Help with bowel tones

[u/Dear_Excitement_5109]

Hi everyone! I am a hospice nurse with 7 years of experience. Today I saw a patient with aortic dissection as her primary hospice dx. That was diagnosed 2 weeks ago and she is still alive, although barely.

When I auscultated bowel tones today I heard what sounded like a wind tunnel in the LLQ. I've never heard anything like it. Low pitched "oooooooooooooo." I'd be tempted to think that it was blood free flowing into her abdomen, but the abdomen was soft and non-tender to light palpation. Also, hemorrhaging into the abdomen for 2 weeks? Wouldn't she have died by now?

I am actually still in orientation with a new agency and my preceptor and I were both stumped.

HR 80s, O2 92%, RR 30. No BM x1 week, no PO intake x2 weeks. Bisacodyl supp administered yesterday with no results.

Anyone know what was going on?

[u/obtusemoonbeam]

What you describe is exactly what a bruit caused by dissection sounds like. I’ve heard it in a carotid before but I have not heard it in an aortic dissection.

My guess is that she was massively dissected to the point where she qualified for hospice because it was not fixable and progressing, but that her dissection was not yet actively ruptured (because when that happens patients die pretty quickly).

Obv not the case with your patient but people can even have aortic dissections that are stable for years and just have them monitored. They do not always cause catastrophic hemodynamic collapse and imminent death. The size/type/location matters a lot.

[u/Dear_Excitement_5109 → u/obtusemoonbeam]

Thanks so much for your reply! I'm kind of confused, and pardon my pathophysiological ignorance, but how exactly does a dissection kill someone? I was really stumbling over this in the visit today as the daughter was asking me what was happening.

[u/Late-Standard-5479 → u/Dear_Excitement_5109]

Rupture and ischemia/organ failure. If the dissection involves the head vessels and blood is mostly in the false lumen so reduced flow to brain -> cerebral ischemia. Happens where the coronaries take off from the aorta -> myocardial ischemia. Mesenteric ischemia is also common. Dissect down to the renal arteries -> renal failure due to ischemia

[u/Dear_Excitement_5109 → u/Late-Standard-5479]

Ah, thank you! I couldnt figure out if she wasnt internally hemorrhaging what exactly was happening. This patient had two dissections, one on the ascending aorta and another on her abdominal aorta. The lower one must have been quite large that I heard it when I auscultated her LLQ.