Overview of constipation
Constipation caused by non-organic factors often manifests as difficulty in defecation, reduced frequency of defecation, hard or dry defecation, often due to poor defecation, dietary habits, lack of exercise, mental factors and changes in lifestyle. Treatment is based on improvement of lifestyle, dietary habits, more exercise, and medication.
Definition
Constipation is defined as a decrease in the frequency of bowel movements, hard, dry stools and difficulty in passing stools.
Among them, reduced frequency of defecation refers to defecation less than 3 times per week, and defecation difficulty refers to feeling laborious, prolonged, a sense of incomplete defecation, and a sense of anal blockage during defecation [1-4].
Constipation is divided into functional constipation, organic constipation and drug-related constipation, and chronic constipation is mostly functional constipation.
Functional constipation belongs to a kind of functional bowel disease, which refers to the constipation caused by weakened peristalsis of the gastrointestinal tract and uncoordinated intestinal motility without abnormalities of the gastrointestinal tract structure and does not meet the diagnostic criteria of constipation-type irritable bowel syndrome.
Typing
According to the pathophysiologic changes of functional constipation, it is divided into the following four types.
Normal Transmission Type
The more common type, which refers to the presence of constipation symptoms when one’s own colonic transport function tests are normal.
Slow transmission type
Generally refers to the presence of delayed transmission in the whole colon or all segments of the colon, mainly due to insufficient colonic propulsive force, reduced colonic dynamics, and reduced colonic propulsive peristaltic contractile activity, which results in prolonged passage of feces through the colon and manifests itself in severe symptoms such as fewer defecations, laborious defecation, and dryness of feces, but there is no defecation coordination disorder.
Defecation disorder type
Defecation obstruction is mainly due to contradictory contraction and incomplete relaxation of the pelvic floor muscle groups, or increased anal resting pressure.
Mixed type
Multiple manifestations of the above types are present.
Morbidity
The prevalence of functional constipation is on the rise with the change of dietary structure, accelerated pace of life and the influence of psychosocial factors.
The prevalence of chronic constipation in adults in China is 4.0% to 10.0% [3].
The prevalence of chronic constipation increases with age, and the prevalence of women is higher than that of men.
Currently, the prevalence of functional constipation in China varies from region to region, and the sampling method and diagnostic criteria applied are not uniform.
Causes
Causes
The causes of functional constipation are not very clear, and are often caused by a combination of factors in daily life, which are categorized into the following two main groups.
Unhealthy living habits
Poor dietary habits
If the amount of food is too small, the intake of fiber foods (vegetables and fruits) is small, the calorie content of food is too high, and the amount of drinking water is small, coupled with irregular diets, it will lead to insufficient stimulation of the gastrointestinal tract, which is easy to cause constipation.
Lack of physical exercise
If there is a lack of exercise, sedentary, bedridden and other bad habits, it will easily lead to weakening of gastrointestinal power, which will easily cause constipation.
Bad defecation habits
Irregular bowel movements, frequent inhibition of normal bowel movements, and inappropriate bowel postures are all likely to cause constipation.
If you often repeatedly inhibit your bowel movement, it will lead to the prolongation of the time for the stool to pass through the intestinal tract, and the sensory function is reduced, etc. [5].
Psychosocial factors
Mental factors
When interpersonal relationships are not handled properly, families are not harmonious, and moods are in a state of long-term depression and mental tension due to various things, all of which may lead to abnormal body nerve function, cause abnormal intestinal peristalsis, and make it easy for functional constipation to occur.
Changes in life rules
Such as illness and hospitalization, travel, overtime work or other emergencies, can lead to changes in bowel patterns.
Predisposing factors
According to current research and epidemiological data, people with the following characteristics are prone to functional constipation:
Elderly people
With age, the glands of the gastrointestinal mucosa shrink, leading to a decrease in fluid secretion, and at the same time, the muscles in the area related to defecation decrease in mobility, which ultimately leads to easy drying of the feces and difficulty in defecation.
Women
Especially during pregnancy or postpartum, women’s mental state is prone to change, which may lead to functional constipation.
Mental and psychological abnormalities
People who have high pressure in study and work and are prone to mental tension are prone to constipation, and people with functional constipation may also suffer from psychological problems such as anxiety and depression, forming a vicious circle [6].
