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OVERVIEW

Definition

Constipation is a group of clinical symptoms manifested by difficulty in defecation and/or decreased frequency of defecation and dry, hard feces that can be caused by functional disorders, organic disorders, and medications.

Difficulty in defecation includes straining to defecate, difficulty in evacuating, a feeling of anorectal blockage, a feeling of incomplete evacuation, time-consuming defecation, and the need for manipulation to assist defecation [1-4].

Decreased bowel movements are defined as <3 bowel movements per week.

The duration of chronic constipation should be ≥6 months.

Staging and classification

Classification by etiology

Slow-transport constipation: patients have reduced contraction of the colon after eating, which prolongs the transportation of food through the intestine.

Obstructed defecation type constipation: patients experience obstruction of rectal emptying during defecation, which is related to the inability of coordinated movement of abdominal muscles, rectum, pelvic floor muscles, and anal sphincter, ultimately leading to insufficient rectal propulsion and difficulty in defecation.

Normal transmission type constipation: the patient has normal intestinal transportation after eating, and the appearance of constipation is related to mental and psychological factors.

Mixed constipation: patients have both prolonged colonic transport time after eating and rectal emptying disorder [5].

Constipation caused by intestinal diseases such as rectal and anal lesions, or due to extra-intestinal diseases such as neurological and endocrine systems.

Constipation caused by the patient’s use of some medications that cause constipation, such as antidepressants, antiepileptics, antihistamines, and calcium antagonists.

Pathogenesis

Constipation is a common clinical symptom of the digestive system, with the accelerated pace of life, changes in dietary structure and the influence of psychosocial factors, the prevalence of which is currently on the rise.

The prevalence rate of adults in China is 7.0%~20.3%. The prevalence rate of the elderly is 15%-20% [6].

The prevalence is higher in rural areas than in urban areas, and the prevalence in women is higher than in men.

Causes

Causes

Functional diseases

Excluding organic diseases and drug-induced constipation, caused by functional defecation disorders, irritable bowel syndrome and other functional diseases, the etiology of which is still unclear, mostly due to colorectal and anal dysfunction, and may be related to the following factors:

Adverse defecation habits: patients usually have a long time to go to the toilet, defecation attention is not focused, and so on.

Poor dietary habits: patients usually have too little dietary fiber and water intake.

Unhealthy exercise habits: patients sit or lie in bed for a long time due to work or physical reasons, and fail to exercise regularly.

Mental factors: patients usually live a stressful life, mental tension and anxiety can lead to defecation difficulties.

Organic diseases

Diseases of colon and anus: such as inflammatory bowel disease, narrowing of intestinal lumen caused by surgery, trauma or tumor, and anal canal and perianal diseases such as hemorrhoids and anal fissure.

Endocrine and metabolic diseases: such as hypothyroidism, hyperthyroidism, diabetes mellitus, hypokalemia, uremia, etc.

Neurological diseases: such as Parkinson’s disease, multiple sclerosis, cognitive impairment or dementia, autonomic neuropathy, etc.

Muscle diseases: e.g. scleroderma, systemic sclerosis, etc.

Medications

Medications that tend to cause constipation include:

Antihistamines: benadryl, etc.

Antispasmodics: atropine, belladonna, probenecid, etc.

5-hydroxytryptamine receptor antagonists: ondansetron, etc.

Antipsychotics: chlorpromazine, etc.

Antidepressants: amitriptyline, fluoxetine, doxepin, etc.

Analgesics: pethidine, morphine, etc.

Non-steroidal anti-inflammatory drugs: aspirin, acetaminophen, ibuprofen and so on.

Anticonvulsants: carbamazepine, etc.

Calcium antagonists: verapamil, nifedipine, etc.

Diuretics: furosemide, hydrochlorothiazide, etc.

Antiarrhythmic drugs: amiodarone, etc.

Drugs acting centrally: colistin, etc.

Beta-blockers: metoprolol, atenolol, etc.

Bile acid sequestrants: cholestyramine, colestipol, etc.

Antacids: magnesium aluminum carbonate, aluminum thiosulfate, bismuth potassium citrate, etc.

Iron: ferrous sulfate, ferrous succinate, etc.

Chemotherapeutic drugs: vincristine, cyclophosphamide, etc.

Predisposing factors

Inadequate intake of dietary fiber and water by patients.

Usually defecation attention is not focused, defecation time is long, causing hemorrhoids, and then lead to constipation.

Patients’ fast pace of life, high pressure of life, or mental tension due to changes in working and living environments.

