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 laxative medication is not used. A survey of elderly people over 60 years of age in Beijing, Tianjin and Xi’an showed that the rate of chronic constipation among elderly people over 60 years of age in China was as high as 15%-20%. A randomized, stratified and graded survey of adults aged 18-70 in Beijing showed that the prevalence of chronic constipation was 6.07%, more than 4 times that of men in women, and that mental factors were one of the high-risk factors. The danger of constipation: 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, constipation can lead to life accidents; some constipation and anorectal diseases, such as hemorrhoids, anal fissures, etc. are closely related Therefore, early prevention and reasonable treatment of constipation can lead to life-threatening accidents. Therefore, early prevention and reasonable treatment of constipation will greatly reduce the serious consequences and social burden caused by constipation. The need to establish a process for the diagnosis and treatment of constipation: Considering that there are so many patients suffering from constipation in clinical practice, and that a clear diagnosis often requires a high cost, it is extremely important to find an effective way to diagnose and treat constipation. The whole society will benefit from the development of a simple, effective, and operational constipation management process that is appropriate to the current situation in China, in order to make more efficient use of limited health resources. In the following, we will briefly describe the etiology, examination methods and treatment of constipation, review the diagnostic criteria of Rome II and the international constipation diagnosis and treatment process, and present a draft of the diagnosis and treatment process of chronic constipation and its principles in China, which has been widely conceived and discussed. We hope to get in-depth discussion and consensus again in the meeting. A. Etiology of constipation, evaluation and treatment of examination methods Healthy people have 1-2 bowel habits a day or 1-2 days a bowel movement, the stool is mostly formed or soft stool (such as Bristol type 4 and 5), a few healthy people have up to 3 times / day, or 3 days a time. The stools are semi-formed or hard and salami-like (e.g., Bristol types 6 and 3). Normal defecation requires that intestinal contents pass through the segments at normal speed, reach the rectum in a timely manner, and stimulate the recto-anus to cause a defecation reflex and coordinated activity of the pelvic floor musculature 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 gastrointestinal tract such as diabetes, scleroderma, neurological diseases, etc. Many drugs can cause constipation, as follows: organic lesions of the intestinal tract 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, mental 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 Diagnostic methods for chronic constipation include history, physical examination, relevant laboratory tests, imaging tests and special examination methods. History: A detailed medical history, including symptoms and course of constipation, gastrointestinal symptoms, concomitant symptoms and diseases, and medication can often provide very important information. (1) the presence or absence of alarm symptoms (such as blood in stool, anemia, wasting, fever, black stool, abdominal pain, etc.), (2) the characteristics of constipation symptoms (frequency of stool, bowel movement, difficulty or dyspareunia, and stool properties), (3) concomitant gastrointestinal symptoms, (4) history related to etiology, such as abnormal intestinal anatomy or systemic diseases, and constipation caused by drug factors, (5) mental and psychological status and social factors. (5) mental and psychological status and social factors. (1) Anorectal examination can often help to understand fecal impaction, anal stenosis, hemorrhoids or rectal prolapse, rectal masses, etc. It can also understand the functional status of the anal sphincter. (2) 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. For suspected anal and rectal lesions, proctoscopy or sigmoidoscopy/colonoscopy, or barium enema can directly observe the intestine or show imaging data. Special examination methods: For patients with chronic constipation, the following relevant examinations can be selected as appropriate. 1, gastrointestinal transit test (GITT): commonly used opaque X-ray markers, swallowed with the 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 manometryARM: 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. To determine the presence or absence of colonic weakness, it has guiding significance for treatment. 4.Balloon expulsion testBET: 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 or absence of expulsion disorder, and further examination is required for positive patients. 5.Fecal defecography (barium defecographyBD): 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 to 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. (c) Diagnosis of chronic constipation The diagnosis of patients with 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 tissue involved (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). Types of chronic constipation: They are classified as slow-transmission, exit-obstruction, and mixed types. The constipation type of IBS is a type of constipation related to abdominal pain or bloating, and at the same time, may also have the characteristics of each of the following types. (1) Slow transit constipation (STC) has the following manifestations: (1) There is often a decrease in the number of bowel movements, less bowel movements, hard stools, and therefore difficult to defecate. (2) No stool or hard stool on anorectal examination, while the contraction and force of the external anal sphincter function normally. (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 obstructive constipation (outlet obstructive constipation, OOC) may have the following manifestations: (1) defecation effort, incomplete or downward feeling, small volume of defecation, bowel movement or lack of bowel movement. (2) There is a lot of mud-like stool in the rectum on 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 principle of treatment is based on the severity, etiology and type of constipation, comprehensive treatment 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 suitable for 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 severe psychological disorders, the presence of digestive tract abnormalities other than the colon, and the need for preoperative prediction of outcome.