Checking for bowel sounds a joke?

[drmistga]

I learned very early on third year during my surgery rotation that listening for bowel sounds is useless unless you are doing it as a cover for testing rebound or pain to the touch with your scope. But it really bugs me in medicine or most any docs these days asking about bowel sounds?? For one even a normal person often has absent bowel sounds at any given time. Loud bowel sounds indicate nothing more than quiet ones-which indicate nothing at all. Location is useless obviously since sound travels all over-

I just think it is funny I still am asked when I present-"what about bowel sounds?" lame!

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[Tired]

I learned very early on third year during my surgery rotation that listening for bowel sounds is useless unless you are doing it as a cover for testing rebound or pain to the touch with your scope. But it really bugs me in medicine or most any docs these days asking about bowel sounds?? For one even a normal person often has absent bowel sounds at any given time. Loud bowel sounds indicate nothing more than quiet ones-which indicate nothing at all. Location is useless obviously since sound travels all over-

I guess you haven't taken the time to read the older Physical Exam texts. Bowel sounds are extremely relevant, in terms of quantity, location, and character. I'd suggest that you not express your opinion on Surgery, unless you are desperate need of a new rectum.

 

[TheMightyAngus]

I guess you haven't taken the time to read the older Physical Exam texts. Bowel sounds are extremely relevant, in terms of quantity, location, and character. I'd suggest that you not express your opinion on Surgery, unless you are desperate need of a new rectum.

Surgeons routinely DO NOT check bowel sounds because they are not diagnostic of anything.

Older physical exam texts? Ha! Does your book have a chapter on 'foul humours' too?

 

[deleted109597]

1. No normal person has absent bowel sounds if you listen more than 15 seconds.
2. When bowel sounds become normal again is when many surgeons advance the diet.
3. Hyperactive bowel sounds are just as specific as an elevated sed rate, meaning that they are there, but don't mean anything.
4. Just do what you are told and third year will be a lot easier.

 

[drmistga]

Ok then give me one scenario where bowel sounds would change your decision making or treatment plan. The diet thing is simply not true-a diet is advanced as patient tolerates the food-you must not have had your clinical experience or are not paying attention-there is no scenario. Also that last post is completely inaccurate.

1. MOST patients have absent bowel sounds for more than 15 seconds many times per day
2. Hyperactive bowel sounds can be normal in one person and not in the next-there is no "normal value" like a sed rate has so your analogy is piss poor. WIth no baseline comparison for all people someones hyperactive sounds is purely subjective.

Anyway still think its useless, none of your arguments even make sense, nevermind are convincing

 

[deleted109597]

1. MOST patients have absent bowel sounds for more than 15 seconds many times per day

No, they don't, unless you are on a gastric bypass service. Normal, healthy, eating people have regular bowel sounds, and if they don't, then there is something going on. What are you writing on these soap notes in the mornings "bowel sounds not present during the time I listened, but I assume this is normal?" It doesn't take a Master Cardiology stethescope to listen to

2. Hyperactive bowel sounds can be normal in one person and not in the next-there is no "normal value" like a sed rate has so your analogy is piss poor.

Wow, you're really a dick. Sed rates don't really have normal values either. There is this threshold cutoff, but that can miss many abnormal patients while getting many normal patients. Once again, the more you listen to people, the more you standardize them. But like I mentioned, since one isn't planning on doing anything about it, all one do is notate it so that when the surgeon listens, they don't blast you for writing "bowel sounds present", which by the way, is the worst thing you can possibly write. Present doesn't mean level of activity, one really should learn to be specific and write hypo, normal, or hyperactive.
And no, advancing the diet isn't done until bowel sounds (and/or flatus/BM) are heard, because otherwise you're just going to have a puking patient.

 

[albaniandoc]

I see docs that don't do **** as part of their PE or ask the nurses. It is a very bad habit. A while back one of our docs wrote that pupils were equal and reactive when in fact, when my shift started they were not. As it turned out this patient had a weird thing going and had had unequal pupils all her life, but that documentation created a cascade of events because we thought that she might have developed a stroke. As a rule of thumb always do full assessments. The older docs even though they have years and years of experience they always do.
As a nurse we listen to bowel sounds constantly. Eventually with experience you pick up differences in the sounds. For most patients, 20 seconds is the maximum time that bowels should be silent. Now with drugs like morphine they will slow down which tells you that you need a stool softener. Often after surgery bowel sounds return it's a good thing because treatment decisions will be made, such as removing the NG or advancing the diet. Also, if they don't return you can suspect ileus, especially if it associated with typical ileus symptoms like pain, nausea and bloating
Tympanic bowel sounds can tell you about blockages or strangulations etc.
As a good practitioner you should use every available tool before resorting to scans and tests. Listening to bowel sounds it's just that. It helps you diagnose or at least gives you some indication of what might going on.

