Constipation is a common condition caused by a variety of etiologies. Patients often have dry stools, difficulty in defecation or a sense of incompleteness, and a significant decrease in the number of complete evacuation of stools when no laxative is used.
With the change of diet structure and the influence of psychological and social factors, constipation has seriously affected the quality of life of modern people; and has an important role in the occurrence of colon cancer, hepatic encephalopathy, breast disease, progeria and other diseases; in acute myocardial infarction, cerebrovascular accidents and other diseases constipation can lead to life accidents; some constipation and anal diseases, such as hemorrhoids, anal fissure, etc. are closely related. Therefore, early prevention and reasonable treatment of constipation, will greatly reduce the serious consequences of constipation and social burden.
A. Etiology of constipation, evaluation of examination methods and diagnosis and treatment
The defecation habit of healthy people is 1-2 times a day or 1-2 days a defecation, the stool is mostly formed or soft stool, a few healthy people can defecate up to 3 times / day, or 3 days a time. The stools are semi-formed or hard and bologna-like. Normal defecation requires the intestinal contents to pass through the segments at normal speed, to reach the rectum in time, and to stimulate the rectum-anus, causing the defecation reflex, and the coordinated activity of the pelvic floor muscles during defecation to complete defecation. Failure of any of the above links may cause constipation. Therefore, patients with constipation should understand the links, mechanisms and related etiology and triggers that cause defecation failure, in order to develop a reasonable treatment plan.
(A) Etiology of chronic constipation
Chronic constipation has functional and organic causes. Organic causes can be caused by gastrointestinal diseases, systemic diseases involving the digestive tract such as diabetes, scleroderma, neurological diseases, etc. Many drugs can cause constipation, as follows: organic lesions of the intestinal canal such as tumors, inflammation or other causes of intestinal lumen narrowing or obstruction.
1, rectal and anal lesions: endorectal prolapse, hemorrhoid disease, anterior rectal distension, puborectal muscle hypertrophy, puborectal separation, pelvic floor disease, etc.
2, endocrine or metabolic diseases: such as diabetic enteropathy, hypothyroidism, parathyroid disease, etc.
3, neurological disorders: such as central brain disorders, stroke, multiple sclerosis, spinal cord injury and peripheral neuropathy
4, Intestinal smooth muscle or neuronal lesions.
5, colonic neuromuscular lesions: pseudo-intestinal obstruction, congenital megacolon, megarectum, etc.
6.Spiritual and psychological disorders.
7, pharmacological factors: aluminum antacids, iron, opioids, antidepressants, anti-Parkinson’s disease drugs, calcium channel antagonists, diuretics and antihistamines, etc.
(B) Examination methods and assessment of chronic constipation
The diagnosis of chronic constipation includes medical history, physical examination, relevant laboratory tests, imaging tests and special examination methods.
History: A detailed history, including symptoms and course of constipation, gastrointestinal symptoms, concomitant symptoms and diseases, and medication use often provides important information.
Note
1. the presence of alarm symptoms (e.g., blood in stool, anemia, wasting, fever, black stool, abdominal pain, etc.).
2. Characteristics of constipation symptoms (frequency of stools, bowel movements, whether they are difficult or uncontrolled, and stool properties).
3.Concomitant gastrointestinal symptoms.
4. Medical history related to the cause, such as abnormal intestinal anatomy or systemic diseases, and constipation caused by drug factors.
5. Spiritual and psychological status and social factors.
General examination methods.
1, anorectal finger examination can often help to understand fecal impaction, anal stenosis, hemorrhoid disease or rectal prolapse, rectal masses, etc., and also to understand the functional status of the anal sphincter.
2. Routine blood, stool and fecal occult blood tests are important and easy routines to rule out organic lesions of the colon, rectum and anus. If necessary, biochemical and metabolic tests should be performed.
3, for suspected anal and rectal lesions, proctoscopy or sigmoidoscopy/colonoscopy, or barium enema can directly observe the intestine or show imaging information.
Special examination methods: For patients with chronic constipation, the following tests can be selected as appropriate.
