Diagnostic value of digital continuous bowel sounds in critically ill patients with acute gastrointestinal injury: A prospective observational study

doi:10.4240/wjgs.v16.i12.3818

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World Journal of Gastrointestinal Surgery

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1948-9366

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Observational Study

World J Gastrointest Surg. Dec 27, 2024; 16(12): 3818-3834
Published online Dec 27, 2024. doi: 10.4240/wjgs.v16.i12.3818

Table 1 Admission characteristics and observation results, n (%)

Characteristics	Total, n = 75
Male sex	51 (68.0)
Age (years)	64 (51, 74)
Body mass index (kg/m²)	22.9 (19.3, 26.1)
Acute Physiology and Chronic Health Evaluation II score, points	19 (15, 24)
Sequential Organ Failure Assessment score, points	8 (5, 10)
Main reason for admission to ICU
Respiratory system (severe pneumonia, acute respiratory distress syndrome, respiratory failure, immunosuppressive host pneumonia)	45 (60.0)
Cardiovascular circulation (pulmonary embolism, shock, heart failure, disseminated intravascular coagulation)	22 (29.3)
Urinary system (acute kidney injury)	14 (18.7)
Sepsis/septic shock	31 (41.3)
Multiple organ dysfunction syndrome	17 (22.7)
Postoperative care	14 (18.7)
Post-cardiopulmonary resuscitation	5 (6.7)
Trauma/multiple injuries	5 (6.7)
Severe acute pancreatitis	4 (5.3)
Hemorrhagic fever with renal syndrome	4 (5.3)
Others (immune checkpoint inhibitor-related damage, Japanese encephalitis, refeeding syndrome)	3 (4.0)
Operation
Gastrointestinal surgery	7 (9.3)
Non-gastrointestinal surgery	11 (14.7)
Non-operative medical treatment	57 (76.0)
Nutrition
Enteral nutrition	30 (40.0)
Parenteral nutrition	18 (24.0)
Enteral and parenteral nutrition	3 (0.04)
Life support
Vasoactive drugs	36 (48.0)
Invasive mechanical ventilation	36 (48.0)
Non-invasive mechanical ventilation	16 (21.3)
Outcome
Duration of mechanical ventilation (days)	4 (0, 9)
ICU length of stay (days)	10 (6, 17)
Hospital length of stay (days)	16 (8, 26)
28-day mortality	25 (0.33)

Data are expressed as n (%) or median (25^th percentile; 75^th percentile) unless stated differently. ICU: Intensive care unit.

