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Bowel Sounds - Decreased

Decreased bowel sounds can be as innocent as a hungry patient anticipating a 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 following abdominal palpation or percussion (examiner should always listen for bowel sounds before palpating the abdomen)
  • Complete bowel obstruction
    –Note: Partial bowel obstructions often have increased bowel sounds
  • Intestinal ischemia
  • 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
      –Perforated diverticulum or diverticulitis
      –Ruptured ectopic pregnancy
      –Ruptured abdominal aortic aneurysm
      –Pancreatitis
      –Pelvic inflammatory disease
      –Infected peritonitis
      –Solid organ injury (i.e., following trauma)
    • Less common etiologies include diabetic coma, hypoparathyroidism, rib fractures, myocardial infarction, spinal injury, perforated gallbladder, and black widow spider bite

    Workup and Diagnosis

  • A careful history and physical exam are crucial, including rectal exam
    –Characterization of the pain
    –Patients with peritonitis will 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, glucose, 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 gives 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 alone, 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
        –Ambulation is encouraged
        –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: Signs and Symptoms
    • Author(s): Scott Kahan, Ellen G. Smith
    • Year of Publication: 2004
    • Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

    Other Book Chapters Related to Digestive symptoms

    Read excerpts from these other book chapters related to Digestive symptoms:

    Medical Books Excerpts
    • Vomiting
    • "In A Page: Pediatric Signs and Symptoms" (2007)
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    • Vomiting
    • "Handbook of Signs & Symptoms (Third Edition)" (2006)
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    • Constipation
    • "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
    • [ read ]
    • Vomiting
    • "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
    • [ read ]
    • Constipation
    • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
    • [ read ]
    • Nausea and Vomiting
    • "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
    • [ read ]
    • Vomiting
    • "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
    • [ read ]
    • Constipation
    • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
    • [ read ]
    • Vomiting
    • "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
    • [ read ]
    • Constipation
    • "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
    • [ read ]
    • Vomiting
    • "Nursing: Interpreting Signs and Symptoms" (2007)
    • [ read ]
     

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

    More About Causes of Digestive symptoms



    More About This Book:
    Title: In a Page: Signs and Symptoms
    Authors: Scott Kahan, Ellen G. Smith
    Publisher: Lippincott Williams & Wilkins
    Copyright: 2004
    ISBN: 1-4051-0368-X

     » Next page: Bowel Sounds - Increased (In a Page: Signs and Symptoms)

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