Advertisement

Is abdominal auscultation a still relevant part of the physical examination?

Published:April 22, 2017DOI:https://doi.org/10.1016/j.ejim.2017.04.013
      Abdominal auscultation represents a fundamental part of the clinical examination, especially in patients with gastroenterological complainants [
      • Moll van Charante E.P.
      • de Jongh T.
      Auscultation of the abdomen.
      ]. However, over the last years, many divergent views have emerged on the value and utility of abdominal auscultation in daily clinical practice. As well known, both physiological and pathological bowel sounds are generated by peristaltic contractions [
      • Gu Y.
      • Lim H.J.
      • Moser M.A.
      How useful are bowel sounds in assessing the abdomen?.
      ]. Despite the ability to perform a complete and adequate physical examination is still an essential part of the medical education, medical schools often teach in different way how to listen to the bowel sounds. Indeed, in some cases, it is highly recommended to perform the abdominal auscultation prior the palpation, whereas other schools teach to auscultate after the palpation. The rationale for the use of the former technique has been justified by the fact that palpation could trigger the peristalsis, confounding the physical exam. However, there are fewer evidences that could justify this approach. Felder et al. in their prospective study reported that auscultation of bowel sounds is not useful in clinical practice when differentiating subjects with normal versus pathological bowel sounds, because the listener frequently assumed an incorrect diagnosis [
      • Felder S.
      • Margel D.
      • Murrell Z.
      • Fleshner P.
      Usefulness of bowel sound auscultation: a prospective evaluation.
      ]. Other authors concluded that auscultation is of very limited diagnosis utility and a prolonged listening of bowel sounds is an ineffective use of time despite it could reveal pathological findings [
      • Silen W.
      Cope's early diagnosis of the acute abdomen.
      ]. Massey et coll. in 2012 suggested that the routine assessment of bowel sounds for resolution of post-operative ileus was an unnecessary procedure [
      • Massey R.L.
      Return of bowel sounds indicating an end of postoperative ileus: is it time to cease this long-standing nursing tradition?.
      ]. Considering these findings, the question is: can we consider abdominal auscultation as an outdated practice? Firstly, the lack of consensus in teaching the abdominal auscultation is a major issue in this field. If any kind of palpation could influence the pathological findings at clinical examination, it'd be a big deal in daily clinical practice! Secondly, the different types of study which have analysed the different inter-observer agreement in abdominal auscultation have often considered this part of clinical examination as a diagnostic test. Indeed, this manoeuvre is fundamental rising the clinical suspicion, which should be confirmed by further tests. Moreover, many co-variables could influence the results of these types of studies, as the physician skill's, the type and severity of patient's disease, the presence of abdominal fat, etc. Furthermore, the abdominal auscultation must be evaluated in the clinical scenario. In fact, Durup-Dickenson et al. suggested that the value of abdominal auscultation increases with the addition of previous medical history and evaluation of symptoms [
      • Durup-Dickenson M.
      • Christensen M.K.
      • Gade J.
      Abdominal auscultation does not provide clear clinical diagnosis.
      ]. The important technical improvements in imaging techniques as, computed tomography (CT) or ultrasonography (US), have scaled down the role of physical examination over the years. It is important to remember that the physical examination remains and should remain in the future as the cornerstone of differential diagnosis, guiding any clinical or diagnostic decisions. In this setting, abdominal auscultation, represents a main stem of physical examination, especially in patients with abdominal symptoms. It would be a mistake considering this part of the clinical assessment as an outdated practice. If this happens, the patient-centre perspective will be lost in favour of an imaging centre-perspective. As consequence, the risk is to perform a diagnosis of bowel obstructions or ileus only putting the patient inside a “magic machine”, as the CT, without any prior physical evaluation, and waiting of the final diagnosis. Indeed, as clinicians, prior to any other instruments, we must use eyes, ears and hands. Doubtless, at the same time we should also look to the future, using new technologies. Indeed, from a theoretical point of view, abdominal auscultation should lead us to prescribe a bedside ultrasound or abdominal CT, in order to make the correct diagnosis. However, we believe that it is important to still teach to the future generations of doctors the value of the abdominal auscultation. In fact, digitalization of teaching has partially changed the interactions between teachers and medical students [
      • Zuin M.
      • Rigatelli G.
      • Zuliani G.
      • Faggian G.
      • Roncon L.
      The secret of the questions: medical interview in 21st century.
      ]. In this setting, it is important that specialist in internal medicine, which are well-trained in semeiology, emphasise the role of this semeiological manoeuvre between physicians and teaching it to the next generation of colleagues. Besides, what we are without a stethoscope in our pocket?

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to European Journal of Internal Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Moll van Charante E.P.
        • de Jongh T.
        Auscultation of the abdomen.
        Ned Tijdschr Geneeskd. 2011; 155
        • Gu Y.
        • Lim H.J.
        • Moser M.A.
        How useful are bowel sounds in assessing the abdomen?.
        Dig Surg. 2010; 27: 422-426
        • Felder S.
        • Margel D.
        • Murrell Z.
        • Fleshner P.
        Usefulness of bowel sound auscultation: a prospective evaluation.
        J Surg Educ. 2014; 71: 768-773
        • Silen W.
        Cope's early diagnosis of the acute abdomen.
        (New York: Oxford)in: Method of diagnosis: the history. 2010: 18-27
        • Massey R.L.
        Return of bowel sounds indicating an end of postoperative ileus: is it time to cease this long-standing nursing tradition?.
        Medsurg Nurs. 2012; 21: 146-150
        • Durup-Dickenson M.
        • Christensen M.K.
        • Gade J.
        Abdominal auscultation does not provide clear clinical diagnosis.
        Dan Med J. 2013; 60: A4620
        • Zuin M.
        • Rigatelli G.
        • Zuliani G.
        • Faggian G.
        • Roncon L.
        The secret of the questions: medical interview in 21st century.
        Eur J Intern Med. 2016; 35: e21-e22