Table 2 Acute gastrointestinal injury and clinical variables

Variables	Non-AGI (n = 30)	AGI (n = 45)	t/Z	P value
Mean bowel sound rate (counts per minute)	4.343 ± 2.756	1.185 ± 1.441	-5.352	< 0.001^b
Duration of bowel sounds (seconds)	1.579 ± 1.049	0.534 ± 0.919	-5.041	< 0.001^b
Amplitude (dB)	0.121 ± 0.097	0.037 ± 0.076	-5.029	< 0.001^b
Average frequency (Hz)	708.559± 219.649	355.458± 238.318	-5.094	< 0.001^b
Interval time (seconds)	3.977 ± 1.410	2.098 ± 1.508	-4.448	<0.001^b
Citrulline (μmol/L)	19.29 ± 1.46	18.47 ± 1.68	2.165	0.034^a
Intestinal fatty acid-binding protein (ng/L)	467 ± 59	493 ± 60	-1.863	0.067
Gastrin (ng/L)	79.45 ± 12.16	74.95 ± 12.87	1.493	0.140
Motilin (ng/L)	215.20 ± 37.58	211.73 ± 38.27	0.382	0.703
Sequential Organ Failure Assessment score, points	6 ± 3	9 ± 5	-2.596	0.009^b
Acute Physiology and Chronic Health Evaluation II score, points	17 ± 6	22 ± 9	-2.430	0.018^a
Hemoglobin (g/L)	98 ± 26	96 ± 21	0.418	0.678
Platelets (10⁹/L)	161 ± 104	122 ± 89	-1.553	0.120
white blood cell (10⁹/L)	8.45 ± 3.36	10.08 ± 4.41	-1.462	0.144
Neutrophil count (10⁹/L)	7.32 ± 3.09	8.82 ± 436	-1.697	0.094
Percentage of central granulocyte count	84.9 ± 7.9	88.6 ± 6.7	-1.430	0.153
C-reactive protein (mg/L)	99.3 ± 72.7	104.4 ± 80.2	-0.159	0.874
procalcitonin (ng/mL)	3.768 ± 7.037	7.250 ± 12.337	-1.187	0.235
Interleukin 6 (ng/mL)	103.688 ± 256.797	166.78 ± 322.69	-2.262	0.024^a
Total protein (g/L)	52.0 ± 6.7	49.8 ± 6.3	1.421	0.160
Albumin (g/L)	28.6 ± 3.6	27.7 ± 4.2	0.905	0.369
Creatinine (µmol/L)	115 ± 108	109 ± 82	-0.108	0.914
Blood urea nitrogen (mmol/L)	11.25 ± 6.00	11.96 ± 8.16	-0.132	0.895
Serum sodium (mmol/L)	140.28 ± 5.17	138.94 ± 4.90	-1.070	0.284
Serum potassium (mmol/L)	4.09 ± 0.52	4.03 ± 0.42	0.509	0.613
Serum calcium (mmol/L)	2.07 ± 0.17	2.02 ± 0.15	1.397	0.167
Serum phosphorus (mmol/L)	0.94 ± 0.32	0.96 ± 0.43	-0.053	0.958
Arterial blood gas potential of hydrogen	7.457 ± 0.060	7.422 ± 0.074	2.158	0.034^a
Partial pressure of oxygen (mmHg)	106.4 ± 37.8	105.5 ± 34.9	-0.024	0.981
Partial pressure of carbon dioxide (mmHg)	36.8 ± 8.9	38.0 ± 8.1	-0.591	0.556
Bicarbonate (mmol/L)	26.4 ± 5.6	24.6 ± 4.3	1.564	0.122
Lactic acid (mmol/L)	1.2 ± 0.8	1.5 ± 1.0	-1.308	0.191
Serum magnesium (mmol/L)	0.95 ± 0.13	0.94 ± 0.13	0.186	0.853
Body mass index (kg/m²)	22.52 ± 4.25	23.19 ± 5.01	-0.552	0.583
Age (years)	59 ± 16	62 ± 19	-1.098	0.272
Duration of mechanical ventilation (days)	7 ± 16	8 ± 11	-1.054	0.292
Intensive care unit length of stay (days)	16 ± 16	13 ± 12	-0.774	0.439
Hospital length of stay (days)	19 ± 17	20 ± 16	-0.292	0.770

^aP < 0.05.

^bP < 0.01.

Data are expressed as mean ± SD. t/Z value is the test statistic, P value is the comparison between the non-acute gastrointestinal injury (AGI) and AGI groups. AGI: Acute gastrointestinal injury.

Table 3 Multi-factor regression analysis of factors influencing acute gastrointestinal injury

Variables	Odds ratio (95%CI)	P value
Mean bowel sound rate (counts per minute)	0.380 (0.225–0.642)	< 0.001^b
Citrulline level (μmol/L)	0.543 (0.308–0.957)	0.035^a

^aP < 0.05.

^bP < 0.01.

Table 4 Receiver operating characteristic curves

Variables	Area under the curve	95%CI	P value	Sensitivity	Specificity
Mean bowel sound rate	0.8815	0.7906–0.9725	< 0.0001^b	0.902	0.821
Cit level	0.6488	0.5223–0.7754	0.0313^a	0.419	0.867
Mean bowel sound rate combined with Cit level	0.8956	0.8171–0.9741	< 0.0001^b	0.872	0.857

^aP < 0.05.

