Bowel sounds are produced by movement in the small intestine. The diaphragm of the stethoscope should be used to listen in the right upper quadrant or all four quadrants for at least 5 minutes. Normal bowel sounds occur every 5-10 seconds and have a low to moderate pitch and intermittent quality. Hypoactive sounds are absent or diminished while hyperactive sounds are excessive or high pitched. Interpretation of bowel sounds can be difficult due to variation.
acute abdomen conditions in radiology and their evaluation
acute pancreatitis, cholicystitis, pelvic pathology, mri evaluation , intra abdominal abcess, plain radiography evaluation of acute abdomen, vascular causes of acute abdomen, causes of acute abdomen.
acute abdomen conditions in radiology and their evaluation
acute pancreatitis, cholicystitis, pelvic pathology, mri evaluation , intra abdominal abcess, plain radiography evaluation of acute abdomen, vascular causes of acute abdomen, causes of acute abdomen.
Pancreatitis is a dreaded condition associated with development of acute and sudden inflammation of the pancreas.
Pancreatic enzymes are released in the abdomen and cause inflammation by the damage from digestion of normal body structures, especially fat in the abdomen.
Mortality ranges from 3 percent in patients with interstitial edematous pancreatitis to 17 percent in patients who develop pancreatic necrosis.
This presentation gives general overview of all aspects of bowel sounds including its pathophysiology, auscultation techniques and features of normal versus abnormal bowel sounds.
Pancreatitis is a dreaded condition associated with development of acute and sudden inflammation of the pancreas.
Pancreatic enzymes are released in the abdomen and cause inflammation by the damage from digestion of normal body structures, especially fat in the abdomen.
Mortality ranges from 3 percent in patients with interstitial edematous pancreatitis to 17 percent in patients who develop pancreatic necrosis.
This presentation gives general overview of all aspects of bowel sounds including its pathophysiology, auscultation techniques and features of normal versus abnormal bowel sounds.
This presentation explains in detail the definition, pathophysiology, signs & symptoms, management, and prognosis of intestinal obstruction, ileus, and volvulus.
Cellulose (C 6 H 10 O 5) n is one of the most ubiquitous organic polymers on the planet. It is a significant structural component of the primary cell wall of green plants, various forms of algae and oomycetes. It is a polysaccharide consisting of a linear chain of several hundred to many thousands of β(1 → 4) linked d-glucose units. There are various extraction procedures for cellulose developed by using different processes like oxidation, etherification and esterification which convert the prepared celluloses in to cellulose derivatives. Since it is a non-toxic, biodegradable polymer with high tensile and compressive strength, it has widespread use in various fields such as nanotechnology, pharmaceutical industry, food industry, cosmetics , textile and paper industry, drug-delivery systems in treating cancer and other diseases. Micro-crystalline cellulose in particular is among the most frequently used cellulose derivatives in the food, cosmetics, pharma industry, etc. and is an important excipient due to its binding and tableting properties, characterized by its plasticity and cohesiveness when wet. Bacterial cellulose's high dispensability, tasteless and odourless nature provides it with lot of industrial applications. Currently, about half of the waste produced in India contains about 50% cellulose which can be used productively. This chapter deals with the chemistry of cellulose, its extraction and its properties which help various industries to make the most of it.
