bowel sounds on my exam, I would have been much more likely to think he had another cause of not feeling well. The absent bowel sounds on top of the rest of the exam prompted us to call the surgeons right after the exam and get the kid down for his air contrast enema. Since we were able to diagnose it quickly, he only had 6" of bowel removed instead of a lot more.

I'm sure someone who knows more than me will say a real doctor should have known what the Dx was without the bowel sound exam, or how obvious the Dx was. But since you weren't there, I'd just tell you to shove it since we all know that presentations of illness can vary dramatically and sometimes subtle differences are the key pieces of information that lead to the correct diagnosis or treamtent decision.

Wait. . .the part that confuses me is if the child got the air-contrast enema, and it was indeed intussusception, why did he need a bowel resection at all?? Isn't the enema diagnostic and therapeutic?? I'm asking out of curiosity, not being judgemental or anything (I dont know enough to be judgemental ) I still have to disagree with the utility of bowel sounds even in this case though. As you say in a subsequent post, it was a constellation of physical exam findings (whatever they were) that led you to call the surgeons. If the kid indeed was to have a bowel resection, the surgeons would not touch him before confirming the diagnosis with imaging (and indeed they requested the air contrast enema). This is because opening up a belly purely on the basis of bowel sounds would lead to many unnecessary major abdominal surgeries.

Now rebound--yes that is more convincing. Though I had a lady s/p colonoscopy+cautery of AVMs who developed fever, rigors, and rebound later that day--pretty darned convincing for a perforation (no bowel sound auscultation needed). Called the surgeons, who also agreed that this was suspicious for a perf, however, even in such a clear cut case, they refused to take her to the OR before obtaining some form of imaging.

I can see your point though, that not hearing the bowel sounds in your patient put intussusception higher on your list (though not sure how it did so) and so you could directly send the patient for an air-contrast enema instead of doing a CT-abd or flat plate.

 

[megacolon]

True, air contrast enema is diagnostic and theraputic. However, it doesn't always work. In this kiddo, the air contrast only partially reduced it...because in reality part of it had already died, in which case reducing it wouldn't even matter, it won't revive dead bowel and it had to get cut out. Since the enema was unable to relieve the obtruction, he went to the OR.

 

[LanceArmstrong]

This is something I just do not get-as a third year early on I learned from surgery what I had already suspected which was listening for bowel sounds is completely useless and will give you no helpful info anyway-unless you are using it as a cover to test rebound or pain to touch.

Many people have no bowel sounds at any given time and many have loud, really active sounds at any given time. Thus hearing none or lots tells you jack. Location obviously tells you nothing since sound travels.

Just silly IMO yet every medicine person always includes it or asks about it-like give me one scenario where the bowel sounds effect any decision or thought about a patients problems? waste of time

Actually according to Bates you're supposed to listen for something like 90 seconds (which is about as long as an avg PE takes now-a-days) and <3-4 BS in 90s is hypoactive.

But generally unless you're really good and have a trained eye PE's are generally non specific but I guess you'll never get to a high level of proficiency without training and guidance. unfortunately now a days few attendings will actually guide you how to do a proper pe in USA.

 

[Chinnychin]

I am a troll because I disagree with the usefullness of bowel sounds-this was MY thread I started, if you guys disagreed and did not want to hear the opposing views than yours well you should not have posted and really in this case it is you being a troll for saying what you say.

Second I did not attack IM docs or any docs whereas you were attacking psychiatry-now who is the troll. I questioned the usefullness and asked for examples-I then critiqued the example once normally. Than a second reply by the person still justifiying it led me to a second more frustrated reply at someone who is still not grasping that bowel sounds were not only used incorrectly in that case-because once again BS has nothing to do with diagnosing intuss.-but also the fact that hypothetically even if they were-they added or changed nothing in his plan-Just because bs helped this one person put it higher on his list-that does not mean that it should have-it was false logic used by him that just happened to coincide with the diagnosis.

If I told you I thought crackles in the lung led me to more highly suspect meningitis-and than tried to justify the utility of crackles in diagnosing meningitis-than I would be wrong and would have just luckily heard the crackles in a case of meningitis-they have no correlation-it is the rules of fallacy in statistics-I will not list them but you guys can look them up.

