ABDOMINAL ASSESSMENT

A critical review of auscultating bowel sounds

Heather Baid

bdominal physical assessment has traditionally included auscultation (listening for bowel sounds) because the presence of bowel sounds is thought to be a key feature of a healthy gastrointestinal system. Normal gurgling sounds are produced from the movement of gas and fluid during peristalsis, and can be heard through a stethoscope when the diaphragm is placed over the abdominal area. Listening for bowel sounds continues to be taught in nursing and medical education and is advocated as an essential assessment technique in current physical assessment textbooks. However, there remains a lack of empirical evidence demonstrating any clinical significance to the finding of either normal or abnormal bowel sounds. In addition, there is great variation in the way the technique of auscultation for bowel sounds is performed by practitioners, and the way it is described in the literature on abdominal physical assessment. Consideration of these discrepancies raises some important questions: What are the features of normal and abnormal bowel sounds? How many areas of the abdomen should be auscultated? How long should the practitioner listen for bowel sounds if none are heard initially? Should auscultation of the abdomen be performed before palpation? How should normal and abnormal bowel sounds be interpreted? This article sets out to answer these questions through a critique of the practice of auscultating bowel sounds; it will evaluate the technique involved, attempt to interpret the results of normal and abnormal findings, and appraise the value of listening for bowel sounds as part of an abdominal physical assessment.

Abstract
Auscultation (listening for bowel sounds) is part of an abdominal physical assessment and is performed to determine whether normal bowel sounds are present. This article evaluates the technique involved in listening for bowel sounds and the significance of both normal and abnormal auscultation findings. Review of the relevant literature reveals conflicting information and a lack of available research on the topic of auscultating bowel sounds. The clinical significance of auscultation findings when there is no evidence base to support the practice of listening for bowel sounds is explored by further analysis of the literature and reflection by the author on the teaching she received and her own personal practice. Key words: Abdominal physical assessment n Abdominal physical examination n Auscultation n Bowel sounds literature to support any discussion on the technique or value of auscultation for bowel sounds. Furthermore, only three research articles investigating the practice of auscultating bowel sounds were found, and each had limitations that prevented any generalizations being made (Table 3).

Abdominal auscultation technique

The surface of the abdomen can be subdivided into nine abdominal regions (right and left hypochondriac, right and left lumbar, right and left iliac, epigastric, umbilical and hypogastric) or four quadrants (right and left upper quadrants and right and left lower quadrants). The diaphragm of the stethoscope is used to auscultate for bowel sounds, either listening in one area of the abdomen until bowel sounds are heard, or in all four quadrants. Some authors feel that because sounds are easily transmitted throughout the abdomen, auscultating in one place is sufficient (Bickley and Szilagyi, 2009; Kahan et al, 2009; Talley and OConnor, 2006). Listening in three or more areas is thus thought to be unnecessary, although Rushforth (2009) and Seidel et al (2006) recommend covering all four quadrants if an abnormality is found in the first area. The minimum amount of time to auscultate before concluding that no bowel sounds are present varied within the literature from 30 seconds (Epstein, 2008) to 7 minutes (Cox and Steggall, 2009). Many authors advised practitioners to auscultate for at least 5 minutes if no sounds are heard initially (Smith, 1987; McConnell, 1994; Kirton, 1997; Mehta, 2003; Estes, 2006; Seidel et al, 2006; Jarvis, 2008).

Literature review
A literature review of the keyword bowel sounds was conducted through the CINAHL Plus, PubMed and Science Direct databases. Initially, the search was conducted over the period 19992009, but when this revealed very few journal articles specific to the topic of bowel sounds it was widened back to 1980. The keywords abdominal examination and abdominal physical assessment were then included in the literature search, which indirectly provided further articles containing information on bowel sounds. Key points from relevant journal articles and textbooks on abdominal physical assessment are summarized in Tables 1 and 2. There was a distinct lack of clinical research within this

Heather Baid is Senior Lecturer and Intensive Care Pathway Leader, University of Brighton, Brighton Accepted for publication: September 2009

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Table 1. Bowel sounds review from journal articles

Author Cox and Steggall (2009) Mehta (2003) McChesney and McChesney (2001) McConnell (1994); Kirton (1997) Smith (1988); Smith (1987) Normal frequency 535 sounds/minute Not mentioned 535 sounds/minute Every 520 seconds Every 515 seconds Auscultation duration if no sounds heard 7 minutes 5 minutes 2 minutes in right lower quadrant 35 minutes 5 minutes if none heard, use palpation to stimulate peristalsis Location 4 quadrants 4 quadrants 4 quadrants 4 quadrants 4 quadrants Sequence Auscultate before palpation Auscultate before palpation Auscultate before palpation Auscultate before palpation Auscultate before palpation

