The Humble Stethoscope Has Much to Offer Gastroenterologists

This transcript has been edited for clarity.

Hello. I'm Dr David Johnson, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia. Welcome back to another GI Common Concerns.

The stethoscope is something that we almost always have in our coat pocket to use on our patients, perhaps to listen to their heart or maybe their abdomen. But what do we do with that information?

In a recently published review, Dr Larry Brandt, one of the true masters of gastroenterology and the renowned educators during my 40 years in the field, expounds on the use of a stethoscope to further aid in the diagnostic evaluation of gastrointestinal (GI) and hepatic disorders.

I'd like to highlight some of Dr Brandt's very erudite advice for different areas of the physical exam, as well as add some of my tips.

Esophagus

Cervical auscultation begins with positioning the stethoscope over the median line of the cricoid cartilage.

In medical history, German physicians described certain sounds, which may be caused by the fluid or bolus moving through this area in the epiglottis or laryngeal elevation, or to the contraction of the pharynx. In the German literature, the terms used are Durchpressgeraeusch and Durchspritzgeraeusch, which describe the squeezing of the upper esophageal sphincter and its squirting-type actions.

The way I perform this evaluation at the bedside is by placing my finger on the cricoid cartilage and then my stethoscope on the upper abdomen, at the area of the esophagogastric junction.

I then have the patient swallow a bolus of water in the recumbent position, which typically will be heard by the cricopharyngeal elevation, followed by a splashdown sound that you hear in the abdomen about 2 seconds later. This tells me that the transit is normal.

I've used this in a bedside evaluation for patients who may have esophageal gastric outflow obstruction or achalasia, as well as in some of my patients as a prelude to further testing with timed barium swallow or EndoFLIP for post-achalasia treatment.

It's a very easy bedside test with no cost and no radiation. Obviously, there are digital acoustic recording techniques that allow this to be a little bit more perfunctory.

Some conditions may potentially delay a liquid bolus transit, such as Zenker diverticulum or a mid-esophageal traction diverticulum, and would be anticipated to do so.

Stomach and Duodenum

Gastric emptying, when it's impeded either by obstruction or neuromuscular disorders with gastroparetic diseases, can create what was characteristically described as a succussion splash. The volume of the ingested or secreted fluid to produce this splash is not well known or characterized.

You should perform an examination to listen for a succussion splash when the patient has had nothing by mouth for several hours. It's a very simple thing to perform. You place the stethoscope over the stomach area and with a mere sloshing back and forth, you can hear the succussion splash.

When patients have compression of the duodenum, between the aorta posteriorly and the superior mesenteric artery (SMA) anteriorly, which is known as SMA syndrome, a succussion splash also may be evident.

Normally, the SMA transits off the aorta, and its angle is largely determined by a pad of fat and averages approximately 45°. When that fat is reduced by severe weight loss, the angle of the SMA takeoff is diminished and it obstructs the duodenum as it transits up toward the ligament of Treitz. This was first described during the Vietnam War era, in patients who had profound weight loss associated with being in body casts.

Small Intestine

The small intestine propels intraluminal content distally. Dr Brandt talks about a very interesting technique of putting the earpiece of two stethoscopes in and determining which way the peristalsis is going. This just goes to show how you can be detailed in the evaluation, though it doesn't really have substantial pathologic implications.

Normally in a small-bowel obstruction with associated hyperperistalsis, this increase is heard in the form of more frequent, higher-pitched sounds. This tends to diminish over time as an ileus develops. Certainly, you can hear a succussion splash if there is some type of formidable obstruction.

Dr Brandt also points out that prior to a colonoscopy, especially in an older man who's not able to provide a good history, we should evaluate the scrotum to make sure there is not a hernia in the small bowel protruding into the hernial opening. Again, peristalsis may be heard over this area with a herniated intestine. Obviously, in such cases, the hernia should be reduced before you start inducing colonic scopes and air.

I'd like to add one piece of advice that wasn't mentioned by Dr Brandt, which I have found rarely necessary but invaluable when it is. A GI bleed creates a catharsis that develops with the blood in the gut. We see hyperperistalsis uniformly in patients with significant upper GI bleeds. There is a special consideration worth noting in patients who are immunosuppressed, particularly those on steroids.

An example is a transplant patient I saw who presented with an active GI bleed. I listened to the abdomen, and there was no hyperperistalsis. In fact, the abdomen was quiet. Percussed over the liver, there was a little bit of resonance and loss of hepatic dullness, suggesting intraperitoneal air. We did an x-ray, rather than emergent endoscopy, and the patient did have free air in the abdomen. The patient went on to surgery rather than to endoscopy, which clearly would have been the wrong decision.

