1Concept of constipation
“Constipation, also closed”, closed knot also. Some foreign scholars believe that where the bowel movement force is more than 25% of normal or / and once a week and less than one bowel movement, or the interval between bowel movements more than two days, can be considered constipation. Some people even calculate the amount of daily bowel movements in grams to decide whether constipation.
Chen Shiwei, Department of Anorectal Medicine, Guangdong Provincial Hospital of Traditional Chinese Medicine
When the process of defecation is laborious, the time of defecation is prolonged, or the desire to defecate is not defecated despite the intention to defecate, or it is unpleasant after defecation, or the anus is swollen, it can be concluded as constipation. On the contrary, if you have the above symptoms, even if you have one or more bowel movements per day, you should be considered constipated. In some cases, the abdominal distension and fullness, irritability but no bowel movement or very weak bowel movement signal.
If constipation is present continuously or intermittently for about 3 out of 12 months of the year, it can be considered chronic constipation.
With the change of medical model, the traditional biomedical model is changing to a bio-psycho-social medical model, and the concept of “disease” and non-disease is also changing. As far as the physiological phenomenon of defecation is concerned, the defecation pattern of each person is determined by their own physiological needs and varies depending on their diet, life, defecation habits and food composition. Although the interval between bowel movements is long, or the number of bowel movements is not much, but as long as the process of defecation is smooth and not accompanied by discomfort, it should be regarded as a personal physiological phenomenon, rather than a generalized constipation.
2 clinical manifestations of constipation.
(1) less bowel movement, less stool: this type of constipation can be seen in slow transmission type and outlet obstruction type constipation. The former is due to slow transmission, so that the number of stools and stool are less, a longer interval before the emergence of stool, stool is often dry and hard, forceful defecation helps to expel feces. The latter is often a high sensory threshold, not easy to cause the desire to stool, and therefore, the number of stools, and stools are not necessarily dry and hard.
(2) difficult defecation, effort: highlighted by the abnormal difficulty of fecal discharge, also seen in two cases, more common with exit obstructive constipation. Patients force to discharge if the abdominal muscle contraction is weak, it is more difficult to defecate. The second case is due to slow passage, excessive absorption of water in the stool, dry stool, especially for a long time without defecation, making the discharge of dry hard stool abnormally difficult, can occur fecal impaction.
(3) Poor defecation: there is often a feeling of obstruction in the anorectum and poor defecation. Although there are frequent bowel movements, there are many bowel movements, even if the effort is not helpful, it is difficult to have a smooth bowel movement. It may be accompanied by anorectal irritation symptoms, such as cramping and discomfort. These patients often have reduced sensory thresholds, hypersensitivity of rectal sensation, or abnormalities in the anatomy of the rectum, such as endorectal overlap and internal hemorrhoids. Individuals with elevated rectal sensory thresholds may also have similar symptoms, which may be related to the combination of local anorectal anatomical changes. Treatment of this group of patients requires raising sensory thresholds, reducing the number of bowel movements, and treating local anorectal lesions, such as local management of constipation of hemorrhoidal origin.
(4) Constipation with abdominal pain or abdominal discomfort: common in IBS constipation type, often relieved after defecation.
3 Hazards of constipation
The human body transforms the food and nutrients it consumes every day into components necessary for the body’s growth activities through a complex conversion process, and excretes waste products. The human body also absorbs many harmful substances from the external environment every day. Metabolic wastes and harmful substances in the body are mainly excreted through four major excretory systems – the colon, skin, respiratory tract and urinary tract. The malfunction of any one of these four excretory systems will definitely increase the burden of other systems, which will lead to dysfunction and disease of these systems, resulting in autointoxication and damage to the health of the body. If the function of these excretory systems is seriously impaired or lost in a short period of time, it will immediately threaten life, typically such as respiratory failure, asphyxia; such as renal failure, uremia, etc. Among the four major excretory systems, the colon is the most important and most neglected excretory system. Many human diseases are related to the malfunction of the large intestine.
The large intestine is the lower part of the digestive tract and is about 1.5 meters long. Food residues are left in the large intestine, and some of the water is absorbed by the mucous membrane of the large intestine, while fermentation and decay by bacteria turn into feces, which includes shed intestinal epithelial cells and a large number of bacteria, in addition to food residues. Bacteria in human feces account for about 20%-30% of the total solid feces, and the amount of bacteria and decomposition products in the feces of patients with constipation is higher because the pH and temperature in the large intestine are extremely favorable to the reproduction of bacteria. Studies have found that there are about 22 kinds of harmful substances in feces, including hydrogen sulfide, ammonia, methane, carbon dioxide and other harmful gases and benzene, indole, botulinum toxin, necrotoxin, mycotoxic bases, cresol, butyric acid, etc., as well as some heavy metal salts that are harmful to humans.
