What is chronic constipation? Chronic constipation is a common and complex clinical symptom rather than a disease. It mainly refers to long-term dry stools, difficult or incomplete bowel movements and reduced frequency of bowel movements. Usually food is digested and absorbed by the gastrointestinal tract, and the residue is excreted in 24 to 48 hours. If the interval between bowel movements exceeds 48 hours, it can be considered as constipation. Is chronic constipation common? With the change of people’s diet structure and the influence of psychological and social factors, the incidence of constipation has a tendency to increase. The prevalence of constipation in the population is as high as 27%, but only a small percentage of people with constipation will seek medical attention. Constipation can affect people of all ages. It affects more women than men, and more elderly than young and middle-aged people. Because of the high incidence and complex causes of constipation, patients often experience a lot of distress, and constipation can affect the quality of life when it is severe. What are the dangers of constipation? Because chronic constipation is a more common symptom, symptoms vary in severity, most people often do not pay special attention to constipation is not a disease, do not need treatment, but in fact, constipation is very harmful. 1, chronic constipation in some diseases such as colon cancer, hepatic encephalopathy, breast disease, the occurrence of premature dementia plays an important role, there are many studies in this regard. 2, constipation in acute myocardial infarction, cerebrovascular accident patients can lead to life accidents, there are many tragic cases to alert us. 3, some constipation and anorectal diseases, such as hemorrhoids, anal fissures, etc. have a close relationship. Therefore, early prevention and reasonable treatment of constipation will greatly reduce the serious consequences of constipation, improve the quality of life, and reduce the burden on society and families. What are the causes of chronic constipation? How is it classified? Chronic constipation can be classified into two categories: organic and functional, in terms of etiology. 1, organic causes mainly include: (1) intestinal tube organic lesions: tumor, inflammation or other causes of intestinal lumen narrowing or obstruction. (2) rectal and anal lesions: endorectal prolapse, hemorrhoids, prerectal bulge, puborectal hypertrophy, puborectal separation, pelvic floor disease, etc. (3) Endocrine or metabolic diseases: diabetes mellitus, hypothyroidism, parathyroid disease, etc. (4) Systemic diseases: scleroderma, lupus erythematosus, etc. (5) Neurological disorders: central brain disorders, stroke, multiple sclerosis, spinal cord injury, and peripheral neuropathy, etc. (6) Smooth muscle or neurogenic lesions of the intestinal canal. (7) Neuromuscular lesions of the colon: pseudo-intestinal obstruction, congenital megacolon, megarectum, etc. (8) Neuropsychological disorders. (9) Pharmacologic factors: iron, opioids, antidepressants, antiparkinsonian drugs, calcium channel antagonists, diuretics, and antihistamines. If chronic constipation does not have a clear cause such as the above, it is called chronic functional constipation (CFC). In the population with a history of constipation, functional constipation accounts for about 50%. 2, functional causes mainly include: (1) excessive mental stress. (2) eating less, especially the diet contains too little fiber. (3) or excessive obesity. (4) less exercise. What are the manifestations of chronic constipation? Chronic constipation is often manifested as follows: less bowel movement and less frequent bowel movements; difficult and laborious bowel movements; poor bowel movements; dry and hard stools and a sense of unclean bowel movements; constipation accompanied by abdominal pain or abdominal discomfort. Some patients also have insomnia, irritability, dreaminess, depression, anxiety and other mental and psychological disorders. What are the “alarm” symptoms in patients with constipation? Alarm signs include blood in the stool, anemia, weight loss, fever, dark stools, abdominal pain, and a family history of tumors. If alarm signs appear, you should go to the hospital immediately for further investigation. Which patients with constipation need to undergo colonoscopy? It is generally considered that colonoscopy should be done if any of the following conditions are present: 1. over 50 years of age 2. alarm signs 3. intractable constipation How to diagnose chronic functional constipation? First of all, constipation caused by organic diseases should be clearly excluded. The current diagnostic criteria for chronic functional constipation use the internationally recognized Rome III criteria: 1. 2 or more of the following must be included: (1) at least 25% of bowel movements are strained (2) at least 25% of bowel movements are dry and hard (3) at least 25% of bowel movements have a sense of incompleteness (4) at least 25% of bowel movements have anorectal obstruction/blockage (5) at least 25% of bowel movements require manual assistance (6) at least 25% of bowel movements have a sense of obstruction/blockage (7) at least 25% of bowel movements have a sense of obstruction/blockage (8) at least 25% of bowel movements have a sense of obstruction/blockage (9) at least 25% of bowel movements have a sense of obstruction/blockage (6) Less than 3 bowel movements per week 2. Rarely have loose stools when laxatives are not used 3. Do not meet the diagnostic criteria for irritable bowel syndrome Symptoms have been present for at least 6 months prior to diagnosis, and the above diagnostic criteria have been met in the last 3 months What is refractory constipation? The severity of constipation can be classified as mild, moderate or severe. Mild refers to symptoms that are mild, do not affect life, and can improve with general treatment without medication or with less medication. Severe means that the constipation symptoms