Various types of hernia are dealt by a general or laparoscopic surgeon
For details plz visit - https://drnitinjha.com/
https://drnitinjha.com/inguinal-hernia-surgery-noida/
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
2. QUERIES
1. Sourceof bowelsounds
2. Position of patient
3. Part of stethoscope to beused?
4. Site of auscultation
5. Minimum amount of time to auscultate before concluding that no bowel sounds are present?
6. Normal frequency
7. Sequence
8. How to holdstethoscope?
9. Features of normal bowelsounds
10. Hypoactive bowel sounds
11. Hyperactive bowel sounds
12. Clinical significance of bowelsounds
4. 1. Source of bowelsounds
Movementsofthesmall
intestine
Pendular movements
Mixing contractions
(segmentation contractions)
Toniccontractions
Propulsive movements
Anti-peristaltic movements
• Wavesof contraction moving in downwarddirection
along gut;
• Seenasside to side movement during surgery
• Rhythmic lengthening and shortening of gutloops;
• myogenic origin;
• serve to reassume gut loops within limited spaceof
abdominal cavity
5. 1. Source of bowelsoundsMovementsofthesmall
intestine
Pendular movements
Mixing contractions
(segmentation contractions)
Toniccontractions
Propulsive movements
Anti-peristaltic movements
• 12 per minute (duodenumand proximal jejunum) and 8-9 per minute (terminal ileum)
• Help in mixing intestinalcontents with digestive juices
• Also increasevascularand lymphatic flow, aids inabsorption
• Decreasethe transit time, further favors digestion and absorption
6. 1. Source of bowelsounds
Movementsofthesmall
intestine
Pendular movements
Mixing contractions
(segmentation contractions)
Toniccontractions
Propulsive movements
Anti-peristaltic movements
• Involves relatively larger segments of
intestine with intermediate zonesof
relaxation (large segments of intestine are
isolated from eachother)
• Serveto increase transit time toallow
digestion and absorption
7. 1. Source of bowelsoundsMovementsofthesmall
intestine
Mixing contractions
(segmentation contractions)
Toniccontractions
Propulsive movements
Anti-peristaltic movements
1. Peristalsis in the smallintestine
Pendular movements
• Occur irregularly and don’t travel along whole of intestine (unlike
esophageal and gastric peristalsis); i.e. canoccur in any part of small
intestine
• Produced in response to stretch (myentericreflex)
• 1st moves in both directions but immediately its travel upwardsis
inhibited;
• Serve to propel chyme towards distal end/anus at velocity of 0.5 to 2
cm/sec (faster in proximal intestine and slower in terminalintestine)
• Very weak and usually die out after travelling only3-5cm, very rarely >
10 cm. (net movement along small gut normally averageonly 1
cm/min; i.e. 3-5 hours needed for passageof chyme from pylorus to
ileocecal valve).
8. 1. Source of bowelsounds
Movementsofthesmall
intestine
Pendular movements
Mixing contractions
(segmentation contractions)
Toniccontractions
Propulsive movements
Anti-peristaltic movements
2. Propulsive effect of segmentationmovements:
• Also travel 1 cm or soin anal direction and duringthat
time help propel the food down theintestine.
3. Peristaltic Rush(Rush Peristalsis):
• Contrary to normally weak small bowel peristalsis,
intense irritation of intestinal mucosa, asoccurs in some
severe casesof infectious diarrhea (intestinal obstruction
proximal to lesion), cancauseboth powerful and rapid
peristalsis
• 2-25 cm/min (average 10cm/min)
• Travellong distances in small gut within minutes,
sweeping the contents of intestine into the colon and
thereby relieving the small intestine of irritativechyme
and excessive distension.
9. 1. Source of bowelsounds
Movementsofthesmall
intestine
Pendular movements
Mixing contractions
(segmentation contractions)
Toniccontractions
Propulsive movements
Anti-peristaltic movements
• Resembles peristalsis in every aspectbut
moves in opposite direction ie.Orally
• Normally occur in 2nd and 3rd parts of
duodenum; causing regurgitation of its
contents into stomach lowering of acidityof
gastric contents
• Also occur in terminal ileum: preventsrapid
entry of ileal contents into cecum, thus
favoring intestinal absorption.
11. 3. Part of stethoscope to beused?
Part of stethoscope used: Diaphragm isused Bell is used
Reference: Macleod’s Clinical examination,12th
edition, pg. 204
SRB’sclinical methods in
surgery, 1st edition, pg.469-470
12. 4. Site of auscultation?
1st school ofthought 2nd school ofthought
listening in one site on the abdomen until bowelsounds are
heard, don’t move it from site to site,
right to umbilicus(umbilicalregion)
Closeto ileocecal junction
in all 4quadrants
Rationale Becausesounds are easily transmitted throughout the
abdomen, auscultating in one place issufficient
if an abnormality is fond in thefirst
area
References Bickley and Szilagyi, 2009
Kahanet al, 2009
Macleod’s Clinical examination,12th edition, pg. 204
SRB’sclinical methods in surgery, 1st edition, pg. 469-470
Bedside techniques: Methods of clinical examination,3rd
edition, pg. 164
Hutchisons clinical methods, 22nd edition, pg.132
Rushforth 2009
Seidel et al2006
16. 5. Minimum amount of time toauscultate before
concluding that no bowel soundsare present?