^bP < 0.01.

Cit: Citrulline.

Table 5 Acute gastrointestinal injury severity and clinical variables

Variables	AGI I (n = 32)	AGI II (n = 10)	AGI III-IV (n = 3)	P_F/χ²
Mean bowel sound rate (counts per minute)	1.308 ± 1.610	0.942 ± 0.994	0.717 ± 0.690	0.828
Duration of bowel sounds (seconds)	0.513 ± 0.795	0.719 ± 1.385	0.178 ± 0.180	0.719
Amplitude (dB)	0.032 ± 0.043	0.065 ± 0.144	0.011 ± 0.009	0.818
Average frequency (Hz)	366.215 ± 238.280	344.720 ± 256.841	287.276 ± 260.841	0.858
Interval time (seconds)	2.180 ± 1.554	1.851 ± 1.285	2.045 ± 2.171	0.854
Citrulline (μmol/L)	18.47 ± 1.68	18.53 ± 1.94	18.22 ± 0.88	0.973
Intestinal fatty acid-binding protein (ng/L)	489 ± 58	516 ± 61	467 ± 68	0.364
Gastrin (ng/L)	72.49 ± 12.11	77.07 ± 11.22	93.33 ± 13.01	0.019^a
Motilin (ng/L)	212.23 ± 38.97	218.42 ± 33.79	186.32 ± 46.98	0.459
Sequential Organ Failure Assessment score, points	9 ± 4	9 ± 6	12 ± 3	0.510
Acute Physiology and Chronic Health Evaluation II score, points	21 ± 8	27 ± 12	20 ± 5	0.240
Hemoglobin (g/L)	95 ± 21	96 ± 23	110 ± 8	0.509
Platelets (10⁹/L)	138 ± 95	78 ± 52	67 ± 38	0.076
White blood cell (10⁹/L)	10.58 ± 4.78	9.07 ± 2.41	7.01 ± 2.34	0.170
Neutrophil count (10⁹/L)	9.56 ± 4.61	6.84 ± 3.03	6.16 ± 1.68	0.159
Percentage of central granulocyte count	89.5 ± 6.0	84.9 ± 8.3	89.3 ± 7.0	0.322
C-reactive protein (mg/L)	98.2 ± 77.6	107.3 ± 96.1	159.3 ± 50.3	0.410
Procalcitonin (ng/mL)	7.504 ± 14.053	4.888 ± 4.323	10.927 ± 7.004	0.897
Interleukin 6 (ng/mL)	164.07 ± 358.46	169.29 ± 232.63	187.21 ± 170.99	0.292
Total protein (g/L)	50.8 ± 6.3	47.1 ± 6.0	46.1 ± 4.808	0.171
Albumin (g/L)	28.0 ± 4.4	27.2 ± 3.8	25.7 ± 3.0	0.630
Creatinine (µmol/L)	111 ± 88	94 ± 66	131 ± 79	0.664
Blood urea nitrogen (mmol/L)	11.03 ± 6.90	10.64 ± 7.24	25.19 ± 13.52	0.141
Serum sodium (mmol/L)	138.51 ± 3.96	139.12 ± 7.87	142.91 ± 3.64	0.338
Serum potassium (mmol/L)	4.02 ± 0.44	4.08 ± 0.37	4.03 ± 0.46	0.791
Serum calcium (mmol/L)	2.04 ± 0.15	2.00 ± 0.16	1.92 ± 0.09	0.396
Serum phosphorus (mmol/L)	0.93 ± 0.40	1.02 ± 0.58	1.10 ± 0.12	0.472
Arterial blood gas potential of hydrogen	7.427 ± 0.075	7.397 ± 0.075	7.441 ± 0.074	0.520
Partial pressure of oxygen (mmHg)	106.5 ± 39.7	103.3 ± 15.7	101.7 ± 31.7	0.886
Partial pressure of carbon dioxide (mmHg)	39.0 ± 8.3	35.8 ± 7.4	34.6 ± 8.7	0.435
Bicarbonate (mmol/L)	25.6 ± 4.3	21.8 ± 3.4	23.1 ± 2.3	0.050
Lactic acid (mmol/L)	1.4 ± 1.0	1.6 ± 1.1	1.7 ± 1.3	0.722
Serum magnesium (mmol/L)	0.96 ± 0.14	0.91 ± 0.11	0.84 ± 0.19	0.345
Body mass index (kg/m²)	23.47 ± 4.96	22.07 ± 4.98	23.44 ± 7.21	0.813
Duration of mechanical ventilation, days	10 ± 12	3 ± 5	8 ± 11	0.132
Intensive care unit length of stay (days)	14 ± 13	10 ± 10	17 ± 11	0.552
Hospital length of stay (days)	21+16	11 ± 11	32 ± 22	0.040^a
Age (years)	62 ± 18	58 ± 23	73 ± 13	0.460

