Constipation is a common condition caused by a variety of etiologic factors. Patients often experience dry feces, difficult or incomplete bowel movements, and a significant decrease in the number of times the feces are completely emptied when laxatives are not used. Epidemiology: survey information on constipation in various countries, methodology varies. The prevalence of constipation in the U.S. population ranges from 2% to 28%, and surveys on the elderly over 60 years old in Beijing, Tianjin and Xi’an show that the rate of chronic constipation among the elderly over 60 years old in China is as high as 15%-20%. A randomized, stratified, graded survey of adults aged 18-70 in Beijing showed that the incidence of chronic constipation was 6,07%, and the incidence rate of women was more than 4 times of that of men, and the mental factor was one of the high-risk factors. The harmfulness of constipation: with the change of dietary structure and the influence of mental psychological and social factors, constipation has seriously affected the quality of life of modern people; and in the colon cancer, hepatic encephalopathy, breast disease, early senile dementia and other diseases have an important role in the occurrence of constipation in acute myocardial infarction, cerebral vascular accidents, etc. can lead to life accidents; part of the constipation and anus-intestinal diseases, such as hemorrhoids, fissures, etc. have a close relationship. Therefore, early prevention and rational treatment of constipation are essential. Therefore, early prevention and reasonable treatment of constipation will greatly reduce the serious consequences of constipation and social burden. The necessity of establishing constipation diagnosis and treatment process: Considering the fact that there are so many patients suffering from constipation in the clinic, and that a clear diagnosis often requires high costs, it is extremely important to find an effective way of diagnosing and treating constipation. The development of a simple, effective and operational constipation diagnosis and treatment process that is suitable for China, and that is consistent with the current situation in China, in order to make more effective use of limited health resources, will certainly benefit society as a whole. In the following, we will briefly describe the causes, examination methods and treatment of constipation, review the Rome II diagnostic criteria for constipation and the international constipation diagnosis and treatment process, and propose a draft diagnosis and treatment process for chronic constipation and its principles in China, which has been widely conceived and discussed. It is hoped that in-depth discussion and consensus will be obtained again at the meeting. First, the etiology of constipation, evaluation of examination methods and diagnosis and treatment Healthy people’s defecation habits are mostly 1-2 times a day or 1-2 days 1 time defecation, the feces are mostly shaped or soft stool (such as Bristol type in the type 4 and 5), a few healthy people’s defecation up to 3 times / day, or 3 days 1 time. Stools are semi-formed or hard and salami like (e.g. Bristol types 6 and 3). Normal defecation requires that the intestinal contents pass through the segments at a normal rate, arrive at the rectum in time, and stimulate the recto-anal opening to elicit the defecation reflex, and that the pelvic floor muscle groups coordinate their activities during defecation to complete the defecation. Failure of any of the above links may cause constipation. Therefore, patients with constipation should understand the links and mechanisms that cause defecation failure, as well as the relevant etiological factors and triggers, so that a reasonable treatment program can be developed. (A), the etiology of chronic constipation chronic constipation has functional and organic causes. Organic etiology can be caused by gastrointestinal diseases, systemic diseases involving the digestive tract such as diabetes mellitus, scleroderma, neurological diseases, etc. Many drugs can cause constipation, as follows: organic lesions of the intestinal tract such as tumors, inflammation, or narrowing of the intestinal lumen or obstruction caused by other reasons. 1, rectal, anal lesions: rectal prolapse, hemorrhoidal disease, anterior rectal dilatation, puborectal muscle hypertrophy, puborectal separation, pelvic floor disease, etc.; 2, endocrine or metabolic disorders: such as diabetic enteropathy, hypothyroidism, parathyroid disorders, etc.; 3, neurological disorders: such as central brain disorders, strokes, multiple sclerosis, spinal cord injuries, as well as peripheral neuropathy; 4, intestinal smooth muscle or neuronal Neuromuscular lesions of the colon: pseudo-intestinal obstruction, congenital megacolon, megalorectum, 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. (ii), 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 illnesses, and medications often provide very important information. Attention should be paid to (1) the presence or absence of alarm symptoms (such as blood in stool, anemia, emaciation, fever, black stools, abdominal pain, etc.); (2) the characteristics of constipation symptoms (frequency of stools, bowel movements, whether it is difficult or uncomfortable, and fecal characteristics); (3) the accompanying gastrointestinal symptoms; (4) the history of the cause of the disease, such as intestinal anatomical structure abnormalities or systemic disorders, and medication-induced constipation; and (5) the mental and psychological state and social factors. General examination methods: (1) anorectal fingerprinting can often help to understand the fecal impaction, anal stenosis, hemorrhoidal disease or rectal prolapse, rectal masses and other conditions, but also to understand the functional status of the anal sphincter; (2) blood routine, stool routine, fecal occult blood test is to rule out the colonic, rectal and anal organisms of the routine is important and simple. If necessary, relevant biochemical and metabolic tests; (3) for suspected anal and rectal pathology, proctoscopy or sigmoidoscopy/colonoscopy, or barium enema can be visualized to observe the intestinal tract or to show imaging information. Special examination methods: for patients with chronic constipation, the following relevant examinations can be selected as appropriate. 