Interpretation Studies
Varied from 30 secondsto Epstein, 2008
7 minutes Coxand Steggall,2009
Many authors advised to auscultate forat Smith, 1987;
least 5 minutes if no soundsheard McConnell, 1994;
initially Kirton, 1997;
Mehta, 2003;
Estes, 2006;
Seidel et al, 2006;
Jarvis, 2008
17. 5. Minimum amount of time toauscultate before
concluding that no bowel soundsare present?
Interpretation References
Several minutes Bedside techniques: Methods of clinical examination,3rd
edition, pg. 164;
Hutchisons clinical methods, 22nd edition, pg.132
Up to 2minutes Macleod’s Clinical examination,12th edition, pg.204
30 seconds Browse’s introduction to the symptoms and signsofsurgical
disease, 4th edition, pg. 390-391
18. 5. Minimum amount of time toauscultate before
concluding that no bowel soundsare present?
19. 5. Minimum amount of time toauscultate before
concluding that no bowel soundsare present?
20. 5. Minimum amount of time toauscultate before
concluding that no bowel soundsare present?
21. 6. Normal frequency
Interpretation References
2-4 in number/minute SRB’sclinical methods in surgery, 1st edition, pg. 469-470
Every5-10 seconds, but frequencyvaries Macleod’s Clinical examination,12th edition, pg.204
Bedside techniques: Methods of clinical examination,3rd edition,
pg. 164;
Everyfew seconds Browse’s introduction to the symptoms and signsofsurgical
disease, 4th edition, pg. 390-391
25. 7.Sequence
1st School ofthought 2nd school ofthought
Auscultation performed immediately after inspection,before
touching the patient
Traditional sequence of inspection,
palpation, percussion and
auscultation.
Rationale Palpation canstimulate peristalsis, causing subsequent
bowel sounds that may not have been thereotherwise.
(Use of light palpation to stimulate peristalsis if no sounds
were heard)
29. 8. How to hold thestethoscope?
• not putting pressure on the diaphragm otherwise peristalsis couldbe
stimulated and thereby maskthe true auscultationfindings.
30. 8. How to holdstethoscope?
• BUT no research evidenceto support within the articlesand
textbooks reviewed.
• Technique appears to be based on tradition, personal preferenceand
anecdotal teaching, resulting in dissimilar advice being given in
literature.
31. 9. Features of normal bowelsounds
(Volume/
intensity)
Pitch depends on
1. Distension of bowel
2. Proportion of gas&
fluid
32. 9. Features of normal bowelsounds
• Intermittent
• Frequency: already discussed
• Quality: Gurgling/Clicking/Rumbling
• Pitch: Low (or moderate)
• Irregular pattern
(interspersed with an occasional high-pitches noise/tinkle)
34. 9. Features of normal bowelsounds
• Practical difficulties
• Difficult to determine whether bowel sounds are truly hypoactive or
hyperactive due to variation in normal range of frequency.
• Variation in normal volume and pitch difficult to assess.
• Variation in minimum time and site(s) required to hear bowel sounds.
• Inter-observer variation in interpretation forsamepatient.
35. 9. Features of normal bowelsounds
• Practical difficulties
• Failure to recognize very loud and long bowel sounds easily producedby
healthy bowel during an active stage of digestion asanormalsound.
• Borborygmus(P. borborygmi) =technical term for loud rumblingsounds
• Normal bowel sounds can be quite loud and often audible without a
stethoscope, which is not necessarily acasefor concern.
36. 9. Features of normal bowelsounds
• Document abdominal auscultation findings asimply
‘bowel sounds present’
with the assumption thatthey are normal sounds.
37. 10. Hypoactive bowelsounds
• Absent bowel sounds (‘Silent abdomen’) -peristalsis ceased
OR
• Diminished bowel sounds (low in frequency andvolume)
Differential Diagnosis:
• Paralytic ileus(heart and breath sounds audible but no bowel sounds)
• Primary versussecondary
• Late intestinal obstruction
• Intestinal/Mesenteric ischemia
• Peritonitis
• Pancreatitis
38. 10. Hypoactive bowelsounds
• Caution:
• Late paralytic ileus:
• (short run of faint, very) high pitched tinkling sound due to spill over of contents/fluids
from one distended loop toanother.