A large number of decomposition metabolites and harmful substances exist in the feces, and if they cannot be excreted on time, some of them can be absorbed through the colonic mucosa and enter the liver through the portal vein system. On the one hand, this increases the burden on the liver, depletes the liver’s detoxification enzyme system and damages the liver function; on the other hand, the harmful substances entering the blood can cause serious damage to various organs and systems, such as gastrointestinal nerve disorders, colorectal cancer, inducing heart and cerebrovascular disease attacks, causing sexual life disorders, affecting brain function and leading to premature aging; causing neuroendocrine dysfunction and mental Mood disorders, such as depressed mood, depression, inattention; or discord with colleagues and even family members, marital crisis, depression; or impatience and irritability, hitting and destroying things, suicidal tendencies, and even schizophrenia.
4 Diagnosis of constipation.
The first national symposium on constipation in Nanchang in 2002 recommended the adoption of the Rome II criteria.
Having 2 or more of the following symptoms continuously or intermittently for at least 12 weeks in the past 12 months.
(1) Having straining to defecate > 1/4 of the time.
(2) > 1/4 of the time there is a mass of fast or hard stool.
(3) a feeling of incomplete defecation > 1/4 of the time
(4) >1/4 of the time there is a feeling of anal obstruction or anorectal obstruction during defecation.
(5) >1/4 of the time, there is a need to use manual assistance to defecate.
(6) >1/4 of the time, the patient had <3 bowel movements per week. The absence of loose stools does not meet the diagnostic criteria for IBS.
5 Classification of constipation
Chronic constipation is subdivided into two categories: functional and organic. In the past, due to the limitation of examination methods and the lack of awareness, except for the typical organic constipation, these patients were often referred to the internist, and therefore there was a lot of mismanagement. In recent years, due to the improvement of testing methods and instruments, the diagnosis of constipation, especially the diagnosis of functional constipation, has developed by leaps and bounds. Functional constipation (functional
constipation), according to the Rome II diagnostic criteria, functional constipation, in addition to meeting the above diagnostic criteria, also needs to exclude intestinal or systemic organic causes and drug-induced constipation.
In fact, many functional constipation is accompanied by different degrees of organic changes in the colorectum and its nearby structures, such as mucosal prolapse, overlap, and hypertrophy of the puborectal muscle, which need to be recognized in a discriminatory manner.
6 Common functional constipation
(1) Colon constipation: clinical bloating, abdominal pain, abdominal discomfort, no bowel movement or poor bowel movement signal, long interval between bowel movements, days or even more than 10 days without bowel movement. Colon constipation is caused by the power disorder of the colon.
① Slow transmission disorder of the colon.
② Colonic paralysis: the severe slow transmission disorder of the colon is called colonic paralysis.
(2) rectal type constipation: the clinical manifestation is that there is a bowel movement or even frequent bowel movements but difficult or even impossible to pass.
(i) endorectal prolapse.
(ii) prolapse of the rectum.
③ pelvic floor hernia.
④ pelvic floor spasm syndrome.
⑤puborectal muscle syndrome.
(vi) perineal descent syndrome.
(vii) internal sphincter loss retardation.
(viii) isolated intestinal ulcer syndrome.
7 Ancillary treatment methods for functional constipation.
(1) Defecography.
(2) Colonic transmission test.
(3) barium enema.
(4) Others: ① colorectal manometry test; ② anal electromyography test; ③ balloon forcing out test; ④ endoscopy.
8 Treatment of constipation
Treatment principles of constipation: (1) Firstly, strict non-surgical treatment is used. a. Improve lifestyle to conform to the physiology of gastrointestinal passage and bowel movement. Increase dietary fiber intake and water intake, and develop good bowel habits. Increase exercise. b. Adjust psychological status to help establish normal defecation reflex. c. Treat primary and concomitant diseases to facilitate the treatment of constipation. d. Avoid medication factors as much as possible to reduce drug-induced constipation. e. Select medication for the pathophysiology leading to constipation and avoid laxative abuse. f. Biofeedback therapy to correct inappropriate and ineffective bowel movements. g. Chinese medicine treatment. (2) After a period of strict non-surgical treatment with no obvious effect, various special examinations showing clear pathological anatomy and conclusive functional abnormal sites, surgical treatment can be considered. The indications for surgery should be carefully grasped, and the corresponding surgical procedure should be selected for the lesion.
8.1 Conservative treatment
(1) Psychotherapy: Psychological problems have long been recognized as part of chronic constipation. Psychotherapy,including cognitive-behavioral therapy, individualized psychotherapy, hypnotherapy and tension-relieving activities, etc. Make patients develop good habits, work and rest moderately, keep cheerful mood, and release anxiety and tension.
