Overview of mixed constipation (MC)
Mixed constipation (MC) (Slow Transmission Constipation + Obstructive Outlet Constipation (STC+OOC)) is a type of constipation with clinical features of both Slow Transmission Constipation (STC) and Obstructive Outlet Constipation (OOC). Most of them are stubborn constipation, with the clinical manifestations of both colon slow transmission constipation and outlet obstruction constipation. According to epidemiologic research statistics, about 1/5 of the patients with constipation are mixed constipation patients. The main morbidity groups are young and middle-aged women and the elderly.
Causes
The causes of constipation due to abnormalities in the morphology and motility of the large intestine are multifaceted and can be generally categorized into primary and secondary factors. Primary factors include insufficient stimulation of the intestinal tract, insufficient defecation power, and neglect of the urge to defecate; secondary factors include organic lesions, functional disorders, abnormalities of colon motility, neurological disorders, endocrine disorders, toxicity and pharmacological effects, and long-term abuse of laxatives.
Mixed constipation has colonic transport dysfunction and functional outlet obstruction, both of which can also be causative of each other. Although it is difficult to accurately determine the cause of many patients with this disease, the history can provide insight into whether the problem of outlet obstruction or the slow transmission of the colon preceded the onset of the disease.
Symptoms
1. Stools are small, hard, and difficult to pass.
2. There may be prolonged straining to pass stools, rectal distension, a sensation of falling, a feeling of incomplete evacuation, or the need for maneuvers to help pass stools.
3. The number of bowel movements is less than 2 to 3 times in 7 days.
Examination
1. Specialized examination
(1) Visual diagnosis Visual diagnosis may have no positive signs, or may be accompanied by external hemorrhoids and other symptoms of anal diseases.
(2) Rectal palpation Patients with anterior rectal protrusion can palpate a round or ovoid area of weakness in the anterior rectal wall that protrudes into the vagina during rectal palpation, which is more obvious when straining to defecate, and the tip of the finger feels that the tension of the intestinal wall is reduced, and the intestinal wall recovers slowly or fails to recover at the end of the palpation. In patients with combined rectal mucosal prolapse, the patient takes the squatting position or the side lying position, does the defecation action, can touch the rectal lumen mucosa folding and accumulating, soft and smooth, moving up and down, with a sense of congestion, and there is a ring shaped groove between the part of the prolapsed part and the intestinal wall. In patients with combined perineal descent syndrome, anal canal dilatation is diminished at rest, and when the patient is instructed to perform casual contractions, the anal canal contraction is markedly weakened. In patients with pelvic floor dystrophy, the anal canal tension is high and requires force to pass through the anal canal. The anal canal was long, and the puborectalis muscle was hypertrophied and spastic. When simulating defecation, the anal canal contracts instead of relaxing, which is often called “paradoxical contraction”.
(3) Sigmoidoscopy or anorectoscopy, such as the combination of rectal mucosal prolapse and perineal descent syndrome in patients with a little abdominal pressure can be seen in the rectal submucosal accumulation, like a cork-like protrusion into the opening of the lens tube. In the recto-anal junction, there is a ring or cervix-like mucosal fold. Proctoscope can see too much rectal mucosa, when doing forceful defecation action can be seen embedded in the mirror cavity or appear below the tooth line, the patient can see mucosal edema, brittle, congestion, or ulcers, polyps and other lesions.
2. Colon Transmission Test
A test to determine the function of the colon.
3. Fecography
A positive fecography in a patient with mixed constipation.
4. Balloon ejection test
A relatively simple test to determine whether constipation is caused by outlet obstruction.
5. Anorectal manometry
Anorectal manometry can be used to find out the change of anorectal pressure during defecation.
6. Pelvic floor electromyography
By recording the bioelectrical activity of the neuromuscles, it can be used to determine the changes in neuromuscular function and morphology.
Diagnosis
Diagnostic criteria:Adopting the Rome III (2006) criteria, mixed constipation (MC) should include: slow-transmission constipation (STC) + outlet-obstructive constipation (OOC), as follows.
1.STC diagnostic criteria
(1) Meet the Rome III criteria;
(2) Constipation due to intestinal or systemic organic etiology as well as pharmacologic factors should also be excluded;
(3) Exclusion of C-IBS; d Clinical features of decreased frequency of bowel movements (<3 times/week), absence of bowel movements, difficulty in defecation, or hard stools (Bristol types 1 to 2);
(4) GITT examination support.
2. OOC diagnostic criteria
A combination of obstructive outlet disorders as determined by defecography, including.
(1) anterior and posterior proptosis of the rectum;
(2) Rectal mucosal laxity;
(3) Delay of the internal anal sphincter.
Treatment
The aim of treatment is mainly to relieve symptoms and restore bowel regularity. Non-surgical treatment is the mainstay and surgical treatment is supplementary. After systematic non-surgical treatment is ineffective, constipation symptoms are serious, affecting normal work, study and life of patients, voluntary request for surgical treatment, no mental anomaly, can consider surgical treatment, and must strictly abide by the indications and contraindications for surgery.
1. Conservative treatment
The conservative treatment of mixed constipation is the same as constipation.
2.Surgical treatment
Mixed constipation treatment principle: first treat the outlet obstruction constipation, then consider the treatment of colon slow transmission constipation. Not limited to a single choice of surgery, should be based on the actual situation of the patient’s comprehensive treatment.
Prognosis
Most of the patients can be relieved by changing life habits and conservative treatment; some patients can be relieved by surgery if conservative treatment is ineffective; a few patients are still unsatisfied after various treatments.
Prevention
1. Mental state
Mental state has a greater impact on mixed constipation. Mental depression, upset, excessive tension and so on may lead to the occurrence of mixed constipation. Therefore, the prevention of this disease should firstly adjust the mood to make oneself relaxed as much as possible, avoid excessive tension and labor, and keep optimistic and relaxed mood.
2. Balanced diet
Usually eat fresh vegetables and fruits, eat more coarse grains, eat more food such as sweet potatoes, corn, bananas and other foods to help defecation, try to avoid the cream thick flavor.
3. Keep bowel movement smooth
Quit smoking and limit alcohol, regular exercise, strengthen the exercise, so that the blood and qi unimpeded, good gastrointestinal function, help to keep the stools unimpeded.
4. Use medication at the right time
It is advisable to apply under the guidance of a doctor and not to use laxatives frequently.
5. Seek medical attention in a timely manner
If after all kinds of efforts are not effective, you should go to the hospital immediately, and ask the doctor to check whether there are organic lesions in the anus and intestines and treat them in time.