Abuse or irrational application of laxatives can lead to intestinal dysfunction and weakened bowel movement, resulting in constipation.

Low weight women are also prone to constipation.

Symptoms

Main Symptoms

Difficulty in defecation

Difficulty in defecation manifests itself in the form of straining to defecate, the feeling that the bowels are not emptied after each bowel movement, a feeling of blockage in the anus, and dry and hard feces, which are not easy to pass, or the need to pick with the hand to assist in defecation.

Decreased frequency of bowel movements

Defecation <3 times per week and prolonged duration of each bowel movement. If the duration of constipation is ≥6 months, it is called chronic constipation.

Other symptoms

Some patients with constipation may experience abdominal distension and abdominal pain due to dry stools that block the intestines.

Chronic constipation can lead to loss of appetite and fatigue, as well as dizziness, irritability, insomnia and anxiety.

Some patients may experience anal pain due to straining to pass a hard fecal mass.

Some patients may palpate a striated mass in the left lower abdomen before defecation.

Complications

Hemorrhoids

Due to the hard and dry feces, constipated patients often force to defecate, which may lead to varicose veins around the patient’s anus and subsequently cause hemorrhoids. There are manifestations such as blood in stool and blood stains on hand paper.

Anal fissure, anal papillitis

Patients with prolonged constipation, so that the fecal discharge is blocked, long stay in the rectum of the feces in the water is sucked dry, fecaliths can be formed, force defecation can lead to anal fissure, anal papillitis, the patient will have a knife-like pain or burning pain dry sensation, defecation after the symptoms can be relieved.

Consultation

Department of Medicine

Gastroenterology

If the patient has difficulty in defecation, dry stools, decreased frequency of defecation, or is accompanied by abdominal distension or abdominal pain, it is recommended that he/she consults the Department of Gastroenterology.

Anorectal Medicine

If the patient has difficulty in defecation with symptoms such as blood in the stool or blood on the tissue, the patient may consult the Department of Anorectal Medicine.

Preparation

Preparation for consultation: registration, preparation of documents, common problems

Tips for Consultation

Before visiting the doctor, you should pay attention to your bowel habit, such as how often, and also the color and nature of the stool.

If accompanied by obvious bloating and abdominal pain, it is recommended to fast temporarily and consult a doctor promptly.

Preparation Checklist

Pay special attention to the time of onset of symptoms, special manifestations, etc.

When did you start to have dry stools and less frequent bowel movements?

Do you usually eat a partial diet? Do you eat vegetables, fruits and coarse grains?

How long does it usually take to go to the toilet? Do you like to play with your cell phone or read a book while going to the toilet?

Do you have abdominal pain? Does the abdominal pain subside after going to the toilet?

Do you have hyperthyroidism, diabetes, cerebral infarction, dementia, etc.?

Any history of inflammatory bowel disease, hemorrhoids, colorectal polyps or colorectal tumors?

Are you taking non-steroidal anti-inflammatory drugs (NSAIDs), antidepressants, or other medications that tend to cause constipation?

Have you suffered from frequent insomnia, irritability and anxiety recently?

Test results in the last six months, which can be brought to the doctor’s office

Endoscopy: Colonoscopy.

Laboratory tests: Stool routine, fecal occult blood, etc.

Medication use in the last 3 months, bring along the box or package if available for medical consultation

Opioids such as morphine, pethidine hydrochloride, codeine, etc.

Antidepressants such as fluoxetine, doxepin, etc.

Antispasmodics such as atropine, belladonna, probenecid, etc.

Calcium antagonists such as nifedipine, amlodipine, etc.

Nonsteroidal anti-inflammatory drugs such as aspirin, acetaminophen, ibuprofen, etc.

Diagnosis

Diagnosis is based on

medical history

The following conditions may be present:

Patient’s usual Patient’s usual low dietary fiber and water intake, prolonged toileting time, inattention during defecation, prolonged sitting or bed rest.

The patient’s usual life is stressful with mental tension and anxiety.

Previously suffered from inflammatory bowel disease, narrowing of the intestinal lumen caused by surgery, trauma or tumor, as well as hemorrhoids, anal fissure and other anal canal and perianal diseases.

Pre-existing hypothyroidism, hyperthyroidism, diabetes mellitus, Parkinson’s disease, dementia, scleroderma, and systemic sclerosis.

Currently taking non-steroidal anti-inflammatory drugs, antidepressants, and other medications that tend to cause constipation.