^aP < 0.05, P value was obtained from the comparison of differences between groups.

Data are expressed as mean ± SD. F/χ² is the test statistic. AGI: Acute gastrointestinal injury.

Table 6 Comparison of clinical variables between groups

Groups	P value
Groups	Gastrin	Hospital length of stay
I-II	0.898	0.078
I-III	0.019^a	1.000
II-III	0.136	0.127

^aP < 0.05.

I: Acute gastrointestinal injury (AGI) I group; II: AGI II group; III: AGI III group.

Table 7 Influencing factors for acute gastrointestinal injury severity in ordered logistic regression analysis

Variables	b	Wald χ²	P value
Gastrin	0.071	5.417	0.020^a
Hospital length of stay	-0.022	0.857	0.355

^aP < 0.05.

“b” refers to the maximum likelihood estimation of the regression coefficient. Wald χ² is the statistical value of the Wald test, and P is the P-value of the Wald test.

Table 8 Acute gastrointestinal injury grade and clinical variables

Variables	Non-AGI (n = 30)	AGI I (n = 32)	AGI II (n = 10)	AGI III-IV (n = 3)	P_F/χ²	P_r	r_s
Mean bowel sound rate (counts per minute)	4.343 ± 2.756	1.308 ± 1.610	0.942 ± 0.994	0.717 ± 0.690	< 0.001^b	< 0.001^b	-0.621
Duration of bowel sounds (seconds)	1.579 ± 1.049	0.513 ± 0.795	0.719 ± 1.385	0.178 ± 0.180	< 0.001^b	< 0.001^b	-0.572
Amplitude (dB)	0.121 ± 0.097	0.032 ± 0.043	0.065 ± 0.144	0.011 ± 0.009	< 0.001^b	< 0.001^b	-0.568
Average frequency (Hz)	708.559 ± 219.649	366.215 ± 238.280	344.720 ± 256.841	287.276 ± 260.841	< 0.001^b	< 0.001^b	-0.592
Interval time (seconds)	3.977 ± 1.410	2.180 ± 1.554	1.851 ± 1.285	2.045 ± 2.171	< 0.001^b	< 0.001^b	-0.514
Citrulline (μmol/L)	19.29 ± 1.46	18.47 ± 1.68	18.53 ± 1.94	18.22 ± 0.88	0.212	0.044^a	-0.237
Intestinal fatty acid-binding protein (ng/L)	467 ± 59	489 ± 58	516 ± 61	467 ± 68	0.145	0.106	0.191
Gastrin (ng/L)	79.45 ± 12.16	72.49 ± 12.11	77.07 ± 11.22	93.33 ± 13.01	0.016^a	0.651	-0.054
Motilin (ng/L)	215.20 ± 37.58	212.23 ± 38.97	218.42 ± 33.79	186.32 ± 46.98	0.625	0.692	-0.047
Sequential Organ Failure Assessment score, points	6 ± 3	9 ± 4	9 ± 6	12 ± 3	0.033^a	0.008^b	0.308
Acute Physiology and Chronic Health Evaluation II score, points	17 ± 6	21 ± 8	27 ± 12	20 ± 5	0.025^a	0.017^a	0.276