 

[8744]

I see docs that don't do **** as part of their PE or ask the nurses. It is a very bad habit. A while back one of our docs wrote that pupils were equal and reactive when in fact, when my shift started they were not. As it turned out this patient had a weird thing going and had had unequal pupils all her life, but that documentation created a cascade of events because we thought that she might have developed a stroke. As a rule of thumb always do full assessments. The older docs even though they have years and years of experience they always do.
As a nurse we listen to bowel sounds constantly. Eventually with experience you pick up differences in the sounds. For most patients, 20 seconds is the maximum time that bowels should be silent. Now with drugs like morphine they will slow down which tells you that you need a stool softener. Often after surgery bowel sounds return it's a good thing because treatment decisions will be made, such as removing the NG or advancing the diet. Also, if they don't return you can suspect ileus, especially if it associated with typical ileus symptoms like pain, nausea and bloating
Tympanic bowel sounds can tell you about blockages or strangulations etc.
As a good practitioner you should use every available tool before resorting to scans and tests. Listening to bowel sounds it's just that. It helps you diagnose or at least gives you some indication of what might going on.

I hear you, and I certainly agree. But the problem with the way we practice medicine is that the physical exam often offers nothing but incidental findings because we're going to get the tests anyways. A surgical abdomen is (or should be) obvious and at our hospital they take these to the OR directly but we eventually get a CT scan on everybody for anything so subtle physical exam findings are not really good for anything. Treatment and management decisions are rarely based on history and physical exam without the usual battery of lab tests and imaging to verify findings.

I think bowel sounds by themselves add almost nothing to the diagnosis. For example, if I have a patient with a grossly distended abdomen, bilious vomitting, and obstipation I don't need to listen to the bowels to deduce that he may have an illeus or an SBO. On the same note, a normal-appearing patient in no distress with no bowel sounds doesn't mean much because nobody would ever call it an early illeus or do anything about it.

 

[Sean2tall]

Per the colo-rectal surgery department at our institution and a research project they did, bowel sounds are not useful in determining when to advance diet. Additionally, bowel sounds can be present in dead gut, due to the transmission of sound that someone mentioned. The high-pitched tinkle of obstructed bowel might be a decent finding but I'm not sure.

 

[turkleton]

I'd suggest that you not express your opinion on Surgery, unless you are desperate need of a new rectum.

Thank you Tired. All SDN posters need an occasional splash of wtf is the matter with you.

 

[gschl1234]

I learned very early on third year during my surgery rotation that listening for bowel sounds is useless unless you are doing it as a cover for testing rebound or pain to the touch with your scope. But it really bugs me in medicine or most any docs these days asking about bowel sounds?? For one even a normal person often has absent bowel sounds at any given time. Loud bowel sounds indicate nothing more than quiet ones-which indicate nothing at all. Location is useless obviously since sound travels all over-

I just think it is funny I still am asked when I present-"what about bowel sounds?" lame!

i noticed the same thing on surgery and every other service. this is my take, surgeons muck around in the bowel so hearing bowel sounds means NOTHING. the bowels may have motility however, the sounds tell you nothing of whether they are moving in a coordinated manner (peristalsing, sp?). on the other hand, in every other service, no one has been physically touching/disturbing bowel so if you hear no bowel sounds, then it's a sign that something isn't right.

 

[albaniandoc]

I definitely agree with you. Same thing with the bowel sounds, it doesn't tell you much, but it takes 10 seconds to do so why not. On that logic why listen to the lungs, we can look at the morning chest X-ray and see everything we need to know.

Another point is that we live in a such litigious society that most docs want their diagnosis backed by scans no matter how expensive. Just the other day we had a huge pleural effusion on the Xray and they called the CC surgeon. He went ahead and put in a chest tube. In the meantime the family doc had come by and ordered another CT scan just in case. The CC surgeon was like: WTF, it pretty clear what this patient has? Why the CT.

I hear you, and I certainly agree. But the problem with the way we practice medicine is that the physical exam often offers nothing but incidental findings because we're going to get the tests anyways. A surgical abdomen is (or should be) obvious and at our hospital they take these to the OR directly but we eventually get a CT scan on everybody for anything so subtle physical exam findings are not really good for anything. Treatment and management decisions are rarely based on history and physical exam without the usual battery of lab tests and imaging to verify findings.

I think bowel sounds by themselves add almost nothing to the diagnosis. For example, if I have a patient with a grossly distended abdomen, bilious vomitting, and obstipation I don't need to listen to the bowels to deduce that he may have an illeus or an SBO. On the same note, a normal-appearing patient in no distress with no bowel sounds doesn't mean much because nobody would ever call it an early illeus or do anything about it.