persist, the patient is in great pain and life is seriously affected, and the medication cannot be stopped or the treatment is ineffective. Moderate is somewhere in between. So-called refractory constipation is often severe constipation and can be seen in constipation with outlet obstruction, colonic weakness, and irritable bowel syndrome (IBS) with severe constipation. Does constipation require a thorough examination? Not every patient with constipation needs to be examined clinically. It is important to be specific and not to have as many tests as possible. Too many unnecessary tests on patients with constipation can add to the patient’s burden. We are opposed to the “casting a wide net” type of tests that are not targeted to the patient. In the diagnosis and differential diagnosis of chronic constipation, the necessary tests should be performed according to clinical needs. First of all, attention should be paid to the presence of alarm symptoms and evidence of other organic pathologies; colonoscopy should be performed in patients over 50 years of age with a history of chronic constipation and worsening symptoms within a short period of time to exclude the possibility of colorectal tumors; for long-term laxative abuse, colonoscopy can determine the presence of laxative colon or (and) colonic melanosis; barium enema angiography can help in the diagnosis of congenital megacolon. If OOC is suspected, anal examination and fecography are necessary. Special tests include: gastrointestinal passage test (GITT), rectal and anal manometry (ARM), recto-anal reflex, tolerance sensitivity test, balloon expulsion test (BET), pelvic floor electromyography, pubic nerve latency test and anal canal ultrasonography, etc. These tests are only chosen for refractory constipation. What are the common tests for refractory constipation? 1.Fecal routine and occult blood. 2. Biochemical and metabolic tests. 3.Anorectal finger examination, which can understand the presence of masses and the function of the anal sphincter. 4.Colonoscopy or barium enema can help to determine the presence of organic etiology. 5.Gastrointestinal transmission test (GITT) is helpful to determine the presence or absence of slow transmission, and is often taken at 48h and 72h. 6.Fecal imaging can dynamically observe the anatomical and functional changes of anorectum. 7.Anorectal manometry can check the anorectal function for any obstruction. 8.24h colonic pressure monitoring has certain guiding significance on whether to operate. If there is a lack of specific propulsive contraction wave (SPPW) and a lack of response of the colon to waking up and eating, it indicates colonic weakness and can be considered for surgical resection. 9.Anal manometry combined with ultrasound endoscopy can show whether there is a mechanical deficiency and anatomical deficiency of the anal sphincter, which can provide clues for surgery. 10.The application of perineal nerve latency or electromyography can distinguish whether constipation is myogenic or neurogenic. How to treat and prevent constipation? 1.Analyze the causes of constipation and adjust the lifestyle. Develop the habit of regular bowel movement; quit smoking and alcohol; avoid abusing drugs. 2.Promote a balanced diet, increase dietary fiber in appropriate amounts, and drink more water. (1) High-fiber diet: dietary fiber itself is not absorbed, and can absorb water in the intestinal cavity to increase stool volume, stimulate the colon and enhance power. Dietary fiber-rich foods include bran or brown rice, vegetables, pectin-rich fruits such as mangoes, bananas, etc. (Note: unripe fruits contain tannic acid, which can aggravate constipation). (2) Hydrate: drink more water and beverages to keep the intestinal tract adequately hydrated to facilitate fecal discharge. (3) supply sufficient B vitamins: with B vitamin-rich food, can promote the secretion of digestive juices, maintain and promote intestinal peristalsis, conducive to bowel movements. Such as coarse grains, yeast, beans and their products, etc. In vegetables, spinach, cabbage, which contains a large amount of folic acid, has a good laxative effect. (4) Increase easy gas-producing foods: eat more easy gas-producing foods to promote faster intestinal peristalsis and favorable defecation; such as onions, radishes, garlic, etc. (5) increase the supply of fat: appropriate to increase the high-fat food, vegetable oil can directly laxative, and decomposition products fatty acids have stimulated intestinal peristalsis. Seed kernels of dried fruits (such as walnuts, pine nuts, a variety of melon seeds, almonds, peach kernels, etc.), containing a large amount of oil, has the role of lubricating the intestinal tract, laxative. 3, moderate exercise medical gymnastics as the main, can be combined with walking, jogging and abdominal self-massage. (1) medical gymnastics: mainly to enhance the strength of the abdominal muscles and pelvic muscles. Exercise method: standing position can do in situ high leg walk, deep squatting, abdominal back exercise, kicking exercise and turning exercise. Supine position, you can take turns lifting a leg or lifting both legs at the same time, lift to 40 °, a short pause and then put down. Take turns flexing and extending both legs to imitate the bicycle movement. Raise both legs in a circle from the inside to the outside and sit-ups, etc. (2) fast walking and jogging can promote intestinal peristalsis: help lift constipation. (3) deep and long abdominal breathing: when breathing, the amplitude of diaphragm activity increases compared with usual, which can promote gastrointestinal motility. (4) abdominal self-massage: lie on your back in bed, bend your knees, rub your hands together, put your left hand flat on your navel, put your right hand on the back of your left hand, take your navel as the center, and press clockwise. Do it 2 to 3 times a day, 5 to 10 minutes each time. 4.Apparatus aid, if the stool is hard and stagnant in the rectum near the anal opening or if the patient is old