1, gastrointestinal passage test: commonly used impermeable X-ray markers, swallowed with a test meal containing 20 markers at breakfast, after a certain time interval (for example, 24h, 48h, 72h after taking the markers) to take an abdominal film, calculate the rate of expulsion. Under normal circumstances, most of the markers were excreted by 48-72 h after taking the markers. According to the distribution of the markers on the abdominal film, it can help to assess whether the constipation is slow transmission type or outlet obstruction type, which is a simple and feasible method.
2, anorectal manometry: commonly used perfusion manometry (the same as esophageal manometry), respectively, to detect the resting pressure of the anal sphincter, the systolic pressure of the external anal sphincter and the relaxation pressure during force discharge, the presence or absence of anorectal inhibition reflex after rectal gas injection, and can also determine the perceptual function of the rectum and the compliance of the rectal wall. It helps to assess whether the anal sphincter and rectum have power and sensory dysfunction.
3.Colonic pressure monitoring:The sensor is placed into the colon and the change in colonic pressure is monitored continuously for 24-48h under relatively physiological conditions. It is meaningful to determine the presence or absence of colonic weakness and has guiding significance for treatment.
4. Balloon expulsion test: A balloon is placed in the rectum, inflated or filled with water, and the subject is made to expel it. It can be used as a screening test for the presence of expulsion disorders, and further examination is required for positive patients.
5.Fecal imaging: simulated stool is instilled into the rectum, and the functional changes of the anus and rectum during defecation are dynamically observed under radiation, which can be used to understand whether the patient has concomitant anatomical abnormalities, such as anterior rectal distension and intestinal overturning.
6.Other: such as pelvic floor electromyography, which can help clarify whether the lesion is myogenic. Pubic nerve latency measurement can show the presence of nerve conduction abnormalities. Anal ultrasound endoscopy can understand whether there are defects in the anal sphincter, etc.
(iii) Diagnosis of chronic constipation
The diagnosis of chronic constipation should include: the cause (and triggers) of constipation, the degree, and the type of constipation. If the extent of constipation-related involvement (colon, anorectum, or upper gastrointestinal tract), the involved tissues (myopathy or neuropathy), the presence of local structural abnormalities, and their causal relationship with constipation can be understood. This is very useful in formulating treatment and predicting outcome. The severity of chronic constipation and the type of constipation are described below.
Severity of chronic constipation: Constipation can be classified as mild, moderate or severe. Mild refers to mild symptoms, does not affect life, can be improved by general treatment, no medication or less medication. Severe refers to constipation symptoms persist, the patient is unusually painful, seriously affects life, can not stop medication or treatment is ineffective. Moderate is in between. So-called refractory constipation is often severe constipation, which can be seen in outlet obstruction constipation, colonic weakness and severe constipation-type irritable bowel syndrome (IBS).
The types of chronic constipation: divided into slow transmission type, outlet obstruction type and mixed type. constipation type of IBS is a type of constipation related to abdominal pain or bloating, at the same time, may also have the characteristics of each of the following types.
1, slow transmission type constipation has the following manifestations.
(1) There is often a decrease in the number of bowel movements, less bowel movements, hard stool, and thus difficulty in defecation.
(2) anorectal finger examination without feces or hard feces palpable, while the external anal sphincter contraction and force discharge function is normal.
(3) Prolonged total gastrointestinal or colonic passage time.
(4) Lack of evidence of outlet obstruction type constipation, such as normal balloon expulsion test, anorectal manometry shows normal.
2, outlet obstruction type constipation, may have the following manifestations.
(1) straining to defecate, feeling of incompleteness or falling, low defecation volume, bowel movement or lack of bowel movement.
(2) There is a lot of mud-like stool in the rectum during anorectal examination, and the external anal sphincter is paradoxically contracted during forceful defecation.
(3) Total gastrointestinal or colonic passage time shows normal, and most markers can be retained in the rectum.
(4) Anorectal manometry shows paradoxical contraction of the external anal sphincter during forceful evacuation or abnormal sensory threshold of the rectal wall.