• Like‘bell at eveningpealing’
Normalbowel
sounds
heart and breath
sounds audible but
no bowel sounds
(silent abdomen)
(short run offaint,
very) high pitched
tinkling sound
39. 11. Hyperactive bowelsounds
Normal bowelsounds Hyperactive bowel sounds (‘Noisyabdomen’)
Peristalsis normal Increased (Hyperperistaltic)
Frequency Low (5-35 mins) Increased (excessive bowel sounds)
(> 5/min ; SRBclinical methods)
Pitch Low to moderate Initially high frequency(frequent) loud lowpitched
gurgling/rumbling sounds (Borborygmi)
; often rising to acrescendo of high frequency highpitched
tinkling sounds
Quality Gurgling/Clicking/rumbling (Metallic) ‘Tinkling’
(Likeseawater entering alarge cavethrough anarrow entrance
or rain falling on atin roof)
(Amphoric in nature)
Volume/intensity/
loudness
low Increased (exaggerated bowel sounds)
Pattern Irregular Rhythmic pattern with peristaltic activity*
*Presenceof such soundswith patients experiences bouts of colicky abdominal pain highlysuggestive of small bowel obstruction. In between bouts of peristaltic activity
and colicky pain, bowels is quiet and no sounds onauscultation
42. 12. Clinical significance of bowelsounds
LIMITATIONS
• Conflicting information in the literature aboutauscultation technique
and how to interpret normal and abnormalfindings.
• Practitioners undertake abdominal auscultation in different ways
without astandardized, evidence-based approach.
• Normal findings canbe found in the abnormal bowel, andabnormal
findings in anormal bowel.
43. 12. Clinical significance of bowelsounds
QUERIES
• Doesthe findings of either normal or abnormal bowelsounds hold
any clinical significance?
• Should bowel sound auscultation still be included within aphysical
assessment?
44. 12. Clinical significance of bowelsounds
Does the findings of either normal or abnormal bowel sounds hold
any clinicalsignificance?
Studies Interpretation
Fairclough and Silk (2009) auscultation does not contribute much to the assessmentof abdominal disease
unless there are signsof 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).
Burseyet al(2000) bowel sounds asnot particularly diagnostic.
Thefinding of high-pitched sounds with acute small bowel obstructionwas
considered clinically useful.
Although the trend ofchangesin abnormal bowel sound over time was thought
to be of greater value than aone-offassessmentfinding.
45. 12. Clinical significance of bowelsounds
Does the findings of either normal or abnormal bowel sounds hold
any clinicalsignificance?
Studies Interpretation
Kahanet al (2009) abdominal auscultation was not necessary, claiming in support of thisstatement
that bowel sounds have poor specificity andsensitivity.
Smith (2007) provided more details of the diagnostic significance of hyperactive bowelsounds
with asmall bowel obstruction: specificity 89–94%,sensitivity 40–42%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 otherliterature
with similar information could not be found for comparison.
46. 12. Clinical significance of bowelsounds
Does the findings of either normal or abnormal bowel sounds hold
any clinicalsignificance?
• Absent/hypoactive bowel sounds are only one piece of the puzzle
when assessinga patient.
• Bowel sounds on their own have not contributed significantlyto
helping the practitioners identify aclinicalproblem,
47. 12. Clinical significance of bowelsounds
Does the findings of either normal or abnormal bowel sounds hold
any clinicalsignificance?
• Although they could have increased confidence in the differential diagnosis
derived from avariety of abdominalabnormalities.
• However, it could be argued that practitioners, continue to auscultate for
bowel sounds out of habit and tradition, without truly needing the
auscultation findings to makeadiagnosis and plan suitableinterventions.
48. 12. Clinical significance of bowelsounds
Should bowel sound auscultation still be included within a physical
assessment?
• Likemany other aspects of clinical practice, there is no trueevidence
baseto either support or refute the inclusion of abdominal
auscultation within aphysical assessment.
49. 12. Clinical significance of bowelsounds
Should bowel sound auscultation still be included within a physical
assessment?
• Until further research with more definitive advice becomesavailable,
practitioners must continue to useclinical 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 when
undertaking an abdominal physical assessment.
50.
51. REFERENCES
• Baid H(2006) Theprocessof conducting aphysical assessment:anursing perspective. Br JNurs
15(13):710–14
• Bickley LS,Szilagyi PG(2009) Bates’Guideto PhysicalExamination and History Taking. 10thedn.
Lippincott Williams & Wilkins,Philadelphia
• BurseyRF,FardyJM,MacIntosh DG(2000) Examination of the abdomen. In: ThomsonABR,
Shaffer EA(eds). First Principles of Gastroenterology: TheBasisof Diseaseand an Approach to
Management. 4th edn.AstraZeneca,Mississauga,Ontario
• ChewR(2008) CrashCourse:Gastrointestinal System.3rd edn. Mosby Elsevier,Edinburgh
• CoxC,Steggall M (2009)Astep-by-step guide to performing acomplete abdominalexamination.