and frail, poor defecation power or lack of, the method of colon hydrotherapy or cleansing enema can be used. 5, drug treatment (1) pro-dynamic agent: Moxaburi has a pro-gastrointestinal dynamic effect. (2) laxatives ① volumetric laxatives: magnesium sulfate, sodium sulfate, methylcellulose, agar, etc.; ② stimulant laxatives: senna, castor oil, diethylstilbestrol, etc.; ③ stool softeners: liquid paraffin, lactulose, etc.; ④ rectal administration: glycerin suppositories, cecropia, etc. 6, biofeedback therapy may be effective for some constipation with rectoanal and pelvic floor muscle dysfunction. Biofeedback therapy is the use of specialized equipment, the collection of their own physiological activities, information processing, amplification, with familiar visual or auditory signal display, so that the cerebral cortex and these organs to establish feedback links, through continuous positive and negative attempts to learn to control physiological activities at will, the deviation from the normal range of physiological activities to correct, so that the patient to achieve the “change self The purpose of “change self”. 7, cognitive therapy Patients with severe constipation often have anxiety or even depression and other psychological factors or disorders, should be cognitive therapy, so that patients eliminate tension, if necessary, to give antidepressant, anti-anxiety treatment. 8, surgical treatment for severe intractable constipation the above treatment is ineffective, if the colon transmission dysfunction type chronic constipation, serious condition can be considered for surgery, but the long-term effect of surgery is still controversial, case selection must be careful. What is colonic melanosis? Colonic melanosis is caused by apoptosis of colonic epithelial cells and hyperpigmentation of macrophages due to long-term use of anthraquinone laxatives, resulting in a colonic mucosa covered with brownish spots, which appears as leopard skin-like changes on colonoscopy. Colonic melanosis is generally considered harmless and reversible. Most disappear after 6 months of discontinuation of anthraquinone-based laxatives. What should I do if I had normal stools in the past and have recently become constipated frequently? 1. If this condition occurs in middle-aged and elderly people, first of all, we should be alert to colon tumors, pay attention to whether there is blood in the stool, whether there is deformation of stool, whether there is wasting and weakness, etc. You should see a doctor immediately and do fecal occult blood test repeatedly. If necessary, do colonoscopy. 2.If there is a recent change in lifestyle, excessive fatigue or mental depression, and low food intake, you can first pay attention to rest, focus on diet regulation, eat more high fiber and laxative foods, and drink more water. 3, if the recent emergence of hemorrhoids and anal fissure, constipation can also occur due to the suppression of normal bowel movements. You should treat hemorrhoids first, and if they do not improve, you should consult a doctor and have a colonoscopy. 4, if recently taking certain drugs, including sedatives such as Valium, Librium, etc.; analgesics such as morphine; antacids such as aluminum hydroxide; antispasmodics such as 652-2, atropine, etc.; and iron, antidepressants, anti-Parkinson’s disease drugs, calcium channel antagonists, diuretics, and antihistamines. You can stop the medication first and observe whether it can be corrected, if not, you should seek medical attention. Why do constipated patients have diarrhea? The consistency of stool is related to its water content. If the intestinal tract moves too fast, the water in the intestinal contents will not be absorbed in time, and the stool will become thin. Patients with constipation often have diarrhea after taking laxatives. Then there are a few exit obstruction type constipation, its clinical manifestations have similar to “enteritis” symptoms, diarrhea, incontinence complaints, doctors often mistakenly treat constipation as “enteritis”, anti-diarrheal treatment. Therefore, anorectal examination of patients with constipation is very necessary. Is it possible to use stimulant laxatives for a long time? Laxatives are an important tool in the treatment of functional constipation. However, long-term use of stimulant laxatives is inappropriate and can result in laxative colonization, or (and) colonic melanosis, which manifests as damage to the submucosal neurons of the intestine and the intestinal musculature, severely impaired peristaltic capacity of the intestine, tubular dilatation of the intestine, and loss of the colonic pouch. For patients with slow-transmission constipation whose gastrointestinal passage time is significantly slowed down, it is better to use some prokinetic drugs first, which can help defecation. If the effect is not good, laxatives should be applied appropriately. Nowadays, volumetric or osmotic laxatives are mostly used. Such as polyethylene glycol 24000 (Fosone) or lactulose (Dulcol). It is not advisable to use one laxative for a long time. If it is necessary, it is recommended to alternate different drugs to avoid adverse reactions and dependence on one drug. Can surgical removal of part of the colon prevent constipation? Patients often suffer from constipation and require surgical removal of part of the colon to treat constipation. However, the results of surgery vary. There are mixed opinions on the efficacy of surgical treatment of constipation, as well as on the timing and indications for surgery. The basic consensus is that surgery can be performed with satisfactory results if there is little success after strict non-surgical treatment, including psychological treatment, and if various special tests show a clear pathological anatomy and conclusive functional abnormalities. Indications for surgical procedures include secondary megacolon, partial colonic redundancy, colonic weakness, severe anterior rectal distention, endorectal loops, and endorectal mucosal prolapse.