Clinical manifestations

The patient mainly presents with difficulty in defecation, long time for each defecation, <3 times per week, dry and hard feces.

There may be abdominal pain, loss of appetite, fatigue, anxiety, insomnia and other symptoms.

Some patients may palpate a mass in the left lower abdomen.

Auxiliary examination

For patients >40 years old with blood in stool, lethargy, abdominal pain and abdominal mass, further examination should be performed to clarify the presence of organic disease.

Stool routine can observe the general shape of stool, including its volume, character, color, odor, parasites, etc.

A positive fecal occult blood test suggests that the patient has gastrointestinal bleeding, which may be related to hemorrhoids, anal fissure, or intestinal tumors.

Anorectal fingerprinting can help to understand whether the patient’s anus is narrowed and whether rectal masses and hemorrhoids are present.

Rectal fingerprinting can also help to understand the functional status of the anal sphincter, which can help to diagnose the etiology of constipation in patients.

Abdominal plain film can assist in the diagnosis of constipation and organic constipation caused by intestinal obstruction.

Abdominal plain film shows obvious gas-liquid flatness which supports the diagnosis of intestinal obstruction.

Abdominal plain film can also show well the obvious dilatation of the colon caused by constipation.

Colonoscopy can visually diagnose polyps in the intestinal lumen, colorectal tumors, and other organic lesions that lead to narrowing of the intestinal lumen, and a definitive diagnosis can be obtained when combined with histopathological examination.

Improvement of colonoscopy is required in patients with a previous family history of colorectal tumors, or in patients who have had normal stools in the past and suddenly experience a change in stool character and bowel habit, constipation, or alarming signs such as blood in the stools, emaciation, or anemia.

By taking abdominal plain films after oral administration of X-ray impermeable markers, patients can track and observe the specific trajectory and speed of the markers in the intestinal tract, which helps to assess whether the constipation is of the slow-transmission type, normal-transmission type, or defecation-disordered type of constipation.

During the examination, barium paste is injected into the patient’s rectum to simulate physiological defecation activities, and the functional changes of the anorectum are dynamically observed under X-ray, which helps to diagnose diseases of the rectal-anal area.

The pressure measuring device is placed into the rectum, causing the anus to contract and relax, checking the internal and external anal sphincter, pelvic floor, rectal function and coordination, which can assist in the diagnosis of constipation of the type of dyspareunia.

The water or air bag is placed into the rectum to observe the ability of the anorectum to expel the water or air bag, which can screen for defecation disorder.

A normal person can expel the balloon within 60 seconds.

Diagnostic criteria and grading

Diagnostic criteria

The diagnosis of constipation depends mainly on the symptoms. Anyone who has difficulty in defecation and a reduced number of bowel movements (<3 per week) accompanied by dry, hard feces is diagnosed with constipation.

Note: The number of bowel movements per week is calculated without the use of laxatives.

Functional constipation is currently diagnosed using the Rome IV criteria [7-10].

Functional constipation can be diagnosed when the symptoms of constipation started before 6 months, when loose stools seldom occur without laxatives, when constipation caused by organic diseases of the intestinal tract and the whole body, medications and other reasons are excluded, and when the diagnostic criteria of irritable bowel syndrome are not met, and when the symptoms of the following 2 or more symptoms are met in the last 3 months.

Mild constipation: It does not affect daily life and can be recovered through diet and exercise adjustments and short-term medication.

Moderate constipation: between mild and severe.

Severe constipation: constipation symptoms are heavy and persistent, seriously affecting work and life, and need medication, can not stop medication or medication is ineffective.

Differential Diagnosis

Bowel obstruction

Similarity: Both can have a decrease in the number of bowel movements.

Differences: Patients with intestinal obstruction are often accompanied by vomiting and obvious abdominal pain, and may show signs of bowel hyperphonia. The diagnosis can be further clarified with the improvement of standing abdominal radiographs.

Colon tumor

Similarity: both of them can be palpated in the abdomen, and may present abdominal distension and abdominal pain.

Differences: The symptoms of abdominal distension and abdominal pain in patients with common constipation can be gradually relieved after defecation. In addition to abdominal distension and abdominal pain, patients with colon tumors may also suffer from emaciation and anemia, and abdominal pain and distension may not be relieved after defecation.

Inflammatory bowel disease

Similarity: both may have difficulty in defecation.

Differences: Inflammatory bowel disease includes Crohn’s disease, ulcerative colitis, patients may have constipation and diarrhea alternately, may be accompanied by blood in the stool and weight loss. Diagnosis is usually made by colonoscopy and immunologic tests.

