I. Background of the proposed diagnosis and treatment guidelines (a) Concept and etiology Chronic constipation mainly refers to dry feces, difficult or incomplete defecation, and a decrease in the frequency of defecation. Constipation is a common condition caused by a variety of causes, such as gastrointestinal diseases, systemic diseases involving the digestive tract, and many medications can also cause constipation. The Rome II criteria for functional gastrointestinal disorders (FGID) and chronic constipation include functional constipation, pelvic floor defecation disorder and constipated irritable bowel syndrome (IBS). Among them, functional constipation needs to be excluded from organic etiology as well as pharmacologic factors; while pelvic floor defecation disorder needs to have an objective basis for pelvic floor defecation disorder in addition to meeting the diagnostic criteria for functional constipation. Constipation in constipated IBS is associated with abdominal pain or bloating. Constipation associated with gastrointestinal dyskinesia includes Ogilvie syndrome (megacolon disease), congenital megacolon, slow-transmitting constipation (M/N lesion), and anal sphincter dyssynergia (Anismus). (II) Importance of developing diagnostic and treatment guidelines With the change of dietary structure, mental psychological and social factors, the incidence of constipation is gradually increasing, which seriously affects people’s quality of life. Surveys in Beijing, Tianjin and Xi’an on people over 60 years of age show that chronic constipation is as high as 15% to 20%. A randomized, stratified and graded survey of adults aged 18 to 70 in Beijing showed that the incidence of chronic constipation was 6.07%, and the incidence rate of women was more than four times that of men, and psychiatric factors were one of the high-risk factors. Chronic constipation in colon cancer, hepatic encephalopathy, breast disease, progeria and other diseases may have an important role in the occurrence of dementia; acute myocardial infarction, cerebrovascular accidents and other diseases of constipation can even lead to life accidents; part of the constipation and anorectal diseases, such as internal hemorrhoids, fissures and other close relationship. At the same time, the abuse of laxatives causes many adverse reactions, increasing medical costs and wasting medical resources. Therefore, the prevention and timely and reasonable treatment of constipation, the development of constipation suitable for China’s diagnosis and treatment process is very necessary. 2002 China’s chronic constipation forum launched the diagnosis and treatment process (draft), the Chinese Medical Association Division of Gastroenterological Diseases continue to widely consult the views of the constipation Symposium (Nanchang) in September 2003 on the constipation diagnosis and treatment of constipation guidelines once again for serious discussion, initially reached a consensus. Second, the diagnosis and treatment process of the idea and basis (a) diagnostic points of the diagnosis of chronic constipation should include constipation causes (and triggers), degree and type. If we can understand and constipation related to the scope of involvement (colon, anorectal or accompanying upper gastrointestinal tract), the affected tissues (myopathy or neuropathy), the presence of local structural abnormalities and their cause and effect relationship with constipation, it is very useful for the development of treatment plans and predict the efficacy of treatment. The severity of constipation can be categorized as mild, moderate, or severe. Mild means that the symptoms are mild, do not affect life, can be improved by general treatment, and do not require medication or less medication. Severe means that the constipation symptoms persist, the patient is unusually painful, seriously affects the life, can not stop the medicine or treatment is ineffective. Moderate is given between the two. The so-called refractory constipation is often severe constipation, which can be seen in outlet obstruction type of constipation, colonic weakness, and severe constipation type of IBS. The two basic types of chronic constipation are slow-transmitting and outlet-obstructing, or mixed if both are present. (History can provide important information, such as the characteristics of constipation (frequency of bowel movements, urge to pass stool, difficulty in defecation, and fecal character, etc.), accompanying gastrointestinal symptoms, underlying diseases, and medication factors. The four common manifestations of chronic constipation are: (1) fewer bowel movements and fewer frequency of bowel movements; (2) difficult and laborious bowel movements; (3) irregular bowel movements; and (4) constipation accompanied by abdominal pain or abdominal discomfort. The above categories can be seen in both the slow transmission type, can also be seen in the exit obstruction type constipation, need to be carefully differentiated, can help guide the treatment. Attention should be paid to alarm signs such as blood in the stool, abdominal mass, etc., as well as family history of tumor and psychosocial factors. For patients with constipation who are suspected of having anorectal disease, anorectal fingerprinting should be performed to help understand the presence of rectal masses, fecal storage, and sphincter function. Fecal examination and occult blood test should be listed as routine examination. Relevant biochemical tests are performed when necessary. Colonoscopy or imaging can help determine the presence of an organic cause. A simple method to determine the type of constipation is gastrointestinal transmission test, it is recommended to take 1 abdominal film 48h after taking 20 impermeable X-ray markers (when normal, most markers have reached the rectum or have been discharged), and if necessary, take another abdominal film 72h to observe the distribution of the markers is very helpful in determining the presence of slow-transmission type of constipation. Anorectal manometry can check whether there is any dysfunction of the anorectal function, such as the paradoxical contraction of the external anal sphincter during forceful defecation, the lack of anorectal inhibitory reflexes after rectal balloon inflation, and the abnormal sensory threshold of the rectal wall, etc. The anorectal discharge test reflects the anorectal function of the anorectal wall. The balloon expulsion test reflects the anorectal ability to expel the balloon, although the significance of expulsion of the balloon and hard feces is not yet fully consistent. Some refractory constipation, such as the lack of specific propulsive contraction waves on 24-h colonic pressure monitoring and the