Colon

The colon doesn't normally produce bowel sounds that are frequent enough to be appreciated on a casual exam. In the presence of constipation, Dr Brandt notes that with a sizable amount of stool, particularly in the distal colon, you can get a sound of the stool "peeling" off the mucosa. This is appreciated by auscultation with general palpation and quick release of your hand, performed simultaneously. This is called the "Finochetto sign" (according to the original article), which was news to me, and represents an interesting new approach to use of the stethoscope.

Liver

A lesion of the liver can be well vascularized in patients with hepatocellular carcinoma, cavernous hemangioma, or the shunting that you may see with hereditary hemorrhagic telangiectasia. When this is the case, you can typically hear an arterial bruit over the lesion.

Here, Dr Brandt performs a very adroit examination where, particularly in patients with cirrhosis, he takes the stethoscope's bell and repetitively lifts and replaces it adjacently over the entire area of the liver. He says that in his experience just by using this technique, prior to the radiologic imaging that would obviously follow, lesions as small as 2 cm in diameter have been evident.

Another technique that you may remember from performing physical diagnosis is called the scratch test. This involves a maneuver that is used simultaneously with auscultation to evaluate the size of the liver. It's very simple. The diaphragm of the stethoscope is placed on the abdomen, typically starting in the right lower quadrant. You lightly stroke with a single finger as you move upward and parallel to where you expect the liver edge. When the liver edge is reached, the sound of the scratch transmitted to the stethoscope is amplified with the increased intensity. This is particularly helpful in patients where the abdomen is distended, in patients who are too obese or too tender for evaluation or palpation, and in patients whose abdominal musculature is tense or rigid. This is something you can hear with the liver and may be quite helpful.

If the patient has an abscess or a subcapsular bleed, which sometimes abuts the Glisson capsule, you can get a friction rub as a presage to capsular rupture. This may be something that you can hear with your stethoscope. Of course, the classic hepatic friction rub is seen with Fitz-Hugh–Curtis syndrome, which is gonococcal perihepatitis and explained by the so-called violin strings between the liver capsule and the peritoneum.

With portal hypertension and the formation of collateral circulations, Cruveilhier-Baumgarten syndrome may develop. This may show with prominent veins along the umbilicus, sometimes giving the appearance of a caput medusae and evidence of a venous hum. If you palpate this dilated vein, then you may get a palpable thrill. So again, something you can examine with both your ears and your fingers.

Vasculature

Narrowing of the artery can produce a bruit. Typically, bruits in the abdomen are reflective of bruits in the aorta, splanchnic vessels (particularly celiac artery or SMA), and the renal artery. Presence of a bruit, however, doesn't necessarily imply that it has pathogenic significance, with a couple potential exceptions.

One such exception is a diagnosis of median arcuate ligament syndrome, also known as celiac artery compression syndrome. This requires a very special maneuver that Dr Brandt adroitly points out, which is differentiation from a celiac artery that is stenotic because of atherosclerosis. The bruit of median arcuate ligament syndrome increases during expiration as diaphragmatic compression on the celiac artery is more pronounced in this phase of breathing. This is the only situation in which an abdominal bruit decreases with inspiration and increases with expiration.

This is particularly important when you send that patient for a CT angiogram or conventional angiogram. The radiologist should be instructed to perform this, because if improperly done and the patient is holding their breath, diaphragmatic impingement will be less intense, and you may not see the diagnostic feature that you might otherwise for celiac artery compression syndrome.

The other exception is when listening over the splenic artery. A bruit may be found in a patient with a splenic artery aneurysm or a pseudoaneurysm or with pancreatic cancer that wraps around the artery. These would be seen on CT scan but can be picked up by using a good physical exam.

A Better Evaluation

When done adroitly, the overall takeaway lesson here is that the stethoscope can be applied much more uniformly to obtain a better evaluation of GI and hepatic disorders. This simple act allows us to use our ears as a means of expanding our diagnostic acumen.

Thank you, Dr Brandt, for sharing your wonderful expertise with us. You're the best.

I'm Dr David Johnson. Thanks for listening.

David A. Johnson, MD, a regular contributor to Medscape, is professor of medicine and chief of gastroenterology at Eastern Virginia Medical School in Norfolk, Virginia, and a past president of the American College of Gastroenterology. His primary focus is the clinical practice of gastroenterology. He has published extensively in the internal medicine/gastroenterology literature, with principal research interests in esophageal and colon disease, and more recently in sleep and microbiome effects on gastrointestinal health and disease.

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