Treatment

Aim of treatment: to relieve symptoms and restore normal intestinal motility and defecation function.

Treatment Principle: Individualized comprehensive treatment based on etiological treatment and symptomatic treatment.

Etiologic treatment

Organic constipation

Laxatives can be used temporarily to relieve constipation symptoms, but long-term use of stimulating laxatives should be avoided.

In the symptomatic treatment, it is necessary to treat the cause of the disease, such as inflammatory bowel disease, surgery, tumors and other causes of intestinal stenosis need timely surgical treatment; diabetic patients should use hypoglycemic drugs to control blood glucose according to the doctor’s instructions.

Constipation caused by drugs

If the constipation symptoms are mild, and cause constipation of the drug is necessary drugs, can be temporarily observed, laxative symptomatic treatment can be.

If the symptoms of constipation are serious, or the symptoms do not improve after using laxatives, the dose of the drug can be reduced or replaced by other drugs as prescribed by the doctor.

General treatment

Reasonable diet: increase fiber (25~35 g/d), drink more water (1.5~2.0 L/d).

Regular exercise: aerobic exercise such as walking and cycling can be chosen to improve constipation. The general recommended amount of exercise is 30~60 minutes per day, at least 2 times per week.

Establish good defecation habits: colon activity is most active in the morning after waking up and after meals, patients are recommended to try to defecate in the morning or within 2 h after meals, and focus on attention during defecation; each bowel movement should not be too long (<10 min/time).

Medication

If there is no significant improvement in the symptoms of constipation after 1-2 months of the above basic treatment, appropriate medication can be used as prescribed by the doctor. Commonly used drugs are as follows:

Volumetric laxatives

By replenishing the water in feces and increasing the volume of feces, they can soften the effect of feces, mainly used for mild constipation.

Commonly used medicines include Oxytetracycline, wheat bran, and polycarbophil calcium.

Drink plenty of water while taking the medicine.

Osmotic laxatives

After applying osmotic laxatives, a hypertonic state will be formed in the intestinal tract, absorbing water, increasing the volume of feces, making feces softer, and stimulating intestinal peristalsis.

Commonly used drugs include polyethylene glycol and lactulose.

Adverse effects such as diarrhea and electrolyte disorders may occur with high doses.

Stimulant laxatives

Stimulant laxatives mainly act on the intestinal nerves, stimulate the secretion of intestinal fluid in the intestinal tract and increase intestinal motility.

Commonly used drugs are bisacodyl, castor oil and so on.

Long-term use of stimulant laxatives can lead to enteric nerve damage. Long-term use of anthraquinone laxatives such as castor oil can lead to colonic melanosis [5].

Prokinetic drugs

Prokinetic drugs increase intestinal motility through the release of neurotransmitters or direct action on smooth muscle, thereby relieving constipation.

Commonly used drugs include prucalopride.

Pro-secretory drugs

By stimulating the secretion of intestinal fluid, it promotes defecation in patients.

Commonly used drugs are linaclotide.

Probiotics and prebiotics

The intestinal microecology of patients with chronic constipation is often imbalanced, i.e. the number of beneficial bacteria such as Bifidobacterium spp. and Lactobacillus spp. decreases, while the number of pathogenic bacteria such as Escherichia coli increases. By supplementing probiotics, intestinal microecology can be regulated and intestinal motility can be promoted.

Commonly used drugs include Bifidobacterium bifidum tetragonum, Bacillus subtilis bifidus, etc [5].

Prebiotics are dietary supplements, non-digestible food components, including various oligosaccharides or oligosaccharides, that improve the health of the host by selectively stimulating the growth and activity of bacteria in one or several colonies, which have a beneficial effect on the host.

Probiotics and prebiotics complement each other and work together.

Enemas and suppositories

Clinically used enemas of corkscrew and glycerin are used in the rectum to lubricate the intestinal wall and soften stools, mostly for temporary use in patients with dry stools.

Traditional Chinese Medicine (TCM)

The diagnosis and treatment of Chinese medicine will improve the symptoms of constipation. Chinese medicines such as proprietary pharmaceutical preparations and soups, as well as manipulative massage and tuina can improve the symptoms of constipation.

Acupuncture and moxibustion of acupoints such as tianshu, zhousanli and shangjiuxu can effectively treat chronic constipation, increase the number of bowel movements, alleviate the state of anxiety and depression, and improve the quality of life of patients [5].