 

[drmistga]

I definitely agree with you. Same thing with the bowel sounds, it doesn't tell you much, but it takes 10 seconds to do so why not. On that logic why listen to the lungs, we can look at the morning chest X-ray and see everything we need to know.
quote]

Well you obviously have not seen many patients-listening to the lungs is COMPLETELY different-if you see a patient in the hospital or as an outpatient with no lung history and you listen to their lungs and pick up some crackles or whatever-you then would order a CXR to start-however if you did not listen to the lungs, not everyone gets a CXR in the hospital and especially in outpatient-hardly any get one outpatient-common sense bro-I am not saying no physical diag skills are useless, I think they are crucial sometimes I was just saying that particular one sucked

 

[BigNavyPedsGuy]

On that logic why listen to the lungs, we can look at the morning chest X-ray and see everything we need to know.

Please tell me you're joking. Seriously, you can't mean this.

 

[Tired]

Surgeons routinely DO NOT check bowel sounds because they are not diagnostic of anything.

You're either a liar or an idiot. Every surgery note I have ever seen and written notes bowel sounds, in order to document the progressive resolution of post-op ileus.

Older physical exam texts? Ha! Does your book have a chapter on 'foul humours' too?

You're funny, in the way that only the ignorant can be.

The purpose of physical exam (just like the history and diagnostic testing) is to lend evidence to a specific diagnosis. The quality of bowel sounds is a contributor to a variety of diagnoses, including partial/complete SBO, AGE, appendicitis, ileus, Olgilvie's syndrome, etc. Not to mention that auscultation of the abdomen can also find incidental bruits that may indicate underlying vasculopathy, renal disease, AAA, and on and on.

Physical examination is a skill, and ignoring it has doomed more than one surgeon.

If you prefer to simply get an abdominal CT on everyone to make your diagnoses, then go do radiology. But don't come prancing in here making sweeping (and grotesquely ignorant) statements about what is and is not done in the real world.

 

[sponch]

The physical exam isn't useless. It also isn't real useful because most things you hear/feel will be nonspecific and will require further workup. With respect to post operative ileus, some people use bowel sounds to advance diet, some people use the patient's subjective feeling of hunger, others use passing gas, and others use a combination of the above in their voodoo algorithm. Personally, I take into account bowel sounds because it helps in some borderline cases. If someone has good bowel sounds early on but hasn't farted, in the absence of distended belly, burping, etc., I try to give them some clears and advance quickly as tolerated. I don't really think you can make a sweeping generalization such as listening to bowel sounds is useless, though I do agree that it doesn't predict 100% of the time that bowel function has returned. Medicine is more than these hard and fast rules, you have to observe and listen to the patient for anything that can help you wade through all the gray areas...

 

[asunshine]

Please tell me you're joking. Seriously, you can't mean this.

I've seen that happen on many occasions.

Just throwing in my 2c, but as a med student/resident, I can't understand why you would not do the most detailed physical assessment you could. It's not the listening to the bowel sounds, it's the THINKING that goes behind it--combining your evaluation of NG output, flatus, bowel tones, labs, CT results, etc, to make a thorough and justified assessment.

 

[Smurfette]

As a surgery resident, I do NOT routinely check for bowel sounds in post-op patients unless they have had a clinical change (i.e. more distended, new abd pain). This depends on where you train as to whether on rounds they routinely check.

The problem with bowel sounds is that the small bowel is the first part of the GI tract to "recover" from the "trauma" of surgery. Then the stomach, and then finally the colon. So if you hear bowel sounds, it does not necessarily mean that the pt can tolerate p.o. Once a pt has flatus, we start a diet (yes there are exceptions to this, depending on the pt and what surgery they had, but I am simplifying).

Technically, a pt has decreased bowel sounds if you listen for 15-20 seconds and hear nothing....how highly this correlates with pathology I have no idea, but if a pt has no GI/abdominal complaints and a completely normal abdominal exam except decreased bowel sounds, I am not concerned. Classically, a pt has ABSENT bowel sounds if you listen for 2 full minutes and hear nothing. When I was a med student, the surgery residents (and attendings) would ask us how long we auscultated if we said "no bowel sounds" to make this point clear.

 

[albaniandoc]

The purpose of physical exam (just like the history and diagnostic testing) is to lend evidence to a specific diagnosis. The quality of bowel sounds is a contributor to a variety of diagnoses, including partial/complete SBO, AGE, appendicitis, ileus, Olgilvie's syndrome, etc. Not to mention that auscultation of the abdomen can also find incidental bruits that may indicate underlying vasculopathy, renal disease, AAA, and on and on.

Physical examination is a skill, and ignoring it has doomed more than one surgeon.

If you prefer to simply get an abdominal CT on everyone to make your diagnoses, then go do radiology. But don't come prancing in here making sweeping (and grotesquely ignorant) statements about what is and is not done in the real world.

Thank you, Tired. That was my point. As new physicians cutting corners really does not work to your benefit especially when ignoring important parts of the PE.

 

[albaniandoc]

I've seen that happen on many occasions.

Just throwing in my 2c, but as a med student/resident, I can't understand why you would not do the most detailed physical assessment you could. It's not the listening to the bowel sounds, it's the THINKING that goes behind it--combining your evaluation of NG output, flatus, bowel tones, labs, CT results, etc, to make a thorough and justified assessment.

Nicely put.