Portal de Periódicos da CAPES

Look, Feel, Listen or Look, Listen, Feel?

2007; Elsevier BV; Volume: 120; Issue: 2 Linguagem: Inglês

10.1016/j.amjmed.2006.05.064

1555-7162

Samar Harris, Harris Naina, Sarat Kuppachi,

Medical History and Innovations

Abdominal auscultation has been an integral part of the clinical examination of patients with gastroenterological complaints since 1905, when Cannon assumed that there should be a relation between intestinal sounds and underlying disease.1Cannon W.B. Auscultation of the rhythmic sounds produced by the stomach and intestines.Am J Physiol. 1905; 14: 339-353Google Scholar Although abdominal auscultation is still included as 1 of the 4 components in the physical examination of the abdomen, its position in the sequence has seen much variance. Initially, the clinical examination of the abdomen was described in the order of inspection, palpation, percussion, and auscultation, as it was in the examination of the chest. A review of literature collected from physical examination manuals and from medical journals dated from the early 1900s to 2005 showed an alteration in the accepted format of examination, with clinical books describing auscultation after inspection, followed by palpation and percussion. Since then, several versions of the sequence have been described in various textbooks. The wisdom attributed to this change was that palpation will commonly result in diminution, if not indeed absence of peristaltic movement and, extrapolating this, the logic is that because auscultation of the abdomen is in large part devoted to an analysis of these sounds, the wise diagnostician will take auscultation out of its usual place at the end of examination and will follow the familiar railroad admonition to “stop, look and listen” before palpating. The change in the clinical dictum “look, feel, listen” to “look, listen, feel,” is on the basis that physical handling may alter the frequency of bowel sounds and may disturb the peritoneal contents into silent pouting; however, there is a lack of consensus as to what degree the alteration in bowel sounds is clinically significant. Efforts have been made to objectify bowel sounds, but almost no effort has been made to investigate the clinical value of abdominal auscultation in man.2Yoshino H. Abe Y. Yoshino T. Ohsato K. Clinical application of spectral analysis of bowel sounds in intestinal obstruction.Dis Colon Rectum. 1990; 33: 753-757Crossref PubMed Scopus (48) Google Scholar Studies undertaken for the same have given conflicting reports of the utility of abdominal auscultation in patients with acute abdominal pain (barring peritonitis), with some reporting it to be an essential tool while others question its accuracy in reporting on sounds following surgery.3Gade J. Kruse P. Andersen O.T. Pedersen S.B. Boesby S. Physicians’ abdominal auscultation A multi-rater agreement study.Scand J Gastroenterol. 1998; 33: 773-777Crossref PubMed Scopus (28) Google Scholar, 4West M. Klein M.D. Is abdominal auscultation important?.Lancet. 1982; 2: 1279Abstract PubMed Google Scholar Further, there is little consensus on the ideal time that should be spent in auscultation (15 seconds vs 1 minute) and the utility of 4 quadrants versus single quadrant auscultation.4West M. Klein M.D. Is abdominal auscultation important?.Lancet. 1982; 2: 1279Abstract PubMed Google Scholar Grayer is the area on listening for abdominal bruits—is it necessary? And if at all present, does it require further work-up?5Turnbull J.M. The rational clinical examination Is listening for abdominal bruits useful in the evaluation of hypertension?.JAMA. 1995; 274: 1299-1301Crossref PubMed Scopus (35) Google Scholar Incidentally, the textbooks of surgery do still prescribe the traditional method of abdominal examination, with palpation being an early and crucial step in evaluating the abdomen with auscultation following it. Like many clinical skills, abdominal auscultation has been accepted because of empiricism and tradition, without ever being evaluated in terms of reproducibility, nor has its diagnostic power been assessed. Considering abdominal examination, we still seem to be groping in the dark regarding its methodology and utility. Until the ‘abdominal examination’ is approached more scientifically, the algorithm of inspection, palpation, percussion, and auscultation versus inspection, auscultation, percussion, and palpation lies questioned. The fact that we have not been able to reach a consensus regarding the quality of bowel sounds, single versus 4-quadrant examination, or the power of abdominal bruits as a diagnostic tool, simply states that this still remains an abstract art.