lack of colonic response to awakening from sleep and meals, is helpful in the diagnosis of colonic incompetence. In addition, defecography provides dynamic visualization of anatomical and functional changes in the anorectum. Anal manometry combined with ultrasound endoscopy can show the presence of biomechanical defects and anatomical abnormalities of the anal sphincter, both of which provide clues for surgical localization. Application of perineural nerve latency or electromyography can distinguish whether constipation is myogenic or neurogenic. Patients with significant anxiety and depression should be investigated and the causal relationship with constipation should be determined. (Patients with chronic constipation should receive comprehensive treatment to restore defecation physiology. Emphasis on general treatment, strengthen the education of defecation physiology and intestinal management, adopt reasonable dietary habits, such as increasing the content of dietary fiber, increase the amount of water to enhance the stimulation of the colon, and develop good defecation habits, avoiding forceful defecation, and should increase the activities at the same time. Treatment should pay attention to remove the excessive accumulation of feces in the distal rectum; need to actively adjust the mind, which are extremely important to obtain effective treatment. In the choice of laxatives, attention should be paid to the efficacy, safety and drug dependence. Advocating the use of bulking agents (such as wheat bran, Ocimum basilicum, etc.) and osmotic laxatives (such as polyethylene glycol 4000, lactulose). For slow-transmission constipation, intestinal prokinetic agents can be added if necessary. Long-term application or abuse of stimulating laxatives should be avoided. A variety of proprietary Chinese medicines have laxative effects, and attention should be paid to the composition of the adult medicines, especially the possible side effects of long-term use. For patients with fecal impaction, clean enema or combined with short-term use of stimulant laxatives to release the impaction, and then use bulking agents or osmotic drugs to maintain bowel movement. Kesselol and glycerin suppositories have the effect of softening feces and stimulating defecation. If internal hemorrhoids combined with constipation, can be used to compound coriander acid ester suppositories. For patients with outlet obstruction type constipation and contradictory sphincter contraction during defecation, biofeedback therapy can be adopted to coordinate the activities of abdominal and pelvic floor muscles during defecation; and for patients with abnormal bowel thresholds, emphasis should be placed on reconstruction of defecation reflexes and adjusting the training of bowel movement perception. For patients with severe constipation, the positive effect of psychotherapy should be emphasized. Surgery should strictly grasp the indications, the surgical efficacy needs to be predicted. For patients with chronic constipation, it is necessary to analyze the causes of constipation, triggers, types of constipation and severity, and it is recommended to make a hierarchical, graded three-level diagnosis and treatment triage. The first level of diagnosis and treatment triage: applicable to most of the light, moderate chronic constipation patients. First of all, we should get a detailed history, physical examination, anorectal fingerprinting if necessary, and routine fecal examination (including occult blood test), in order to decide to take empirical treatment or further examination. If the patient has alarm signs, suspected organic pathology, especially rectal and colonic neoplasia, and at the same time for excessive stress and anxiety and over 40 years old, further examination, including biochemistry, imaging and/or colonoscopy to clarify the cause of the disease, and be treated accordingly. Otherwise, empirical treatment is available and is based on the characteristics of constipation and is carried out over a period of 2 to 4 weeks, emphasizing general and etiological treatment and the use of bulking agents or osmotic laxatives. If treatment is ineffective, increase the dose or use a combination of drugs if necessary; if fecal impaction, it is advisable to pay attention to the removal of fecal impaction in the rectum. The second level of diagnosis and treatment triage: the main object is after further examination did not find organic disease patients and after the experience of treatment is ineffective, can be carried out gastrointestinal transmission test and (or) anorectal manometry, to determine the type of constipation and then further treatment, for the exit of obstructive constipation patients, the choice of biofeedback therapy and strengthen the psychological cognitive therapy. The third level of diagnosis and treatment grading: The main target is those patients who are not effective in the second level of diagnosis and treatment triage. Chronic constipation should be reassessed and diagnosed, paying attention to whether there are special causes of constipation, especially the colon or anorectal structural abnormalities that are closely related to constipation, whether there are mental and psychological problems, whether there are unreasonable treatments, and whether unreasonable lifestyles have been changed, etc., and carrying out qualitative and localized diagnosis. Most of these patients are patients with persistent constipation who have had unsatisfactory results after a variety of treatments. Further arrangement of special examination or even a multidisciplinary consultation including psychological discipline is needed in order to decide a reasonable treatment plan. Clinically, patients can be selected to enter the above triage program according to their condition and treatment history. For example, patients with severe constipation, who do not need to receive empirical treatment, can enter the second or third level of diagnostic procedures at the beginning. In the first level of diagnosis and treatment triage, those patients who are ineffective or ineffective after empirical treatment can enter into further examination; similarly, for those who are shown to have organic diseases after further examination, in addition to the treatment of the cause of the disease, according to the characteristics of the constipation, empirical treatment can also be given or enter into the second level of the diagnostic and treatment triage program to determine the type of constipation. The above graded diagnosis and treatment of chronic constipation will reduce unnecessary investigations and treatment costs, but its feasibility and cost-benefit ratio need to be further supported by evidence-based medicine.