A further difference identified related to whether auscultation should precede palpation, with some authors insisting that auscultation should be performed immediately after inspection, before touching the patient (Mehta, 2003; Rhoads, 2006; Jarvis, 2008; Kahan et al, 2009; Rushforth, 2009). The rationale is that palpation can stimulate peristalsis, causing subsequent bowel sounds that may not have been there otherwise (Bickley and Szilagyi, 2009). Smith (1988) proposed the use of light palpation to stimulate peristalsis if no sounds were heard. In contrast, other authors recommended the sequence of inspection, palpation, percussion and auscultation while describing an abdominal physical assessment (Chew,

2008; Epstein, 2008; Ford et al, 2009; Ng, 2009; Turner et al, 2009). It was unclear whether these authors did not agree that palpation might cause new bowel sounds, or whether they felt that bowel sounds produced from palpation were as clinically significant as those occurring spontaneously. The majority of authors did not specify how to hold the stethoscope; however, there was guidance from Cox and Steggal (2009), who recommended not putting pressure on the diaphragm otherwise peristalsis could be stimulated and thereby mask the true auscultation findings. The justification for this is similar to that given for conducting auscultation before palpation, but there was no research evidence to support any of these claims within the articles and textbooks reviewed. The technique involved in abdominal auscultation appears to be based on tradition, personal preference and anecdotal teaching, which has resulted in dissimilar advice being given in the literature on abdominal physical assessment.

Normal bowel sounds

Aorta Right renal artery Right iliac artery Right femoral artery Left renal artery Left iliac artery Left femoral artery

Figure 1. Auscultation sites.

The bowel is continually active, and as a result produces frequent gurgling, rumbling sounds. However, determining whether the frequency, duration, volume and pitch are within normal limits is very subjective. With normal bowel sounds occurring intermittently between 5 and 35 times a minute in an irregular pattern (Rhoads, 2006; Seidel et al, 2006; Bickley and Szilagyi, 2009; Kahan, 2009; Rushforth, 2009), there are practical difficulties in determining whether bowel sounds are truly hypoactive or hyperactive. Variation in normal volume and pitch creates further challenges when trying to determine whether bowel sounds are overly loud or soft. Some practitioners listen for a short period of time, whereas others listen for up to 7 minutes or even longer while auscultating all four quadrants; as a result, different conclusions about the presence of normal bowel sounds can be made with the same patient. Sounds that are heard as soft and quiet by one practitioner may be loud enough for another to consider that normal bowel sounds are present. Very loud and long bowel sounds are easily produced by a healthy bowel during an active stage of digestion, although the increased volume and duration may not be recognized

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Table 2. Bowel sounds review from physical assessment textbooks

Author Bickley and Szilagyi (2009) Ford et al (2009) Ng (2009) Kahan et al (2009) Normal frequency 534/minute Auscultation duration if no sounds heard 2 minutes or longer in right lower quadrant 2 minutes Location 1 quadrant is usually sufficient Right of umbilicus (implies 1 quadrant is sufficient) Implies 1 quadrant is sufficient (states actual location does not matter) 1 quadrant is sufficient because bowel sounds radiate to all areas of the abdomen Begin in right lower quadrant and only move to other quadrants if no sounds heard Implies 1 quadrant is sufficient Implies 1 quadrant is sufficient (mid-abdomen recommended) Only states to auscultate for bowel sounds (if absent, listen for 1 minute over ileocaecal valve) Begin in right lower quadrant (but does not clarify how many areas to listen in) 4 quadrants beginning in right lower quadrant All 4 quadrants 1 quadrant if normal and all 4 quadrants if abnormal 1 quadrant is sufficient Sequence Auscultate before palpation Auscultate after palpation and percussion Auscultate after palpation and percussion Auscultate before palpation

Every 510 seconds

Every 1020 seconds

1 minute

530/minute

5 minutes

Rushforth (2009)

530/minute

5 minutes

Auscultate before palpation

Turner et al (2009) Epstein (2008)

Not mentioned

Not mentioned

Auscultate after palpation and percussion Auscultate after palpation and percussion Auscultate after palpation and percussion Auscultate before palpation Auscultate before palpation Auscultate before palpation Auscultate before palpation Auscultate after palpation and percussion

