Definition of Constipation When it comes to constipation, many people understand it to mean a decrease in the frequency of bowel movements, a decrease in the volume of bowel movements, and straining to pass stools. Epidemiologic studies have shown that there are more symptoms associated with constipation than just these three. In general, constipation is characterized by a decrease in the number of bowel movements, dry and hard stools, and/or difficulty in passing stools. Decreased bowel movements are defined as <3 bowel movements per week. Difficulty in passing stools includes straining to pass stools, difficulty in passing stools, feeling of incomplete evacuation, time-consuming bowel movements, and the need for maneuvers to assist in passing stools. Chronic constipation is defined as constipation of at least 6 months duration. Alarming signs According to the previous consensus, in the diagnosis of constipation, patients aged >45 years with alarming signs, including blood in stool, positive fecal occult blood test, anemia, emaciation, obvious abdominal pain, abdominal mass, history of colorectal polyps and family history of colorectal cancer should undergo the necessary laboratory, imaging and colonoscopy examinations to exclude organic diseases. However, according to a clinical study of more than 30,000 colorectal cancer patients by the Colorectal Cancer Specialized Committee of the Chinese Anti-Cancer Association, the proportion of colorectal cancer patients under the age of 45 was as high as 18.4% from 2005 to 2008. The age of onset of colorectal cancer in China is significantly earlier than that in western countries, and most of the young colorectal cancer patients belong to the progressive stage at the time of diagnosis, with poorer prognosis for surgical treatment. Therefore, it is necessary to relax the age limit of colorectal cancer screening to >40 years old. Comprehensive medical history The diagnosis of chronic constipation is mainly based on symptoms, and medical history is very important in the diagnosis of chronic constipation. Care should be taken to ask about the symptoms of constipation, their severity, the perception of constipation, and their impact on quality of life. Different syndromes suggest possible pathophysiologic mechanisms, and accompanying symptoms may provide clues for differential diagnosis. The patient’s comorbid chronic underlying diseases and medication history may be the main cause or aggravation of constipation. In addition to the above information, it is also important to understand the patient’s dietary structure, knowledge of the disease, and mental and psychological conditions, in order to obtain a comprehensive understanding of the disease for rational diagnosis and treatment. The significance of clinical symptom characteristics for constipation classification At present, according to the pathophysiological mechanism, constipation caused by functional diseases can be classified into slowtransit constipation (STC), defecation disorder constipation, mixed constipation, and normaltransit constipation (NTC). These four types can be initially determined based on clinical symptom characteristics. Preliminary typing of constipation due to functional diseases based on clinical symptom characteristics can help to select empirical treatment options on the one hand, and on the other hand, it is suggestive for the diagnosis and treatment of functional constipation in primary hospitals that lack specific tests related to functional constipation (e.g., rectal-anal manometry, colonic transmission test, etc.). In general, the main symptoms of STC are decreased frequency of defecation, dry feces, and straining to defecate. The main symptoms of dyspareunia type constipation are laborious defecation, feeling of incomplete defecation, feeling of anorectal blockage during defecation, time-consuming defecation, and the need for manipulation to assist defecation. Mixed constipation patients have all of the above symptoms. Constipated irritable bowel syndrome (IBS) is mostly NTC, and patients have abdominal pain and abdominal discomfort associated with constipation. Importance of anorectal fingerprinting Surgeons pay more attention to anorectal fingerprinting for preliminary understanding of organic lesions of the anorectum, such as rectal polyps, rectal cancer, anal fistula and so on. Anorectal fingerprinting is simple, easy to perform, through fingerprinting can understand the presence of anorectal masses and other organic diseases, to understand the function of the anal sphincter and puborectalis muscle, for the anal sphincter incoordination contraction, anorectal muscle syndrome and non-specific functional anorectal pain and other diagnostic significance.Tantiphlachiva et al. conducted anorectal fingerprinting on 209 cases of chronic constipation diagnosed according to the Rome III. Tantiphlachiva et al. evaluated the sensitivity and specificity of anorectal palpation for the diagnosis of pelvic floor spasm in 209 patients with chronic constipation diagnosed according to Rome III with anorectal palpation, colonic transport test, balloon forcing test, and rectoanal manometry. It can be seen that in the diagnosis of chronic constipation rectal anorectal fingerprinting is of great significance. Bowel power detection means In addition to colonic transmission test and anorectal manometry, balloon forced out test and fecography are also important for the diagnosis of constipation. The balloon ejection test is simple, easy to perform, reflects the coordination of the rectum, anal canal and other structures during defecation, and has high consistency with the results of anorectal manometry, so it can be used as a screening method for functional defecation disorders. Defecography injects a certain dose of barium paste into the rectum, simulates physiological defecation activities under X-ray, and dynamically observes the functional and anatomical changes of the anorectum. It is mainly used for the diagnosis of anorectal diseases related to constipation, such as rectal mucosal prolapse, internal condylomata, and anterior rectal protrusion. MRI defecography, on the other hand, is able to observe pelvic soft tissue structures simultaneously and comparatively, with multi-plane imaging. For intractable constipation, fecal imaging is an important basis for surgical decision of surgical treatment. Determining the severity of constipation Determining the severity of constipation helps to accurately recognize the condition and rationally select treatment options. According to the severity of constipation and related symptoms and the degree of impact on life, they are categorized into mild, moderate and severe constipation. For mild constipation, the symptoms are mild and do not affect daily life, and normal bowel movement can be restored through