Spiritual and psychological treatment

For patients with constipation accompanied by depression, anxiety and insomnia, professional psychotherapy and cognitive-behavioral therapy need to be actively carried out. Severe cases can be treated with antidepressant and anxiety drugs under the guidance of doctors.

Fecal Transplantation

Fecal bacteria transplantation is to transplant the bacteria in the feces of a healthy person into the gastrointestinal tract of a patient in order to rebuild the intestinal flora with normal function.

In recent years, studies have found that the number of bowel movements increased significantly after patients passed fecal bacteria transplantation, and the symptom relief rate could reach 71.4% at 4 weeks, but only 42.9% at 12 weeks [11].

The treatment of chronic constipation by fecal bacteria transplantation still has many problems to be studied, such as the choice of donor, the transplantation dose, the frequency of transplantation, etc., and due to the risk of transplanting the feces of other people, it is currently limited to research, and has not been routinely used in clinical treatment.

Other treatments

Biofeedback therapy

At present, the main clinical use of abdominal wall electromyography biofeedback and pressure biofeedback, simulating defecation, abdominal wall electrodes and anorectal pressure receptors can sense and display to the patient the state of the abdominal wall, rectal and anal canal muscles exertion, the patient to use this to self-regulate and correct the uncoordinated defecation of the exertion mode, training the patient to coordinate the abdominal and pelvic floor muscles, so as to restore the normal defecation pattern.

Biofeedback is currently recommended as the treatment of choice for patients with functional defecation disorders.

Sacral Nerve Stimulation

Also known as sacral neuromodulation, the 2015 consensus opinion of the American and European Societies of Neurogastroenterology and Dynamics and the 2016 Rome IV criteria, recommend sacral nerve stimulation for refractory constipation that is not responding to conventional medical therapy [12].

Sacral nerve stimulation involves implanting electrodes into patients with constipation, applying an in vitro modulator to test and regulate, and implanting a permanent sacral neuromodulator in patients in whom the treatment is effective (improvement of constipation symptoms of 50% or more after a 2- to 3-week screening period) [13].

Prognosis

Cure

In general, functional constipation is well treated and potentially curable.

Whether or not constipation due to organic disease is cured is related to whether or not the primary disease is formally treated, and the specific efficacy of the treatment.

The prognosis of constipation is related to whether or not the patient’s dietary and living habits are improved, as well as the treatment of the patient’s primary disease. In addition, long-term abuse of stimulant laxatives can also affect the prognosis.

Harmfulness

Patients with constipation can suffer from bloating, poor appetite and bad breath due to poor intestinal motility, which affects the digestive function.

In patients with chronic constipation, excessively dry stools can damage the rectal mucosa when discharged, affecting venous return, which can lead to proctitis, hemorrhoids and other related diseases.

Long-term constipation of the elderly, if the combination of coronary atherosclerotic heart disease, and hypertension, stroke and other cardiovascular diseases, in patients with excessive force defecation, may lead to myocardial infarction, cerebral hemorrhage and other serious consequences.

Daily

Daily Management

Dietary management

Consume more food with high dietary fiber content, such as strawberries, broccoli, green leafy vegetables and other fresh vegetables and fruits.

Avoid eating too little or foods that are too fine.

Consume 1.5 to 2.0 L of water daily.

Life Management

Don’t sit for a long time, and exercise regularly, which can promote intestinal peristalsis.

Patients should avoid taking too long when toileting, avoiding inattention, not playing with cell phone etc. when toileting.

Develop a good habit of regular daily bowel movement.

Psychological management

Patients with constipation should actively relieve anxiety, such as confiding in family members and friends, or actively seeking medical treatment to alleviate constipation symptoms.

Follow-up

Patients with constipation should consult a doctor to identify the cause of the disease, and then treat the cause accordingly. Regular follow-ups should be conducted during and after treatment to observe the progress of the disease, monitor the effect of long-term treatment, and prevent recurrence of the disease.

Prevention

Develop the habit of regular bowel movements.

Consume 1.5~2.0 L of water per day, insist on proper exercise, rationalize work and life, and avoid sedentary lifestyle.

Eat more food with high fiber content, avoid eating too little or too fine food, resulting in weakened stimulation of the colon.

Actively treat primary diseases to avoid constipation.

When traveling or when the rhythm of life changes, do not suppress your desire to go to the toilet, and go to the toilet as soon as you feel the urge to go to the toilet.

Adjust your mental state when negative emotions arise.

Avoid abusing drugs, especially those related to constipation.

Actively treat the primary causes of constipation.