Symptoms
Main Symptoms
Decreased frequency of bowel movements
The number of bowel movements is less than 3 times per week.
Difficulty in defecation
Mainly characterized by the effort and long time to defecate, feeling anal blockage during defecation, and the need to assist defecation with the help of manipulation, such as pressing the abdomen with the hand and removing the feces from the rectum with the fingers.
Some of the symptoms include lack of urge to defecate, wanting to defecate but not being able to do so, and small amount of defecation.
Feeling of incomplete bowel movement
A feeling of incomplete evacuation of feces even after defecation.
Other symptoms
Some may experience lower abdominal pain, bloating, loss of appetite, fatigue, dizziness, anxiety and insomnia.
Sometimes a streaky fecal mass may be felt in the left lower abdomen.
In a few people, anal pain and blood in the stool may be caused by straining to pass hard feces.
Complications
Hemorrhoids
If the feces are very coarse and hard and force is needed to pass them out of the anus, it may increase the pressure on the veins around the anus, which in turn causes the veins in and around the anus to swell and produce hemorrhoids.
Bleeding, itching or pain in the anal area may occur, and these symptoms may occur occasionally or repeatedly.
Anal fissure
When fecal matter is dry and hard and forcefully expelled from the anus, it may result in tearing of the mucous membrane of the anus.
Anal pain is most often present and tends to worsen after defecation. Anal fissures may be accompanied by blood in the stool or blood on toilet paper wipes.
Rectal prolapse
When very dry and hard feces is passed through the anus, part of the rectal mucosa moves down and even protrudes from the anus.
A series of symptoms such as rectal prolapse, mucus stool, constipation, urgency, swelling and pain in the anal area, and fecal incontinence may occur.
Diverticulosis
When trying to pass dry, hard stools with force, the intestinal wall may be damaged, which can cause part of the wall to protrude outward in the form of a sac. When more than one sac is present, it is called diverticulosis, and can occasionally cause bleeding.
Consultation
Department of Medicine
Gastroenterology
If you experience straining to pass stools, changes in the number of bowel movements, or symptoms such as abdominal pain, bloating, or blood in the stools, you should go to the hospital.
Department of Anal and Intestinal Surgery
If symptoms such as bleeding after defecation, perianal pain or distension that worsens after defecation, or rectal prolapse occur, prompt medical attention is recommended.
Psychiatry
If there is a clear mental reason for decreased bowel movements and straining, it is recommended that you consult a psychiatrist along with the gastroenterologist or anorectal surgeon.
Preparation
Preparation for the consultation: registration, preparation of documents, common problems
Tips for medical treatment
Do not drink alcohol or eat too spicy or greasy food before the consultation.
Avoid stressful work before consultation.
Avoid strenuous exercise before the consultation.
Preparation List
Symptom list
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
Is it difficult to have a bowel movement? Is the stool dry and hard?
How many times a week do you have a bowel movement? How long does a bowel movement last?
When did the symptoms start? Are they persistent or occasional?
Was there abdominal pain or vomiting?
Is blood seen on the toilet paper in the bowel movements?
Have you used any medication? What was the effect?
Medical History Checklist
Has there been little consumption of vegetables and fruits, too little water, too little exercise?
Have you been chronically stressed, or in a state of depression?
Do you take any medication?
Checklist
Test results of the last six months, which can be brought to the doctor’s office
Laboratory tests: blood test, fecal test.
Imaging examination: gastrointestinal barium meal contrast examination, colon transport test, fecal imaging, etc.
Endoscopic examination: colonoscopy
List of medication
Medication used in the last 3 months, if available in a box or package, carry it to the doctor’s office
Laxative drugs: lactulose, sorbitol or polyethylene glycol, etc.
Gastrointestinal stimulant medications: Itopride, Mosapride, etc.
Antidepressants: Cloxacillin, Sertraline, Amitriptyline, etc.
Intestinal microbial agents: Bifidobacterium bifidum, Lactobacillus, etc.
Diagnosis
Diagnosis is based on
Medical history
Poor lifestyle habits, seldom eating vegetables and fruits, drinking too little water, exercising too little, poor bowel habits, etc.
Prolonged mental tension, or in a state of depression.
Clinical manifestations
Symptoms
The main manifestations are reduced frequency of defecation, difficulty in defecation and feeling of incomplete defecation.
