Bowel Sounds – Decreased

Decreased bowel sounds can be as innocent as a hungry patient anticipating his or her next meal or as ominous as an impending abdominal catastrophe necessitating emergent laparotomy. However, the sensitivity and specificity of the auscultation of bowel sounds are quite low, differ subjectively by clinician, and will vary from one moment to the next. Before declaring an absence of bowel sounds, one should auscultate for a minimum of 5 minutes (“if you didn’t hear them, you didn’t listen long enough”).

Differential Diagnosis

• Benign etiologies
  –Normal variant: 5–30 bowel sounds per minute is typical; however, several minutes may elapse without any sounds
  –Failure to auscultate long enough
  –Hunger
  –Auscultation immediately after abdominal palpation or percussion; always listen for bowel sounds before palpating abdomen

• Complete bowel obstruction
  –Partial bowel obstructions often have increased bowel sounds
• Adynamic ileus
  –Abdominal surgery
  –Electrolyte abnormalities (hypokalemia, hyponatremia, hypomagnesemia, uremia)
  –Drugs (e.g., narcotics, α-blockers, -and β anticholinergics, psychotropic agents)
  –Lower lobe pneumonia
  –Sepsis
  –Retroperitoneal hemorrhage
  –Vertebral compression fracture
  • Peritonitis
    –Acute appendicitis (or ruptured appendix)
    –Perforated gastric ulcer
    –Ruptured ectopic pregnancy
    –Pancreatitis
    –Pelvic inflammatory disease
    –Peritonitis
    –Solid organ injury (e.g., after trauma)
  • Intestinal ischemia
  • Less common etiologies
    –Diabetic coma
    –Hypoparathyroidism
    –Rib fractures
    –Myocardial infarction
    –Spinal injury
    –Perforated gallbladder
    –Black widow spider bite

  Workup and Diagnosis

  • A careful history and astute physical exam are crucial
    –Characterization of the pain
    –Patients with peritonitis appear very ill and have abdominal tenderness, rebound, and guarding
    –Auscultate before palpation
    –Auscultation of each quadrant is not crucial; bowel sounds radiate throughout the abdomen
  • Initial labs should include CBC, electrolytes, BUN/creatinine, calcium, liver function tests, amylase, lipase, and urinalysis
  • Imaging studies may include X-rays, CT scan, and ultrasound
    –Flat and upright X-rays may reveal rupture (free air) or obstruction (dilated proximal loops of bowel with air-fluid levels); thoracic and/or lumbar X-rays may reveal spinal fractures
    –Abdominal CT scan will give more anatomic detail and may better differentiate ileus from obstruction
    –Ultrasound is useful for gynecologic concerns
  • Differentiate postoperative ileus from obstruction
    –Some degree of ileus is expected following laparotomy (3–5 days); prolonged ileus should be investigated
    –Both can cause nausea/vomiting, constipation or obstipation, distension, tenderness, and tympany
    –A transition point or lack of gas in the rectum may suggest an obstruction

  Treatment

  • Although treatment decisions should rarely (if ever) be based on bowel sounds, serial assessment may be a useful sign of a patient's clinical evolution
  • Ileus is treated conservatively by bowel rest (NPO), IV hydration, and nasogastric decompression (for nausea and vomiting)
    –Correct electrolyte abnormalities as necessary
    –Discontinue constipating drugs (especially narcotics)
    –Prokinetic drugs (e.g., metoclopramide, erythromycin) have mixed results but are often used
    –Encourage ambulation
    –Decreased nasogastric output, “normal” bowel sounds, passage of flatus, improved X-rays, or patient hunger may indicate readiness to begin oral intake
    • Peritonitis generally requires emergent surgical intervention; treatment is directed at the specific underlying diagnosis

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Auditory hallucinations: Introduction (review 34 causes)
• Next Book Extract About Auditory hallucinations: Bowel Sounds – Increased (In A Page: Pediatric Signs and Symptoms)
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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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