And yes I have seen 3 or 4 intuss. cases and that is exactly why your case made zero sense as BS were not even used one bit in diagnosing them nor were they needed.

Also-if rebound was completely obvious or some surgical belly was TOTALLY obvious than many surgeons would take them up no questions asked. If it wasnot obvious such as in your case but questionable with a sick history than imaging is ALWAYS performed to further assess-you never can let suspiciosu symptoms go undiagnosed only because you are not sure-if you are not sure you image (most even image if they are sure but that is a different story.)

So I do not see how I am a troll-when it was you guys knocking psych and how they cannot evern manage HTN-which has nothing to do with psych-it is the doctor. I never bashed you until you said something and kept saying something siilly. If I had told you I had no idea how to manage BP as a doc than I would accept bashing as I would deserve it.

And if you saw my replies coming-than that just tells you that you were already thinking or had thought of what I said and probably had a similar argument in your head when working this up and now realizing the BS was useless you are just mad-sorry you are not a great diagnostician-some are not-good luck

 

[Onco]

I am a troll because I disagree with the usefullness of bowel sounds-this was MY thread I started, if you guys disagreed and did not want to hear the opposing views than yours well you should not have posted and really in this case it is you being a troll for saying what you say.

Second I did not attack IM docs or any docs whereas you were attacking psychiatry-now who is the troll. I questioned the usefullness and asked for examples-I then critiqued the example once normally. Than a second reply by the person still justifiying it led me to a second more frustrated reply at someone who is still not grasping that bowel sounds were not only used incorrectly in that case-because once again BS has nothing to do with diagnosing intuss.-but also the fact that hypothetically even if they were-they added or changed nothing in his plan-Just because bs helped this one person put it higher on his list-that does not mean that it should have-it was false logic used by him that just happened to coincide with the diagnosis.

If I told you I thought crackles in the lung led me to more highly suspect meningitis-and than tried to justify the utility of crackles in diagnosing meningitis-than I would be wrong and would have just luckily heard the crackles in a case of meningitis-they have no correlation-it is the rules of fallacy in statistics-I will not list them but you guys can look them up.

And yes I have seen 3 or 4 intuss. cases and that is exactly why your case made zero sense as BS were not even used one bit in diagnosing them nor were they needed.

Also-if rebound was completely obvious or some surgical belly was TOTALLY obvious than many surgeons would take them up no questions asked. If it wasnot obvious such as in your case but questionable with a sick history than imaging is ALWAYS performed to further assess-you never can let suspiciosu symptoms go undiagnosed only because you are not sure-if you are not sure you image (most even image if they are sure but that is a different story.)

So I do not see how I am a troll-when it was you guys knocking psych and how they cannot evern manage HTN-which has nothing to do with psych-it is the doctor. I never bashed you until you said something and kept saying something siilly. If I had told you I had no idea how to manage BP as a doc than I would accept bashing as I would deserve it.

And if you saw my replies coming-than that just tells you that you were already thinking or had thought of what I said and probably had a similar argument in your head when working this up and now realizing the BS was useless you are just mad-sorry you are not a great diagnostician-some are not-good luck

Are you FMG?

 

[Chinnychin]

Are you FMG?

haha no way-Top 25 AMG here

 

[Onco]

haha no way-Top 25 AMG here

Whats a 'top 25 AMG'????

And, dude, take some ESL classes.. Only a ******* can write:


And if you saw my replies coming-than that just tells you that you were already thinking or had thought of what I said and probably had a similar argument in your head when working this up and now realizing the BS was useless you are just mad-sorry you are not a great diagnostician-some are not-good luck

Get out of closet

 

[Chinnychin]

Whats a 'top 25 AMG'????

And, dude, take some ESL classes.. An american cannot write following words:


And if you saw my replies coming-than that just tells you that you were already thinking or had thought of what I said and probably had a similar argument in your head when working this up and now realizing the BS was useless you are just mad-sorry you are not a great diagnostician-some are not-good luck

Get out of closet

So "An american cannot write following" and you are pointing out my poor writing-Actually an american can write anything they want *******. That is also not even a sentence.

