Clinical examination of abdomen—time for a consensus?

Clinical examination of abdomen—time for a consensus?

Dear Sir

I recently appeared for the step 2 clinical skills United States Medical License Examination (Step 2 CS USMLE) and during my preparation I was perplexed to find that auscultation seems to be the first step in examination of the abdomen. 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 (Cannon, 1905). Although abdominal auscultation is still included as one of the four 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 examination format, with clinical books describing auscultation after inspection, followed by palpation and percussion. Since then several versions of the sequence have been described in various texts. 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 as 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 the examination and will follow the familiar roadside admonition to ‘stop, look and listen’ before palpating. The change in the clinical dictum ‘look, feel, listen’ to ‘look, listen, feel’ is made 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 on the degree to which the alteration in bowel sounds is clinically significant. Further, there is little consensus on the ideal time that should be spent in auscultation (15 seconds versus 1 minute) (Miguel & Michael, 1982) and the utility of four-quadrant versus single-quadrant auscultation (Hepburn et al., 2004). An even greyer area is listening for abdominal bruits—is it necessary? And if at all present does it requires further work-up (Turnbull, 1995)? 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 not been accepted because of empiricism and tradition, without ever being evaluated in terms of reproducibility, nor has its diagnostic power been assessed. When considering abdominal examination we still seem to be groping in the dark regarding its methodology and utility. The fact that we have not been able to reach a consensus regarding the quality of bowel sounds, single- versus four-quadrant examination, or the power of abdominal bruits as a diagnostic tool, simply states that this still remains an abstract art.