For both the healthy controls and patients, an observer who was blinded to the physical examination order noted the bowel sound frequency. Subjects were examined in the supine position.
Two third-year medical students who were trained in abdominal examination both had previous experience on more than 50 healthy volunteers and patients performed the examinations. The bowel sounds for each subject were listened to with Littman stethoscopes 3M, Littmann, USA in one quadrant for two minutes by both the research student performing the whole exam and the blinded student.
Duplex Doppler USG allowed for the visualization of bowel motility and at the same time allowed us to obtain the Doppler signals created by the motility of the bowel wall. Doppler signals were counted for one minute by a radiology specialist from Ankara University Faculty of Medicine Department of Radiology. The radiologist was blinded to the research protocol.
When the true difference between the means was assumed to be zero, the margin of non-inferiority was selected as The effect of the order of the abdominal physical examination on bowel sound frequency was evaluated by a repeated measures analysis of variance ANOVA and a paired t test. Values of p Abdominal examination analyses were performed on 80 healthy subjects and patients.
Genders were equally distributed among both healthy subjects and patients. Mean age and body mass index of the entire study population were 47 18 - 60 years and 27 21 - 42 BMI. Table 1. Comparison of the groups in terms of listening findings.
Table 2. The results of Doppler USG assessments by group. Despite developing technologies, physical examination still plays the most important role in the diagnosis and treatment of the diseases today.
It is accepted that all laboratory, imaging, and biological tests only make sense when performed in conjunction with physical examination. In other words, laboratory and imaging techniques are only of value in cases where there is accordance between the tests and clinical physical examination. Historically, physical examinations were performed in the order of inspection, palpation, percussion, and auscultation.
However, the order for abdominal physical examination has recently been changed to inspection, auscultation, palpation, and percussion since it has been suggested that performing auscultation prior to palpation and percussion maneuvers may prevent possible effects on bowel sounds. Most of the medical faculties all over the world currently use and teach this order as a standard of care. Reviewing the literature, we realized that there were scarce and inconsistent publications on the value of auscultation.
Moreover, none investigated the relationship between the order of the physical examination and bowel motility. Our current randomized crossover study revealed that palpation and percussion maneuvers had no negative impact on the results obtained during auscultation in healthy subjects and patients without GIS disease. In addition, the results of the Duplex-Doppler ultrasonography, an acceptable method for evaluating intestinal motility 8 , also supported our findings.
Thus, our results indicate that it is not the order of physical examination that is crucial step for confirming the diagnosis but precise history and physical examination. Although the auscultation of bowel sounds is considered an essential component of an adequate physical examination, its clinical value remains largely unstudied and subjective.
It is now more than years since Cannon described the rhythmic bowel sounds and their possible relationship with intestinal disorders 7 , however there is little published information regarding the value of auscultation, and contradictory findings exist in the literature 9.
Gu et al. Similarly, Sugrue et al. They found that bowel sound characteristics were not different among patients with acute, subacute or no intestinal obstruction using the commonly compared parameters including sound duration, sound-to-sound interval, and dominant and peak frequencies In another study, the authors concluded that auscultation of bowel sounds is not a useful clinical practice when differentiating patients with normal versus pat hologic bowel sounds This has been echoed in other studies as well 14 - Furthermore, peristaltic movements, and associated bowel sounds, can vary with the course of disease.
For example, in diarrhea, peristaltic movements increase occasionally, but return to normal after defecation. Auscultation of the abdomen is performed for detection of altered bowel sounds, rubs, or vascular bruits. Normal peristalsis creates bowel sounds that may be altered or absent by disease. Irritation of serosal surfaces may produce a sound rub as an organ moves against the serosal surface. Atherosclerosis may alter arterial blood flow so that a bruit is produced.
Palpation is the examination of the abdomen for crepitus of the abdominal wall, for any abdominal tenderness, or for abdominal masses.
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