Hemoglobin (g/L)	98 ± 26	95 ± 21	96 ± 23	110 ± 8	0.733	0.890	0.017
Platelets (10⁹/L)	161 ± 104	138 ± 95	78 ± 52	67 ± 38	0.087	0.025^a	-0.266
white blood cell (10⁹/L)	8.45 ± 3.36	10.58 ± 4.78	9.07 ± 2.41	7.01 ± 2.34	0.202	0.339	0.115
Neutrophil count (10⁹/L)	7.32 ± 3.09	9.56 ± 4.61	6.84 ± 3.03	6.16 ± 1.68	0.110	0.544	0.073
Percentage of central granulocyte count	84.9 ± 7.9	89.5 ± 6.0	84.9 ± 8.3	89.3 ± 7.0	0.069	0.201	0.154
C-reactive protein (mg/L)	99.3 ± 72.7	98.2 ± 77.6	107.3 ± 96.1	159.3 ± 50.3	0.544	0.625	0.059
Procalcitonin (ng/mL)	3.768 ± 7.037	7.504 ± 14.053	4.888 ± 4.323	10.927 ± 7.004	0.150	0.073	0.215
Interleukin 6 (ng/mL)	103.68 ± 256.797	164.07 ± 358.46	169.29 ± 232.63	187.21 ± 170.99	0.066	0.007^b	0.322
Total protein (g/L)	52.0 ± 6.7	50.8 ± 6.3	47.1 ± 6.0	46.1 ± 4.808	0.124	0.024^a	-0.267
Albumin (g/L)	28.6 ± 3.6	28.0 ± 4.4	27.2 ± 3.8	25.7 ± 3.0	0.604	0.186	-0.159
Creatinine (µmol/L)	115 ± 108	111 ± 88	94 ± 66	131 ± 79	0.827	0.767	0.036
Blood urea nitrogen (mmol/L)	11.25 ± 6.00	11.03 ± 6.90	10.64 ± 7.24	25.19 ± 13.52	0.219	0.746	0.039
Serum sodium (mmol/L)	140.28 ± 5.17	138.51 ± 3.96	139.12 ± 7.87	142.91 ± 3.64	0.216	0.584	-0.066
Serum potassium (mmol/L)	4.09 ± 0.52	4.02 ± 0.44	4.08 ± 0.37	4.03 ± 0.46	0.933	0.944	-0.008
Serum calcium (mmol/L)	2.07 ± 0.17	2.04 ± 0.15	2.00 ± 0.16	1.92 ± 0.09	0.310	0.126	-0.183
Serum phosphorus (mmol/L)	0.94 ± 0.32	0.93 ± 0.40	1.02 ± 0.58	1.10 ± 0.12	0.623	0.725	0.042
Potential of hydrogen	7.457 ± 0.060	7.427 ± 0.075	7.397 ± 0.075	7.441 ± 0.074	0.114	0.021^a	-0.273
Partial pressure of oxygen (mmHg)	106.4 ± 37.8	106.5 ± 39.7	103.3 ± 15.7	101.7 ± 31.7	0.980	0.910	0.014
Partial pressure of carbon dioxide (mmHg)	36.8 ± 8.9	39.0 ± 8.3	35.8 ± 7.4	34.6 ± 8.7	0.590	0.907	0.014
Bicarbonate (mmol/L)	26.4 ± 5.6	25.6 ± 4.3	21.8 ± 3.4	23.1 ± 2.3	0.073	0.036^a	-0.249
Lactic acid (mmol/L)	1.2 ± 0.8	1.4 ± 1.0	1.6 ± 1.1	1.7 ± 1.3	0.529	0.140	0.177
Serum magnesium (mmol/L)	0.95 ± 0.13	0.96 ± 0.14	0.91 ± 0.11	0.84 ± 0.19	0.518	0.388	-0.109
Body mass index (kg/m²)	22.52 ± 4.25	23.47 ± 4.96	22.07 ± 4.98	23.44 ± 7.21	0.855	0.784	0.036
Age (years)	59 ± 16	62 ± 18	58 ± 23	73 ± 13	0.406	0.232	0.140

^aP < 0.05.