There may be abdominal distension, loss of appetite, fatigue, dizziness, irritability, anxiety, insomnia and other symptoms.
In a few cases, straining to pass hard stools may cause anal pain and blood in the stool.
Physical signs
In severe cases of constipation, sometimes a stringy fecal mass may be felt in the left lower abdomen.
Laboratory Tests
The purpose of the following tests is to diagnose functional constipation by differentiating it from organic constipation.
Blood tests
Mainly used to detect the presence of infection, anemia, etc.
It helps to rule out constipation due to organic diseases of the colon, rectum and anus.
Stool test
Mainly used to detect the presence of infection, blood in stool, etc.
Imaging
Gastrointestinal barium meal imaging
This test is useful for understanding the function of gastrointestinal motility.
It can detect lesions such as dilatation of the colon and narrowing of the intestinal lumen, which can help in the diagnosis of the cause of constipation.
Colon Transmission Test
This test is useful in evaluating whether constipation is of the slow-transmission type or the defecation-impaired type.
Specific method: Using X-ray impermeable markers, take flat films of the abdomen at regular intervals after oral intake, track and observe the time and location of the markers in the colon, and determine the speed of the markers in the intestines and the site of obstruction.
Defecography
It is helpful in the diagnosis of constipation of defecation obstruction type.
Specific method: barium is poured into the rectum to simulate the process of defecation, and the changes of anus, rectum and pelvic floor during defecation are observed dynamically under X-ray.
Other examinations
Endoscopy
The colonoscopy can directly observe whether there are lesions in the mucosa of the colon and rectum, especially those who have symptoms of blood in stool or anemia and weight loss should do this examination to exclude the possibility of organic lesions.
Anorectal manometry
A manometric device is placed into the rectum, causing the anus to contract and relax, and checking the function and coordination of the internal and external anal sphincters, the pelvic floor, and the rectum. It is helpful to distinguish the type of functional constipation.
Anal electromyography
Utilizing electrophysiological techniques to examine the function of puborectalis and external sphincter among the pelvic floor muscles.
Diagnostic Criteria
Functional constipation is currently diagnosed using the Rome IV criteria [7-9].
Functional constipation is diagnosed when symptoms of constipation began before 6 months, when loose stools rarely occur without laxative use, when 2 or more of the following symptoms have been met in the last 3 months after exclusion of organic diseases of the intestinal tract and systemic body, medications, and other causes of constipation, and when the diagnostic criteria for irritable bowel syndrome have not been met at the same time.
At least 25% of bowel movements feel labored;
A feeling of incomplete bowel movements in at least 25% of cases;
Dry, bulbous or hard stools in at least 25% of bowel movements;
A feeling of anorectal obstruction or blockage in at least 25% of bowel movements;
At least 25% of bowel movements require manual assistance (e.g., finger-assisted defecation, pelvic floor support);
Less than 3 bowel movements per week.
Differential Diagnosis
Constipated irritable bowel syndrome
Similarities: Both present with constipation symptoms such as difficulty in passing stools, dry stools, and decreased frequency of bowel movements.
Differences: Constipation-type irritable bowel syndrome is characterized by recurrent abdominal pain or discomfort, and the abdominal pain is associated with bowel movements and the number of bowel movements.
Colorectal Cancer
Similarities: Both may present with typical constipation symptoms such as decreased bowel movements, difficulty in passing stools, and incomplete bowel movements.
Differences: Colorectal cancer may also be associated with bloody stools, mucus stools, bloating and abdominal pain. Colonoscopy and pathologic examination can confirm the diagnosis.
Tuberculosis
Similarities: Both may present with a change in bowel habit or typical constipation.
Differences: Tuberculosis of the intestines is characterized by general symptoms such as low-grade fever, night sweats, and weight loss, as well as abdominal pain and, in some cases, a mass, mostly located in the lower right abdomen. Tuberculin test is positive.
Pharmacogenetic disease
Similarities: Constipation may occur secondary to long-term or heavy consumption of stimulant laxatives (e.g., rhubarb, senna, etc.); constipation may also occur if narcotics, antidepressants, etc., have been used.
Differences: The history of drug use is usually clear.
Treatment
Treatment Objective:
Avoid recurrent constipation leading to complications such as hemorrhoids, anal fissures, and rectal prolapse.