And me out of the closet-you do not know what an AMG-American grad-at a top 25 school-I think you definetly do not speak english as first language your comprehension is terrible.

 

[Onco]

So "An american cannot write following" and you are pointing out my poor writing-Actually an american can write anything they want *******. That is also not even a sentence.

And me out of the closet-you do not know what an AMG-American grad-at a top 25 school-I think you definetly do not speak english as first language your comprehension is terrible.

'definetly'???

And you were a spelling bee nerd in your childhood, right?

Get a life, dude. Breathe fresh air. Go to a bar. There's more to life than listening to bowel sounds.

 

[Chinnychin]

Dude we have already establshed my spelling and grammar suck-I could have told ya that-it was you that acted like you were some hot shot english teacher pointing out my poor grammar with a sentence that had extremely poor grammar and was nonsensical-You were implying that you had a good grasp of all that since you pointed it out-you are the one who looks like the fool

and actually I have spent my entire 4th year in a bar so no tips needed-You obviously are in a lower tier school or an IMG-it is that obvious

 

[Onco]

Dude we have already establshed my spelling and grammar suck-I could have told ya that-it was you that acted like you were some hot shot english teacher pointing out my poor grammar with a sentence that had extremely poor grammar and was nonsensical-You were implying that you had a good grasp of all that since you pointed it out-you are the one who looks like the fool

and actually I have spent my entire 4th year in a bar so no tips needed-You obviously are in a lower tier school or an IMG-it is that obvious

Troll-Alert

Ignore

 

[Chinnychin]

Troll-Alert

Ignore

good one-Love when they have no response so they say troll hahaha

 

[chicamedica]

This was a pretty interesting intellectual discussion until it degenerated into name-calling. Let's get it back on track.

 

[Chinnychin]

This was a pretty interesting intellectual discussion until it degenerated into name-calling. Let's get it back on track.

Exactly-how this was called a "troll" thread beats me-what happened to defending your argument-makes sense-what happens when you lose an argument or have no answer-you get frustrated and all Onco could do was call names-I did no such thing nor bash anyone-All I asked for was one example of how BS would change your management or diagnosis-and nobody could provide one-

 

[tibor75]

Dude, you really need intern experience...

You check bowel sounds not to diagnose an abnormality but to confirm that your patient has 'positive bowel sounds'. Period. You need to confirm that regardless of whether its useless or not useless.

If there are NO bowel sounds and the patient is in no distress and is a healthy, normal adult.. dont panic. Jot it down.

Jot it down? why? If a person looks normal, what does the absence of bowel sounds mean? probably that you didnt' listen long enough.

 

[boston]

General surgery resident here. Just wanted to weigh in on the debate. There is definite utility to listening to bowel sounds in the right setting. Most useful in the immediate post-op setting waiting for bowel function. Also useful in a patient who is vomiting and distended for distinguishing between ileus (hypoactive BS) versus SBO (hyperactive high-pitched BS). Not saying that it's perfect or that it's always reliable, but when considering it in the context of the overall clinical picture, there are times when it can add information and help guide you. As prior posts have mentioned, you don't take it in isolation and you don't have to listen on everybody. For example, I wouldn't waste my time listening for bowel sounds on a post-mastectomy patient. But I sure would if it's POD#6 s/p colon resection and we're still waiting for bowel function. True that there's no point in trying to localize BS because of transmission.

 

[chicamedica]

true, just recently i realized that bs can be of use--had a pt with ?c. diff, distended belly, and was trying to decide whether to switch him from po to IV flagyl. last week he had hypoactive bs, so we opted for IV, but then he started having bm's so got switched to po, but then stopped having bm's again. But since he was having more bs and belly was less distended, we figured he probably wasn't making as much stool just cause he's been intubated for like 2 weeks and not really eating much (small amt of tube feeds), so gonna keep him on po flagyl.

So yeah, i kinda take back what i said--bowel sounds can indeed be of use. Still i think they should only be listened to in the appropriate clinical context, like a scenario with an acute abd or n/v.