3, mixed constipation: with the characteristics of 1 and 2 above.
The above three categories are suitable for the type of functional constipation, but also for chronic constipation caused by other etiologies. For example, diabetes mellitus, scleroderma combined constipation and drug-induced constipation are mostly slow transmission type constipation. Irritable bowel syndrome constipation type is characterized by a low number of bowel movements, defecation is often difficult, abdominal pain or bloating after defecation and exhaustion is slow, there may be export dysfunction combined with slow passage type constipation, if it can be combined with the relevant functional examination, the clinical type can be further confirmed.
(D) Treatment of chronic constipation
The treatment principle is to carry out comprehensive treatment according to the severity, etiology and type of constipation, to restore normal defecation habits and defecation physiology.
1, general treatment: strengthen the physiological education of defecation, establish reasonable dietary habits (such as increasing dietary fiber content, increasing water intake) and adhere to good defecation habits, and at the same time should increase activity.
2.Medication: choose appropriate laxative drugs. The choice of drugs should be less toxic, side effects and drug dependence as the principle, often selected such as bulking agents (such as wheat bran, O Che Qian, etc.) and osmotic laxative (such as Fosone, lactulose). Randomized controlled observation of the application of Fosone in the treatment of functional constipation showed that it was effective in increasing the number of bowel movements and improving stool properties. For slow-transmission constipation, prokinetic agents such as cisapride or mosapride can be added.
It should be noted that for patients with chronic constipation, long-term application or abuse of stimulant laxatives should be avoided. A variety of proprietary Chinese medicines have laxative effects, but it should be noted that when taking proprietary Chinese medicines for chronic constipation over a long period of time, attention should be paid to the ingredients within them and their side effects. For patients with fecal impaction, clean enema once or combine with short-term use of stimulant laxatives to release the impaction. After decongestion, use bulking agents or osmotic drugs to keep the bowel movement open. Curettage and glycerin suppositories have the effect of softening stool and stimulating defecation. Compound carrageenan can be effective in the treatment of constipation of hemorrhoidal origin.
3, psychotherapy and biofeedback: moderate and severe constipation patients often have anxiety and even depression and other psychological factors or disorders, should be cognitive therapy, so that patients eliminate tension. Biofeedback therapy is applicable to functional outlet obstruction type constipation.
4.Surgical treatment: If the results are not very effective after strict non-surgical treatment, and various special examinations show that there is a clear pathological anatomy and a conclusive functional abnormal site, surgical treatment can be considered. Indications for surgical procedures include secondary megacolon, partial colonic redundancy, colonic weakness, severe anterior rectal distension, endorectal overlap, and intra-rectal mucosal prolapse. However, attention should be paid to the presence of serious psychological disorders, the presence of abnormalities in the digestive tract other than the colon, and the need for preoperative prediction of efficacy.
5, Chinese medicine treatment, can be divided into hot constipation, cold constipation, qi deficiency, blood deficiency, yin deficiency and other types, the application of Chinese medicine symptomatic treatment also has a very good effect.
Second, our constipation process and its principles
Constipation has degree, type, and etiology and causative factors, therefore, patients with constipation need to be treated in a graded and stratified way, so that the consultation and treatment process is conducive to active and effective consultation and treatment of patients, and produces a reasonable cost-effectiveness ratio.
(A) Treatment flow
Clinically, in order to achieve effective stratified (alarm or not) and graded (degree) triage for patients with constipation, it is necessary to assess the cause and trigger of constipation, the type and degree of constipation. For most patients, a detailed history and physical examination will provide insight into the cause and type of constipation, and empirical treatment; in cases of constipation with alarm signs or suspected organic disease, further examination should be performed to exclude or confirm the presence of organic disease, especially colon tumors.