Relieve symptoms, eliminate concerns and tension, restore normal defecation physiology, and improve quality of life.
Treatment principle: According to the severity, etiology and type of constipation, comprehensive treatment is adopted, including general treatment, medication, biofeedback treatment, and surgical treatment.
General treatment
The symptoms of constipation can be improved by the following measures.
Increase dietary fiber and drink more water appropriately. The recommended amount of dietary fiber for adults is at least 20-30g per day, and consume 1.5-2.0L of fluid per day.
Appropriate activities and exercises, such as jogging, walking, Tai Chi, etc., can help improve gastrointestinal function.
Regular bowel movements help to improve constipation.
Medication
Laxatives
Osmotic laxatives
Suitable for the treatment of mild and moderate constipation.
Commonly used drugs include lactulose, sorbitol, polyethylene glycol, magnesium sulfate and so on.
It can promote the secretion of water and electrolytes, reduce the hardness of feces, increase the volume of feces, thereby promoting intestinal peristalsis, so that feces can be easily discharged.
Precautions for use: overdose can cause electrolyte disorders, the elderly and people with reduced renal function should be used with caution [10].
Volumetric laxatives
Mainly used in the treatment of mild constipation.
Commonly used drugs are Oxytetracycline, methylcellulose and so on.
It can increase the water content of feces and the volume of feces, so that the feces become loose and easy to discharge.
Precautions for the use of medication: attention should be paid to replenish water when using medication to prevent the occurrence of mechanical intestinal obstruction.
Stimulant laxatives
These drugs have strong laxative effect and can be used short-term and intermittently.
Commonly used drugs are bisacodyl and other drugs.
By stimulating the sensory nerve endings in the colonic mucosa, to enhance intestinal peristalsis and intestinal secretion, so that feces can be easily discharged.
Medication precautions: Phenolphthalein has been withdrawn from the market after a possible carcinogenic effect was found in animal studies. Clinical observation of the adverse effects of stimulant laxatives should be continued, with particular attention to the possible intestinal nerve damage and colonic melanosis that may result from long-term application of stimulant laxatives.
Lubricating laxatives
They can be used for people who are old and frail and have difficulty in defecation with hypertension and cardiac insufficiency.
Representative drugs include glycerin and liquid paraffin.
These drugs are taken orally or made into enemas to soften stools by stimulating the intestinal wall, making them easy to pass.
Enema treatment
It is suitable for the temporary use of people with dry feces and fecal impaction.
For people with constipation combined with hemorrhoids, a compound cornsylate preparation can be used.
These medications are administered intra-anally to lubricate and stimulate the intestinal wall, softening the stool and making it easier to pass.
Promoting power medicine
They are effective for slow-transmission constipation and can be used intermittently for a long time.
Commonly used drugs include Itopride and Mosapride.
These drugs stimulate the intestinal nerves to promote gastrointestinal smooth muscle peristalsis.
Microecological preparations
They can be used as adjunctive treatment for chronic constipation in the elderly.
Commonly used drugs are bifidobacteria, lactobacillus, clostridium casei and so on.
Specific mechanism: it can improve the correction of intestinal flora imbalance, promote intestinal peristalsis, which is conducive to relieving the symptoms of constipation.
Antidepressants
Applicable to patients with constipation caused by depression and other mental factors.
Commonly used drugs are tricyclic antidepressants such as chlorhexidine, sertraline, amitriptyline and so on.
Non-drug treatment
Biofeedback therapy
Biofeedback therapy is an effective treatment for constipation caused by pelvic floor muscle dysfunction, and can be used for short-term and long-term treatment of patients with uncoordinated bowel movements. However, it is not yet recommended for people without dysfunctional constipation.
Biofeedback therapy can consistently improve constipation symptoms, psychological status and quality of life, and its efficacy is stable.
Sacral Nerve Stimulation
The efficacy of sacral nerve stimulation in the treatment of functional constipation is controversial, and the European consensus is that the evidence for this treatment for chronic constipation is insufficient and further confirmation is needed.
Fecal bacteria transplantation
Fecal bacteria transplantation therapy is a special microecological treatment method, which not only provides beneficial bacteria, but also helps to build the microecological environment in the intestinal tract, which helps to restore the normal function of the intestinal tract.
It is still in the stage of clinical experimental research, and a large number of tests are needed to verify the clinical effect.