^bP < 0.01.

P_F/χ² is obtained by one-way analysis of variance or non-parametric tests to analyze the differences of observed indexes among different acute gastrointestinal injury (AGI) grades; r_s refers to the correlation coefficient, which was obtained using Spearman’s rank correlation analysis between each observation index and AGI grade. AGI: Acute gastrointestinal injury.

Table 9 Comparison of clinical variables between groups

Group-group	P value
Group-group	Mean bowel sound rate	Duration of bowel sounds	Amplitude of bowel sounds	Average frequency of bowel sounds	Interval time between bowel sounds	Gastrin	Acute Physiology and Chronic Health Evaluation II
III-II	1.000	1.000	1.000	1.000	1.000	0.265	1.000
III-I	1.000	1.000	1.000	1.000	1.000	0.034^a	1.000
II-I	1.000	1.000	1.000	1.000	1.000	1.000	0.354
III-non-AGI	0.066	0.043^a	0.060	0.080	0.218	0.370	1.000
II-non-AGI	0.002^b	0.018^a	0.017^a	0.004^b	0.002^b	1.000	0.018^a
I-non-AGI	< 0.001^b	< 0.001^b	< 0.001^b	< 0.001^b	< 0.001^b	0.172	0.515

^aP < 0.05.

^bP < 0.01.

I, II, III, and non-acute gastrointestinal injury (AGI) are the AGI I group, AGI II group, AGI III group, and non-AGI group, respectively. AGI: Acute gastrointestinal injury.

Table 10 Canonical discriminant function coefficients

Variables	Function
Variables	1	2
Acute Physiology and Chronic Health Evaluation II	-0.039	0.197
Sequential Organ Failure Assessment	0.053	-0.386
Gastrin	0.019	0.032
Citrulline	0.132	0.076
Interval time	0.297	0.250
Amplitude	-8.676	7.212
Mean bowel sound rate	0.473	-0.202
Total protein	0.018	0.001
Platelets	0.004	-0.005
Potential of hydrogen	5.856	-0.090
Bicarbonate	0.005	-0.065
Constant	-50.170	-2.538

Table 11 Fisher linear discriminant function coefficients

Variables	Non-acute gastrointestinal injury	I	II	III
Acute Physiology and Chronic Health Evaluation II	5.865	5.746	6.215	5.383
Sequential Organ Failure Assessment	-0.983	-0.694	-1.595	-0.361
Gastrin	0.174	0.098	0.152	0.382
Citrulline	4.486	4.156	4.093	4.133
Interval time	6.162	5.274	5.449	7.783
Amplitude	-853.653	-844.614	-813.995	-839.793
Mean bowel sound rate	28.872	28.205	26.892	27.004
Total protein	0.604	0.574	0.532	0.325
Platelets	0.235	0.232	0.214	0.229
Potential of hydrogen	2436.999	2426.586	2414.747	2398.098
Bicarbonate	-0.939	-0.880	-1.032	-0.936
Constant	-9230.872	-9136.797	-9048.069	-8942.058

I, II, III, and non-acute gastrointestinal injury (AGI) represent the AGI I group, AGI II group, AGI III group, and non-AGI group, respectively.

Citation: Sun YH, Song YY, Sha S, Sun Q, Huang DC, Gao L, Li H, Shi QD. Diagnostic value of digital continuous bowel sounds in critically ill patients with acute gastrointestinal injury: A prospective observational study. World J Gastrointest Surg 2024; 16(12): 3818-3834
URL: https://www.wjgnet.com/1948-9366/full/v16/i12/3818.htm
DOI: https://dx.doi.org/10.4240/wjgs.v16.i12.3818