Intermittent at 510 second intervals, although longer silent periods can be normal Bowel sounds should be present but not too loud (no normal rate given) 530/minute

30 seconds

Chew (2008)

1 minute

Jarvis (2008) Estes (2006) Rhoads (2006) Seidel et al (2006) Talley and OConnor (2006)

5 minutes

530/minute 535/minute 535/minute

5 minutes in each quadrant 25 minutes in each quadrant 5 minutes

Do not identify sounds 4 minutes as increased or decreased because of normal variation

by all practitioners as a normal sound. Borborygmus (plural borborygmi) is the technical term for loud rumbling sounds (Bickley and Szilagyi, 2009), but is rarely used in clinical practice. This may be due to the fact that normal bowel sounds can be quite loud and often audible without a stethoscope, which is not necessarily a cause for concern. Rather than focusing on the quality, frequency or duration of bowel sounds, practitioners commonly document abdominal auscultation findings as simply bowel sounds present, with the assumption that they are normal sounds.

Abnormal bowel sounds

The literature revealed varied and often contradictory information about what constitutes normal bowel sounds, but consistent throughout was that it is abnormal to have a complete lack of bowel sounds. The differential diagnosis for very diminished or absent sounds includes bowel obstruction, intestinal ischaemia, paralytic ileus and peritonitis (Jarvis, 2008). If there is an extreme increase in bowel sounds, potential causes could be gastroenteritis, diarrhoea, inflammatory bowel disease, laxative use, gastrointestinal bleeding and

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Table 3. Clinical research on bowel sounds

Author Madsen et al (2005) Study details Questionnaire about assessment practice of postoperative abdominal surgery patients n1 = 54 nurse practitioners n2 = 19 staff nurse experts n3 = 9 surgeons Most surgeons felt that monitoring of bowel sounds by nurses was not helpful for patient management, and valued other assessment findings more highly (return of flatus and bowel movement as positive signs and distension, nausea and vomiting as negative signs) Three types of paediatric doctors used for comparison: emergency department residents, emergency department attending physicians and surgeons in training Percentage prevalence of positive finding for absent bowel sounds: resident 6.0%; attending 3.0%; surgeon 9.1% Findings Majority of nurses do not listen for a full 5 minutes if bowel sounds absent, and put other indicators of impaired gut motility as more important signs (pain, distension, firmness, vomiting) Conclusion Other indications of normal bowel function (return of flatus and first postoperative bowel movement) are more useful in assessing return of bowel motility after abdominal surgery No nursing interventions associated with normal or absent bowel sounds Recommendation to not assess bowel sounds of postoperative abdominal surgery patients Individual components of an abdominal examination including auscultation findings were not reliable between different types of doctors Identification of absent bowel sounds is not a reliable assessment finding Listening in only 1 quadrant is adequate and as clinically useful as listening in all 4 quadrants

Yen et al (2005)

Prospective cross-sectional study comparing interexaminer reliability of physical examination of paediatric patients with abdominal pain n = 68 patients

Hepburn et al (2004)

Observational study with Frequency and intensity of bowel sounds were 5 examiners simultaneously equal throughout all 4 quadrants over 3 minutes n = 20 early postoperative patients

bowel obstruction (Jarvis, 2008). A bowel obstruction can therefore be the cause of both hypoactive and hyperactive bowel sounds, depending on whether impaired gut motility is preventing sounds from being produced or increased peristalsis is occurring in part of the bowel in an attempt to overcome the obstruction (Kahan et al, 2009). A partial obstruction may create a hollow, high-pitched tinkling sound from liquid and gas accumulating under pressure in the dilated bowel (Epstein, 2008). This type of abnormality resembles the sound that would be created from small amounts of rain falling on a tin roof.

Clinical significance of bowel sounds

It is difficult to answer the questions set out at the beginning of this article from the literature review, because of conflicting information in the literature about the auscultation technique and how to interpret normal and abnormal findings. It can therefore be assumed from this variation that practitioners are undertaking abdominal auscultation in different ways without a standardized, evidenced-based approach. In addition, some of the literature claimed that normal findings can be found in the abnormal bowel, and abnormal findings in a normal bowel. All of this raises two further questions: Does the finding of either normal or abnormal bowel sounds hold any clinical significance? Should bowel sound auscultation still be included within a physical assessment? The issue of the usefulness of bowel sounds was addressed as far back as 1982 by West and Klein, and more recently by Harris et al (2007). According to Fairclough and Silk (2009), auscultation does not contribute much to the assessment of abdominal disease unless there are signs of an acute abdomen (e.g. severe pain with onset of <24 hours, pain before vomiting, fever, tachycardia, increased white blood cells, guarding, rebound tenderness, abdominal distension and hypoactive bowel sounds). Fairclough and Silk (2009) also recognize that abdominal bruits can occur in a normal patient and very rarely have any clinical value. Similarly, Bursey et al (2000) reported arterial bruits, venous hum and friction rubs as uncommon findings, and bowel sounds as not particularly diagnostic. The finding of high-pitched sounds with acute small bowel

