Question

Give 5 characteristics of Auscultation and Palpation of the abdomen of a patient who has not had a bowel movement for 3 days and states "my belly is getting bigger" and uncomfortable.

Answer 1

Auscultation of the abdomen is performed for the detection of bowel sounds, rubs, or vascular bruits. As food and liquid (chyme ) pass through the intestines through peristalsis, it produces grumbling noises, referred to as bowel sounds indicating that the bowel is active. These sounds occur quite frequently, on the order of every 2 to 5 seconds, although there is a lot of variabilities. Bowel sounds themselves do not carry great significance in an otherwise normal healthy person i.e. whatever pattern they have will be normal for them.

Note:

Always take the history and perform inspection and auscultation before palpation, as this tends to put the patient at ease and increases cooperation. Also, palpation may stimulate bowel activity and thus falsely increase bowel sounds if performed before auscultation.

One should listen over all four quadrants, not simply in one place. Several areas per quadrant would be ideal to auscultate, especially in patients who have gastrointestinal (GI) issues. To chart an assessment finding of no bowel sounds, one needs to listen over the quadrant for at least five minutes.

Auscultation findings in the patient: Possible findings may be –

1. Absent bowel sounds/ileus that is no bowel sound heard on auscultation.

2. Decreased bowel sounds / hypoactive bowel sounds including a reduction in the loudness, tone, or regularity of the sounds (Hypoactive bowel sounds are considered as one every three to five minutes.) They are a sign that intestinal activity has slowed.

Palpation is the examination of the abdomen for any abdominal tenderness, enlargement of organs or masses. The liver and kidneys are palpable in normal individuals, but any other masses are abnormal. In palpating the abdomen, one should first gently examine the abdominal wall with the fingertips.

In the patient palpation, findings may reveal-

3. Diffuse or generalized abdominal pain due to constipation and abdominal distension. Abdominal tenderness is the objective expression of pain from palpation. It should be described as to its location (quadrant), depth of palpation required to elicit it (superficial or deep), and the patient's response (mild or severe).

4. A crunching feeling or crepitus of the abdominal wall, a sign of gas or fluid within the subcutaneous tissues.

5. The patient may have muscle guarding - a voluntary contraction of the abdominal wall musculature to avoid pain. Guarding tends to be generalized over the entire abdomen, whereas rigidity involves only the inflamed area. Guarding can often be overcome by having the patient purposely relax the muscles.

6. A stool filled sigmoid colon in the left lower quadrant or cecum in right lower quadrants are the most commonly identified structures on palpation, though it is difficult to palpate due to abdominal distension.

7. Percussion can be quite helpful in determining the cause of abdominal distention, particularly in distinguishing between fluid (ascites) and gas. These will be variably tympanitic or dull sounds or a combination of both, depending on whether the underlying intestines are gas or fluid-filled.

These are possible non specific auscultation and palpation expected findings.

Other distinctive findings may be there depending on underlying pathological cause if any.

Constipation is a symptom representing a subjective interpretation of real or imagined disturbance of bowel function. A patient's perception of constipation may include not only the objective observation of infrequent bowel movements but also the subjective complaints of straining at stooling, incomplete evacuation, abdominal bloating or pain, hard or small stools, or a need for digital manipulation to enable defecation.

There are multiple causes of constipation.

Functional causes (like dietary factors, NPO, motility disturbance, sedentary lifestyle), structural abnormalities (including malformations, anal or perianal fissures, hemorrhoids), intestinal obstruction, masses, etc) endocrine and metabolic conditions (like hypercalcemia, hyperparathyroidism, hypokalaemia, hypothyroidism, pregnancy), Neurogenic conditions ( like cerebrovascular events, multiple sclerosis, Parkinson's disease, Hirschsprung's disease, spinal cord tumors), Smooth muscle and connective tissue disorders ( like amyloidosis, scleroderma), psychogenic conditions (anxiety, depression) and as a side effect of many drugs like antacids, NSAID’s, antidepressants, diuretics, calcium channel blockers, etc).

Creful history taking and examination will help to rule out particular caiuse.