Normal gut sounds may be audible even without a stethoscope, particularly after meals and with hunger. At other times sounds may be remarkably few, occurring up to every 10 seconds. These borborygmi (gurgles) can be best heard by placing the stethoscope on each side of the umbilicus. The sounds are markedly accentuated in intestinal obstruction, particularly during the contractions of colic. They are also increased by irritation from blood in the bowel or in any form of diarrhea.

Excess fluid in the gut, as for example in pyloric stenosis, may splash around when the abdomen in gently shaken by holding either side of the pelvis. This succussion splash may also be present two to three hours after a meal. It may be audible without a stethoscope. If not, ask the patient to hold the instrument in position, while you use both hands to shake the abdomen from side to side.

Paralyzed gut (paralytic ileus), such as postoperatively or in generalised peritonitis, is silent. But listen intently for a few minutes (figure 49a,b). In the late stages of intestinal obstruction, the gut may be markedly dilated and atonic, with few gut sounds, but with marked hyper- resonance (a condition known as tympanitic) and tinkling sounds of fluid dripping from one distended loop to another. In complete paralysis, breath and heart sounds may be clearly audible over the abdomen. In established obstruction a large amount of fluid accumulates in the gut, this can be shown on a plain radiograph as fluid levels. An occasional level may be seen normally, but many horizontal lines are present in obstruction; the patient can be sitting or standing, or lying on their side (figure 50).



A peritoneal rub is produced by friction between roughened peritoneal surfaces, such as in inflammation and neoplasia. It disappears as fluid accumulates, if the surfaces adhere or the condition improves. Rubs over liver abscesses and splenic infarcts may be misinterpreted as arising from a pleural rub from pulmonary disease or pericarditis.

Bruits may be heard in the epigastrium down to the umbilicus and onwards to each midinguinal point in aortoiliac arterial stenotic disease (figure 51a–f). Increased portasystemic flow in portal hypertension may produce venous sounds: these are increased on inspiration and during a Valsalva manoeuvre.

Renal artery bruits may be more audible posteriorly (figure 52a), they are an important diagnostic sign in renal artery stenosis. Turn the patient onto their right side. While in this position, percuss for splenic dullness and palpate for the spleen and left kidney. Sacral edema (figure 52b) may also be noted (page 231).