For patients with constipation identified as organic disease, in addition to etiologic treatment, it is also necessary to determine the type of constipation according to the characteristics of constipation and treat accordingly; for cases treated empirically or not confirmed to be organic constipation by examination, further examination can determine the type of constipation and then treat accordingly; for a few patients with refractory constipation, the relevant type of constipation examination is performed at the beginning, or even more detailed In a few patients with refractory constipation, the relevant type of constipation examination or even a more detailed examination is performed at the outset to determine the treatment.
(B) Principles of diagnosis and treatment
The principles of diagnosis and treatment of constipation in China include.
1, detailed medical history and physical examination is an important basis for selecting the constipation process. For most patients with constipation, non-invasive methods are used as much as possible to determine the type of constipation and to verify clinical inferences based on the efficacy of empirical treatment.
2, the type of constipation is an important basis for the choice of treatment. Whether it is empirical treatment, or treatment after further examination, we emphasize the corresponding treatment countermeasures for different types of constipation.
3. For patients with alarm signs of constipation, the importance of investigating the cause is emphasized, while for those with refractory constipation and lack of alarm signs, the importance of determining the type of constipation is emphasized.
4.The proportion of patients receiving various means of examination: for most constipation, empirical treatment is the mainstay, while for refractory constipation, further investigations should be performed, and a few patients, especially those requiring surgical procedures, require more in-depth investigations.
5, several routes in the process can be interpenetrated. For example, if the empirical treatment is not effective, further examination to understand the cause and type, and at the beginning, when no organic sexual lesion is found after examination, it can return to understanding the constipation characteristics to make the type of constipation, or further examination about the type of constipation after treatment, etc.
(iii) The basis of empirical treatment
The common manifestations of chronic constipation are as follows.
1, less stool intention, less stool: this type of constipation can be seen in the slow passage type and exit obstruction type constipation. The former is due to slow passage, so that the number of stools and stool are less, but at certain intervals can still appear stool, stool is often dry and hard, forceful defecation helps to expel feces. In the latter case, the sensory threshold is often increased, and it is not easy to cause the urge to defecate, thus, the number of stools is small, and the stool is not necessarily dry and hard. For these patients, we can try bulking agents or osmolytes to increase the water content of stool, increase softness and volume, stimulate peristalsis of the colon, and also increase the stimulation of the rectal mucosa. At the same time should be regular defecation.
2, difficult defecation, effort: prominent performance for the abnormal difficult fecal discharge, also seen in two cases, to export obstructive constipation is more common. When the patient force discharge, the external anal sphincter presents paradoxical contraction, so that defecation is difficult. This type of constipation is not necessarily less frequent, but it is time-consuming and labor-intensive. If accompanied by weakness of the abdominal muscle contraction, the difficulty of defecation is aggravated.
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. This type of constipation can also be tried with bulking agents or osmotic agents to soften the stool and facilitate its discharge, sometimes combined with enema treatment. If the stool is still difficult to pass after softening, it is suggested to be outlet obstructive constipation. Patients in this category need guidance on bowel movements and biofeedback therapy if necessary.
3.Insensible defecation: There is often a feeling of obstruction in the anorectum, and defecation is not smooth. Although there are frequent bowel movements and a lot of bowel movements, even with great effort, it does not help and 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 and hypersensitivity of rectal sensation, or are associated with endorectal anatomy, such as internal rectal overlap and internal hemorrhoids.
Individual cases with elevated rectal sensory thresholds also present with similar symptoms, which may be related to combined anorectal local anatomical changes. Treatment of this group of patients requires raising the sensory threshold, reducing the number of bowel movements, and treating local anorectal lesions, such as local management of hemorrhoid-derived constipation.
4, constipation with abdominal pain or abdominal discomfort: common in IBS constipation type, often relieved after defecation symptoms.
(iii) Relevant etiological examinations
Imaging or endoscopy, if necessary, combined with pathological examination to determine the presence of intestinal organic disease, such as suspected diabetes, endocrinopathy, connective tissue disease, and neurological diseases, the corresponding biochemical and immunological tests should be made.
Common methods to determine the type of constipation: common tests used to determine the type of constipation include gastrointestinal passage test and anorectal manometry, and anorectal examination can help in diagnosis.