Traditional Chinese Medicine (TCM)
Diagnosis and treatment are the characteristics and advantages of Chinese medicine. The traditional identification and typing treatment is based on the outline of deficiency and reality, which is categorized into heat accumulation and secretion, accumulation and cold, qi stagnation and secretion, blood deficiency and secretion, yin deficiency and yang deficiency and secretion for treatment [2].
Internal treatment with Chinese medicines
Insufficient middle qi type
The symptoms include difficulty in defecation despite the intention to defecate, shortness of breath due to sweating, weakness after defecation, fatigue and tiredness, pale tongue, white moss, and weak pulse.
Medicines that nourish the middle Jiao and elevate Qing and lower turbidity can be used, such as tonifying the middle Jiao and Qi Tang.
Spleen and Kidney Yang Deficiency
Difficulty in defecation, cold pain in the abdomen, lack of warmth in the limbs, long and clear urine, pale tongue, white moss, and weak pulse.
Medicines that warm the spleen and kidney can be used, such as Bowel Movement Capsules and other proprietary Chinese medicines.
Yin deficiency and intestinal dryness type
Dry stools, thirst, dry skin, red tongue and dry moss, weak pulse.
Medicines that nourish yin and moisten the intestines can be used, such as nourishing yin and moistening the intestines orally, Ma Ren soft capsule and so on.
Liver Depression and Fire
The manifestations are dry stool, dizziness, toothache, eye redness, swelling and pain, bitter mouth and tinnitus, distension and pain in both ribs, red tongue, yellow dry moss, and stringy pulse.
Drugs that clear the liver and diarrhea fire can be used, such as Angelica Longhui Capsules.
External enema treatment
Make decoction of raw Atractylodes macrocephala, peach kernel and Cistanchis sinensis, warm it up to 40℃ for enema, and the medicinal liquid can be discharged into the stool after retaining it in the intestinal tract for 20 minutes. It should be used not more than twice a day and not more than 3 days in a row.
Acupuncture treatment
Acupuncture and moxibustion treatment with mostly selected acupoints such as Yu of the large intestine, Tianshu, Yu of the spleen and Sanyinjiao.
Prognosis
Cure
The prognosis of functional constipation is related to whether or not to actively cooperate with the treatment and the severity of the disease.
Most normal-transmission and defecation-disordered constipation types respond well to treatment, while slow-transmission types, especially those with prolonged passage time in the right half of the colon, have poor treatment outcomes.
Most treatments are generally more effective and symptomatic improvement is more pronounced after active psycho-psychotherapy.
Harmfulness
Lack of active treatment may lead to complications such as hemorrhoids, anal fissure, rectal prolapse, etc.
Prolonged constipation can affect mood and even daily life, especially for those with psychiatric disorders, and should be treated actively.
Daily
Daily Management
Dietary management
Eat more fiber-rich foods, such as cereals (e.g. whole grain bread, oatmeal and foods containing bran), legumes (e.g. lentils, black beans, soybeans, etc.), vegetables, fruits, and nuts (e.g. almonds, peanuts, walnuts, etc.). It is recommended that adults should consume 20-30g of dietary fiber per day, which can promote intestinal peristalsis and facilitate bowel movement.
Drink more water, recommended adult water intake 1.5 to 2.0L per day.
Avoid drinking strong alcohol, strong tea, coffee, etc., and avoid eating stimulating foods such as leeks, garlic and chili peppers.
It is recommended to develop the habit of eating regular meals at regular intervals to help improve bowel function.
Life Management
Appropriately increase daily activities and exercise, can be appropriate daily jogging for half an hour or walking for one hour, increase the muscle activity of the intestinal tract, which is conducive to the improvement of gastrointestinal function.
To develop the habit of regular daily defecation, it is recommended to defecate early in the morning or 2 hours after meals, establishing good defecation habits can solve the constipation symptoms of most people.
Psychological support
Learning to deal with interpersonal relationships, improving family atmosphere, and being able to face the pressure of work positively without excessive anxiety to form a good and positive mindset can help improve the symptoms of constipation.
Prevention
Eat foods rich in fiber, drink plenty of water, and strengthen exercise.
Make it a habit to have regular bowel movements, do not suppress the urge to have a bowel movement when traveling or when the rhythm of life changes, and use the toilet to have a bowel movement in time when the urge arises.