Other abnormal abdominal auscultation findings

Findings unrelated to the gastrointestinal system may be identified while auscultating the abdomen. An extensive review is beyond the scope of this article, but it is mentioned because a practitioner may be intending to listen for bowel sounds but unintentionally stumble across a different type of abnormality. Vascular sounds are thought to be heard best with the bell, and include bruits over an area of arterial circulation or a hepatic venous hum (Jarvis, 2008). A bruit is a whooshing type of sound caused by turbulent blood flow, as produced by an aortic aneurysm or renal artery stenosis for example (Bickley and Szilagyi, 2009). A hepatic venous hum occurs with portal hypertension, as the blood flows into the lower pressure systemic system and brings about a continuous humming noise (Talley and OConnor, 2006). Finally, a friction rub may be heard if there is peritoneal inflammation, splenic infarct or hepatic metastases (Smith, 2007).

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obstruction was considered clinically useful by Bursey et al (2000), although the trend of changes in abnormal bowel sound over time was thought to be of greater value than a one-off assessment finding. Kahan et al (2009) maintained that abdominal auscultation was not necessary, claiming in support of this statement that bowel sounds have poor specificity and sensitivity. Smith (2007) provided more details of the diagnostic significance of hyperactive bowel sounds with a small bowel obstruction: specificity 8994%, sensitivity 4042% and likelihood ratio 5.0. However, there was no clinical research to support these statistics, the specificity and sensitivity of hypoactive/absent sounds were not covered, and other literature with similar information could not be found for comparison. The author of this article has previously published an article on bowel sound auscultation (Baid, 2006), drawing from physical assessment textbooks and university education which advocated auscultating after inspection, listening in all four quadrants and for a minimum of 5 minutes before ruling out absent bowel sounds.This has left the author reflecting on both the teaching she received and her own clinical practice, which has included listening for bowel sounds despite being aware that many practitioners and some literature suggest that bowel sound findings are irrelevant. An honest evaluation of personal practice recognizes that it would not take a full 5 minutes to listen for bowel sounds, let alone a total of 20 minutes, if ruling out absent sounds in all four quadrants. It would be impractical to take such a long period of time, and past experience has shown that absent/hypoactive bowel sounds are only one piece of the puzzle when assessing a patient. Bowel sounds on their own have not contributed significantly to helping the author identify a clinical problem, although they could have increased confidence in the differential diagnosis derived from a variety of abdominal abnormalities. However, it could be argued that practitioners, including the author, continue to auscultate for bowel sounds out of habit and tradition, without truly needing the auscultation findings to make a diagnosis and plan suitable interventions.
Baid H (2006) The process of conducting a physical assessment: a nursing perspective. Br J Nurs 15(13): 71014 Bickley LS, Szilagyi PG (2009) Bates Guide to Physical Examination and History Taking. 10th edn. Lippincott Williams & Wilkins, Philadelphia Bursey RF, Fardy JM, MacIntosh DG (2000) Examination of the abdomen. In: Thomson ABR, Shaffer EA (eds). First Principles of Gastroenterology: The Basis of Disease and an Approach to Management. 4th edn. AstraZeneca, Mississauga, Ontario Chew R (2008) Crash Course: Gastrointestinal System. 3rd edn. Mosby Elsevier, Edinburgh Cox C, Steggall M (2009) A step-by-step guide to performing a complete abdominal examination. Gastrointestinal Nursing 7(1): 1917 Epstein O [Q14:Epstein et al in text which should it be?] (2008) The abdomen. In: Epstein O, Perkin GD, Cookson J et al (eds). Clinical Examination. 4th edn. Mosby Elsevier, Edinburgh: 186225 Estes MEZ (2006) Health Assessment and Physical Examination. 3rd edn. Thomson Delmar Learning, Clifton Park, New York Fairclough PD, Silk DBA (2009) Gastrointestinal disease. In: Kumar P, Clark M (eds). Kumar and Clarks Clinical Medicine. 