How to Assess Bowel Sounds, Rebound Tenderness, Murphy's Sign, and McBurney's Point

Hi, I'm Maris, and in this article, I'll walk you through a comprehensive assessment of bowel sounds, rebound tenderness, Murphy’s sign, and McBurney’s point. These are crucial physical exam techniques used to assess gastrointestinal and abdominal health.

I’ll be referencing our Health Assessment Flashcards, available at LevelUpRN.com. If you prefer digital resources, check those out as well!


Bowel Sounds: What They Reveal About GI Function

Bowel sounds, or peristaltic sounds, reflect the movement of air, fluid, and food through the intestines. These sounds originate from intestinal smooth muscle contractions coordinated by the enteric nervous system (ENS).

1. Normal Bowel Sounds

  • High-pitched clicks and gurgles, often described as cascading sounds
  • Occur irregularly (not rhythmic)
  • Typically heard 5 to 30 times per minute
  • Clinical significance: Normal peristalsis, indicating that food is moving through the GI tract

👉 Everyday example: If you’ve ever heard your stomach grumble, you've heard normal bowel sounds in action!

2. Hypoactive Bowel Sounds

  • Decreased frequency and intensity
  • Suggest reduced peristalsis, leading to delayed gastric emptying
  • Possible causes:
    • Postoperative ileus (temporary paralysis of the intestines after surgery)
    • Peritonitis (inflammation of the peritoneum, often causing rigidity and decreased motility)
    • Electrolyte imbalances (hypokalemia, hypercalcemia)
    • Opioid medications (which slow peristalsis)

🔹 Distinguishing hypoactive vs. absent bowel sounds:
If bowel sounds are suspected to be absent, you must auscultate in each quadrant for at least five minutes before confirming. Absent bowel sounds suggest a complete bowel obstruction or paralytic ileus, which is a medical emergency.

3. Hyperactive Bowel Sounds

  • More frequent, high-pitched, and possibly louder
  • Indicate increased peristalsis and motility
  • Possible causes:
    • Gastroenteritis (infection or inflammation causing diarrhea)
    • Irritable bowel syndrome (IBS)
    • Dumping syndrome (rapid gastric emptying, common after gastric bypass surgery)
    • Bowel obstruction (early stages may present with high-pitched, tinkling sounds)

🔹 Key term: Borborygmi (pronounced "bor-buh-RIG-mee") refers to audible hyperactive bowel sounds that can often be heard without a stethoscope.

4. Absent Bowel Sounds

  • No detectable sounds in any quadrant after 5 minutes of auscultation
  • Red flag for:
    • Complete bowel obstruction
    • Paralytic ileus
    • Severe peritonitis
    • Vascular occlusion (mesenteric ischemia)

🚨 Clinical emergency: Absent bowel sounds + severe abdominal pain + distension may indicate intestinal perforation or infarction, requiring immediate surgical intervention.

Rebound Tenderness (Blumberg’s Sign): A Marker of Peritoneal Irritation

What Is Rebound Tenderness?

Rebound tenderness occurs when pain is greater upon release of pressure rather than during application. This suggests peritoneal inflammation, a hallmark of acute abdomen conditions.

How to Assess:

  1. Identify an area away from the reported pain.
  2. Press deeply and slowly into the abdomen.
  3. Quickly release the pressure.
  4. A positive response = Sharp pain upon release, indicating peritoneal irritation.

Clinical Significance:

  • Acute appendicitis → Pain is typically in the right lower quadrant (RLQ).
  • Peritonitis → Diffuse pain, often with rigidity and guarding.

🔹 Key Sign: If pressing on the left lower quadrant causes pain in the right lower quadrant, this is known as Rovsing’s sign, which is highly suggestive of appendicitis.

Murphy’s Sign: Detecting Gallbladder Inflammation

What Is Murphy’s Sign?

Murphy’s sign tests for gallbladder inflammation, specifically cholecystitis.

How to Assess:

  1. Place your fingers under the right costal margin (beneath the ribs).
  2. Ask the patient to take a deep breath.
  3. If the patient suddenly stops inhaling due to pain, Murphy’s sign is positive.

Why Does This Happen?

During deep inhalation, the diaphragm descends, pushing the inflamed gallbladder downward. If the gallbladder is infected or swollen, this movement triggers intense pain, leading to inspiratory arrest.

Clinical Relevance:

  • Positive Murphy’s sign → Suggests acute cholecystitis
  • Negative Murphy’s sign → Less likely to be gallbladder-related

🔹 Confirmatory tests: Ultrasound of the gallbladder to check for stones (cholelithiasis) or inflammation.

McBurney’s Point: The Key Landmark for Appendicitis

What Is McBurney’s Point?

  • Located two-thirds of the way from the umbilicus to the right iliac crest.
  • This point corresponds to the anatomical location of the appendix.

Why Is McBurney’s Point Important?

  • Pain at this site is a hallmark of acute appendicitis.
  • As appendicitis progresses, pain often shifts from a diffuse, periumbilical pain to a sharp, localized pain at McBurney’s point.

🚨 Red Flag Symptoms for Appendicitis:

  • RLQ pain
  • Fever, nausea, vomiting
  • Elevated WBC count
  • Rebound tenderness and guarding

Clinical action: Suspected appendicitis = urgent surgical evaluation (appendectomy may be required).

Quick Quiz! Test Your Knowledge

  1. How long must a nurse auscultate the abdomen before determining absent bowel sounds?
    → Five minutes

  2. Where is McBurney’s point located?
    → Two-thirds the distance from the umbilicus to the right iliac crest

  3. A patient suddenly stops inhaling during a Murphy’s sign test. What does this indicate?
    → Possible acute cholecystitis

  4. Rebound tenderness is a sign of what underlying condition?
    → Peritoneal irritation (e.g., appendicitis, peritonitis)

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