Gastrointestinal Nursing 7(1):19–17
52. REFERENCES
• Epstein O[Q14: “Epstein et al” in text – which should it be?] (2008) The abdomen. In: Epstein O,
Perkin GD, Cookson Jet al (eds). Clinical Examination. 4th edn. Mosby Elsevier, Edinburgh: 186–
225
• EstesMEZ(2006) Health Assessmentand PhysicalExamination. 3rd edn. Thomson Delmar
Learning, Clifton Park,NewYork
• Fairclough PD,Silk DBA(2009) Gastrointestinal disease.In: Kumar P,ClarkM (eds). Kumar and
Clark’s Clinical Medicine. 7th edn. SaundersElsevier,Edinburgh:241–318
• Ford MJ,MacGilchristA, ParksRW(2009) Thegastrointestinal system.In: DouglasG,Nicol F,
Robertson C(eds). Macleod’s Clinical Examination. 12th edn. Churchill Livingstone Elsevier,
Edinburgh: 184–215
• Harris S,Naina HV,KuppachiS(2007) Look,feel, listen or look, listen, feel? AmJMed 120(2): e3
53. REFERENCES
• Hepburn MJ,Dooley DP,FraserSL,Purcell BK,FergusonTM, Horvath LL(2004)An examination of
the transmissibility and clinical utility of auscultation of bowel sounds in all four abdominal
quadrants. JClin Gastroenterol 38(3):298–9
• JarvisC(2008) PhysicalExamination and Health Assessment.5th edn. SaundersElsevier,StLouis
• KahanS,Miller R,Smith EG(2009) In a Page:Signsand Symptoms.2nd edn. Lippincott Williams &
Wilkins, Philadelphia
• Kirton CA(1997)Assessingbowel sounds.Nursing 27(3):64
• Madsen D,Sebolt T,Cullen Let al (2005) Listening to bowel sounds: an evidencebased practice
project: nurses find that a traditional practice isn’t the best indicator of returning gastrointestinal
motility in patients who'veundergone abdominal surgery. Am JNurs 105(12): 40–9
54. REFERENCES
• McChesneyJA,McChesneyJW(2001)Auscultation of the chest and abdomen by athletic
trainers. JAthl Train 36(2):190–6
• McConnell EA(1994) Clinical do’s and don’ts: auscultating bowel sounds. Nursing 24(6):
20
• Mehta M (2003)Assessingthe abdomen. Nursing 33(5):54–5
• NgY(2009) Examination of the gastrointestinal and genitourinary systems. In: JevonP
(ed). Clinical Examination Skills.Wiley-Blackwell, Oxford: 99–119
• RhoadsJ(2006) AdvancedHealth Assessmentand Diagnostic Reasoning.Lippincott
Williams & Wilkins,Philadelphia
55. REFERENCES
• Rushforth H(2009) AssessmentMade Incredibly Easy!First UKedition. Lippincott
Williams & Wilkins,London
• Seidel Hm, Ball JW,Dains JE,Benedict GW(2006) Mosby’s Guide to Physical Examination.
6th edn. Mosby Elsevier, StLouis
• Smith CE(1987) Investigating absent bowel sounds. Nursing 17(11):73–7
• Smith CE(1988)Assessingbowel sounds – more than just listening. Nursing 18(2):42–3
• Smith DS(2007) Field Guide to BedsideDiagnosis. 2nd edn. Lippincott Williams &Wilkins,
Philadelphia, PA
56. REFERENCES
• Talley NJ,O’Connor S(2006) Clinical Examination: ASystematic Guide to Physical
Diagnosis. 5th edn. Churchill Livingstone Elsevier, Marrickville, NSWAustralia
• Turner R,AngusBJ,HandaA, Hatton C(2009) Clinical Skills and Examination: The
CoreCurriculum. Wiley-Blackwell, Oxford
• West M, Klein MD (1982) Isabdominal auscultation important? Lancet320(8310):
1279
• YenK, Karpas A, Pinkerton HJ,Gorelick MH (2005) Interexaminer reliability in
physical examination of pediatric patients with abdominal pain. Arch Pediatr
Adolesc Med 159(4): 373–6