7th edn. Saunders Elsevier, Edinburgh: 241318 Ford MJ, MacGilchrist A, Parks R W (2009) The gastrointestinal system. In: Douglas G, Nicol F, Robertson C (eds). Macleods Clinical Examination. 12th edn. Churchill Livingstone Elsevier, Edinburgh: 184215 Harris S, Naina HV, Kuppachi S (2007) Look, feel, listen or look, listen, feel? Am J Med 120(2): e3 Hepburn MJ, Dooley DP, Fraser SL, Purcell BK, Ferguson TM, Horvath LL (2004) An examination of the transmissibility and clinical utility of auscultation of bowel sounds in all four abdominal quadrants. J Clin Gastroenterol 38(3): 2989 Jarvis C (2008) Physical Examination and Health Assessment. 5th edn. Saunders Elsevier, St Louis Kahan S, Miller R, Smith EG (2009) In a Page: Signs and Symptoms. 2nd edn. Lippincott Williams & Wilkins, Philadelphia Kirton CA (1997) Assessing bowel sounds. Nursing 27(3): 64 Madsen D, Sebolt T, Cullen L et al (2005) Listening to bowel sounds: an evidencebased practice project: nurses find that a traditional practice isnt the best indicator of returning gastrointestinal motility in patients who've undergone abdominal surgery. Am J Nurs 105(12): 409 McChesney JA, McChesney JW (2001) Auscultation of the chest and abdomen by athletic trainers. J Athl Train 36(2): 1906 McConnell EA (1994) Clinical dos and donts: auscultating bowel sounds. Nursing 24(6): 20 Mehta M (2003) Assessing the abdomen. Nursing 33(5): 545 Ng Y (2009) Examination of the gastrointestinal and genitourinary systems. In: Jevon P (ed). Clinical Examination Skills. Wiley-Blackwell, Oxford: 99119 Rhoads J (2006) Advanced Health Assessment and Diagnostic Reasoning. Lippincott Williams & Wilkins, Philadelphia Rushforth H (2009) Assessment Made Incredibly Easy! First UK edition. Lippincott Williams & Wilkins, London Seidel Hm, Ball JW, Dains JE, Benedict GW (2006) Mosbys Guide to Physical Examination. 6th edn. Mosby Elsevier, St Louis Smith CE (1987) Investigating absent bowel sounds. Nursing 17(11): 737 Smith CE (1988) Assessing bowel sounds more than just listening. Nursing 18(2): 423 Smith DS (2007) Field Guide to Bedside Diagnosis. 2nd edn. Lippincott Williams & Wilkins, Philadelphia, PA Talley NJ, OConnor S (2006) Clinical Examination: A Systematic Guide to Physical Diagnosis. 5th edn. Churchill Livingstone Elsevier, Marrickville, NSW Australia Turner R, Angus BJ, Handa A, Hatton C (2009) Clinical Skills and Examination:The Core Curriculum. Wiley-Blackwell, Oxford West M, Klein MD (1982) Is abdominal auscultation important? Lancet 320(8310): 1279

Conclusion
This article aimed to critically analyse the process of listening for bowel sounds and the interpretation of normal and abnormal auscultation findings. However, rather than answer the questions identified while developing this aim, the literature review raised an even more fundamental question of whether listening for bowel sounds has any value within clinical practice. The suspicion that bowel sounds may not be clinically significant came from the varied approaches to auscultation adopted by different authors of textbooks on physical assessment and a lack of supporting research. Like many other aspects of clinical practice, there is no true evidence base to either support or refute the inclusion of abdominal auscultation within a physical assessment. Until further research with more definitive advice becomes available, practitioners must continue to use clinical judgment, intuition, past experience and personal interpretation of the available literature to make their own individual decision on how best to perform auscultation and the value of listening for bowel sounds BJN when undertaking an abdominal physical assessment.

Yen K, Karpas A, Pinkerton HJ, Gorelick MH (2005) Interexaminer reliability in physical examination of pediatric patients with abdominal pain. Arch Pediatr Adolesc Med 159(4): 3736

KEY POINTS
n Listening for bowel sounds is part of current practice for an abdominal physical assessment. n Conflicting information on how to listen for bowel sounds and the significance of normal and abnormal findings is found throughout the literature on abdominal physical assessment. n The practice of auscultating bowel sounds is not evidence based, and there is a lack of supporting research on the topic. n Review of the literature on auscultating the abdomen calls into question the clinical significance of bowel sounds.

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