overall adjustment and short-term medication. Severe constipation symptoms are heavy and persistent, seriously affecting life and work, requiring medication that cannot be stopped or is ineffective in treating the medication. Moderate constipation is in between. The treatment principle of chronic constipation In general, the treatment principle of chronic constipation is to carry out individualized comprehensive treatment, including reasonable dietary structure, establish correct defecation habits; for those who have a clear cause of the etiology of the disease, etiological treatment; for those who need to use laxative medication to maintain the treatment of laxatives should avoid the abuse of laxative; should be strictly grasp of the indications for surgical operation, and to make an objective prediction of the efficacy of the operation. In addition, it is very important to adjust the patient’s mental state. Reasonable diet should increase the intake of fiber and water, daily intake of dietary fiber 25~35g; at least 1.5~2.0L of water per day, because the colon is most active in the morning and after the meal, it is recommended that the patient tries to defecate in the morning or 2h after the meal, and concentrate on defecation to reduce the interference of external factors, and gradually establish a good defecation habit. For bedridden elderly patients who have been sick for a long time and have little exercise, moderate exercise is also beneficial to defecation. Selection of Therapeutic Drugs The selection of laxatives should take into account evidence-based medicine (Table 1), safety, drug dependence, and potency ratio. The volumetric laxative OxyContin, the osmotic laxatives polyethylene glycol and lactulose, and the stimulant laxative bisacodyl have been recommended at the B level or higher. In addition to the current clinically familiar laxatives and prokinetic agents, there are some new prosecretory agents such as rubiprostone and linaclotide, which have been proved to have definite efficacy and have been marketed in foreign countries and will be marketed in China in the future. Assessment and treatment of sleep quality and psychological status Patients with chronic constipation often have psychosomatic abnormalities and sleep disorders, both of which also play an important role in the pathophysiologic process of chronic constipation. At the early stage of diagnosis and treatment, we should understand the mental state, sleep state and social support of chronic constipation patients, and analyze and judge the causal relationship between the above conditions and constipation, so that we can adjust the above conditions while adjusting the lifestyle and empirical treatment. Psychological guidance and cognitive therapy should be given to constipated patients with sleep disorders and psychosomatic abnormalities. Patients with significant comorbid psychiatric disorders may be treated with anxiolytic and depressive medications. Patients with severe psychosomatic abnormalities should be referred to psychosomatic specialists for specialized treatment. Attention to special treatment for special populations Elderly people, children, pregnant women, diabetic patients and terminal patients belong to special populations, and there are differences in the treatment of different special populations. Elderly people are usually suffering from chronic constipation due to lack of exercise and taking multiple medications for chronic diseases. They should pay attention to adjusting their lifestyles, and after communicating with the corresponding specialists, they should try to stop the medications that can be discontinued and cause constipation. The choice of drugs preferred volumetric laxatives and osmotic laxatives, for severe constipation, can also be short-term moderate use of stimulating laxatives. Pregnant women need to adjust their lifestyles, such as increasing dietary fiber, drinking more water and appropriate exercise, and can use volumetric laxatives, lactulose and polyethylene glycol with good safety. Bisacodyl, anthraquinone laxatives and castor oil should be avoided. Children are in the learning stage, attention should be paid to family education, reasonable diet and bowel habit training. Volumetric laxatives, lactulose, and polyethylene glycol have been shown to be effective. Although glycemic control may be beneficial in the treatment of constipation in diabetic patients, there are still few specific treatments for diabetic constipation. Volumetric laxatives, osmotic laxatives, and stimulant laxatives may be tried. Constipation in end-stage patients often occurs as a result of decreased exercise and eating, and opioids, among others, may be used. Be aware of prophylactic laxative use. Stimulant laxatives or combined osmotic or lubricating laxatives are recommended. The opioid receptor antagonist methylnaltrexone has been shown to be safe and effective for this type of constipation. Tertiary care strategy Chronic constipation should be treated in a hierarchical manner to minimize the cost of unnecessary investigations and to ensure that patients with constipation are treated appropriately and effectively. Simply put, the core of primary care is empirical treatment. For patients >40 years of age with alarm signs, appropriate examinations should be performed to exclude organic pathology, and if organic pathology exists, appropriate treatment should be carried out. For patients ≤40 years of age who are suspected of having mild to moderate constipation due to functional diseases, empirical treatment can be carried out directly by adjusting lifestyle habits, cognitive therapy and choosing reasonable medications. Patients who have failed to receive empirical treatment in the first level of diagnosis and treatment will be admitted to the second level of diagnosis and treatment. Patients need to undergo appropriate constipation-related examinations such as rectal anal canal manometry, colon transmission test, balloon forcing out test, etc., to understand the type of constipation and the patient’s mental and psychological status, and different types of constipation to choose the appropriate method. Mixed constipation is preferred to biofeedback therapy, and laxatives are added when it is not effective. Tertiary diagnosis and treatment is mainly for patients who are not effective in secondary treatment. At this time, it is necessary to re-evaluate the patient’s living habits, mental and psychological status, rectal and anal canal structure and function, and often requires the comprehensive treatment of multiple disciplines, such as psychiatry, surgery, etc. Surgical treatment must be carefully evaluated to determine the risk of surgery. Surgical treatment must carefully evaluate the risks and benefits of surgery and strictly control the indications for surgery.