(2) The proper and correct view of defecation: According to the previous view, patients are always instructed to get up in the morning to defecate, as a result, many people do not have the intention to defecate but go to wait for the stool, some even squatting in the toilet to read the newspaper, the serious result is to cause increased abdominal pressure, pelvic floor muscle group overstretching, pelvic congestion, etc., accumulation of years will inevitably lead to pelvic floor muscle group relaxation, perineum decline, rectal mucosa and muscle adhesions become relaxed, mucosal prolapse or overlapping internal hemorrhoids, external hemorrhoids, prolapse and so on. The correct defecation habit should be The correct defecation habits should be: casual feeling at any time to defecate change, go with the flow of nature, according to the situation, do not stick to the moment, do not wait not to tolerate.
(3) dietary therapy: increase fiber-containing foods in the diet, such as a variety of vegetables, fruits, coarse grains, grains, drink more water 2000-3000ml. dietary fiber can change the nature of stool and defecation habits, fiber itself is not absorbed, can make the stool swell, stimulate colon dynamics. It is effective for constipated patients with low intake of dietary fiber, but for patients with intestinal obstruction or megacolon and neurological constipation, dietary fiber cannot be increased to achieve the purpose of laxation, and the intestinal contents should be reduced.
8.2 Western medicine treatment: cure constipation laxatives, can be divided into the following categories: a. volumetric laxatives, such as agar; b. softening laxatives, such as docusate or potassium c. lubricating laxatives, such as paraffin; d. salt laxatives, such as sulfates; e. stimulating laxatives, such as phenolphthalein; f. hypertonic laxatives, such as glycerol, lactulose, etc.. The basic effect is to stimulate secretion and reduce absorption, increase the osmotic pressure and hydrostatic pressure in the intestinal cavity, but experts at home and abroad believe that long-term use will undoubtedly produce a series of systemic and gastrointestinal symptoms, and some even cause serious secondary symptoms. Therefore, it should not be used for a long time and should be used under the guidance of a doctor.
8.3 Chinese medicine treatment: Chinese medicine has a history of several thousand years in the treatment of constipation. Chinese medicine to constipation is divided into two categories, deficiency, learning deficiency, Yin deficiency, Yang deficiency, the real are hot knots, wet knots, cold, stagnation, blood stasis, and even mixed deficiency, hot and cold, so the treatment must be based on the person and the time to identify and treat, in order to have a more consolidated effect. Avoid the desire for instant gratification, specializing in pass down, such as some patients think that Chinese medicine is not toxic side effects, long-term use of senna, rhubarb, hemp pill, niuhuang detoxification pill and other capsules to take, not knowing that the next medicine loss of fluid, and bitter cold injury to the spleen and stomach, resulting in the consequences of the more down the more secret. Some patients say, initially with a small amount of laxative can, to later increase the dose is also ineffective, is the reason. Physicians do not understand the principle that laxatives can cause damage to the nerves and muscles of the colon and aggravate constipation, so most physicians treat constipation mainly with laxatives.
8.4 Surgical treatment of functional or dysfunctional constipation.
Surgical treatment indications: (1) History of severe defecation disorders. (2) The long-term conservative treatment is ineffective for at least half a year, and the regular systemic treatment by anorectology is ineffective. (3) The patient himself has a strong demand for surgery on his own initiative.
(1) Proctal protrusion: ① closed suture repair ② incisional repair ③ transvaginal rectal protrusion purse-string suture ④ transvaginal rectal protrusion folding suture ⑤ posterior vaginal wall triangular incisional protrusion repair
(2) treatment of endorectal suture and prolapse: ①multi-row suture fixation ②multi-point adhesive ring ligature method ③sclerotherapy injection fixation method ④mucosal longitudinal suture stack basal sclerotherapy injection
(3) rectus muscle spasm syndrome: ① posterior cut of the puborectalis muscle ② lateral cut of the puborectalis muscle
8.5 Treatment of colonic constipation
Intractable constipation, especially slow-transmission colonic constipation, has been a clinical treatment problem, and its transabdominal surgical treatment began in 1902 and was gradually accepted by clinical surgeons after the 1980s. Indications for surgery: (1) history of severe defecation disorders (2) ineffective after long-term conservative treatment for at least six months and ineffective after regular systemic treatment by anorectal medicine. (3) clear evidence of colonic atelectasis (4) absence of outlet obstructive disease (5) adequate tone of the anal canal (6) absence of diffuse bowel dysmotility symptoms, irritable bowel syndrome (7) a strong demand for surgery initiated by the patient himself.
Total colectomy with ileorectal anastomosis is recognized as the standard procedure for the treatment of intractable colonic constipation. Although total or subtotal colectomy increases the number of bowel movements, there are three problems in the long term: (1) adhesive bowel obstruction (2) diarrhea (3) anal incontinence, and total colectomy for slow-transmission colon constipation.