1, gastrointestinal transit test (GITT): commonly used impermeable X-ray markers, breakfast with the test meal swallowed with 20 markers, after a certain period of time (for example, 24h, 48h, 72h after taking the markers) to take a picture of the abdominal film, calculate the rate of elimination. Under normal circumstances, most of the markers were excreted by 48-72h after taking the markers. According to the distribution of markers on the abdominal film, it can help to assess whether the constipation is of slow transmission type or outlet obstruction type, which is a simple and feasible method. 2, anorectal manometry (anorectal manometry ARM): commonly used perfusion manometry (with esophageal manometry), respectively, to detect the anal sphincter resting pressure, the contraction pressure of the external anal sphincter and the relaxation pressure of the force row, the rectal injection of gas with or without the rectal inhibitory reflexes, but also to determine the perceptual function of the rectum and the rectal wall of the compliance and so on. It can help to assess the anal sphincter and rectum with or without power and sensory dysfunction. 3.Colon pressure monitoring:The sensor is placed into the colon, and the colon pressure changes are monitored continuously for 24-48h under relatively physiological conditions. It is useful for determining the presence or absence of colonic incompetence, and has a guiding significance for treatment. 4, balloon expulsion test (balloon expulsion test BET): in the rectum placed in the balloon, inflatable or water, and make the subject will be expelled. Can be used as a screening test for the presence or absence of excretion disorders, and further examination is required for positive patients. 5, defecography (barium defecography BD): simulated fecal instillation into the rectum, in the radiation dynamic observation of defecation process in the anus and rectum functional changes, can understand the patient has no accompanying anatomical abnormalities, such as anterior rectal dilatation, intussusception and so on. 6.Others: such as pelvic floor electromyography, can help clarify whether the lesion is myogenic. Pubic nerve latency determination can show whether there are nerve conduction abnormalities. Anal ultrasound endoscopy can understand the anal sphincter with or without defects. (C), chronic constipation diagnosis of chronic constipation should include: the cause of constipation (and triggers), the degree, and the type of constipation. If you can understand and constipation related to the scope of involvement (colon, anorectal, or with the upper gastrointestinal tract), the affected tissues (myopathy or neuropathy), there is no local structural abnormalities and their causal relationship with constipation. This is then very useful in both formulating treatment and predicting its efficacy. The severity of chronic constipation and the types of constipation are described below. Severity of chronic constipation: Constipation can be categorized as mild, moderate or severe. Mild constipation means that the symptoms are mild, do not affect life, can be improved by general treatment, and do not require medication or less medication. Severe constipation refers to the persistence of symptoms, the patient is unusually painful, seriously affecting life, can not stop the drug or treatment is ineffective. Moderate is given between the two. The so-called intractable constipation is often severe constipation, can be seen in the exit obstruction type of constipation, colon weakness, and severe constipation type of irritable bowel syndrome (IBS) and so on. Types of chronic constipation: slow transmission type, outlet obstruction type and mixed type.The constipation type of IBS is a type of constipation related to abdominal pain or bloating, and at the same time, it may also have the characteristics of each of the following types. Slow transit constipation (STC) has the following manifestations: (1) often with a reduced number of bowel movements, less bowel movement, and hard feces, thus making defecation difficult; (2) no feces or hard feces palpable on anorectal palpation, and normal contraction and forceful evacuation of the external anal sphincter; (3) prolonged passage time through the entire gastrointestinal or colonic tract; and (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 feeling or feeling of falling,, defecation volume is small, there is a desire to stool or lack of desire to stool; (2) anorectal examination of the rectal memory there are a lot of mud-like fecal matter, the force of discharge of the sphincter of the external anus is paradoxical contraction; (3) the whole gastrointestinal or colonic passage time shows normal, most markers can be anal-rectal pressure measurement shows normal. (3) the whole gastrointestinal or colonic passage time shows normal, most of the markers can be retained in the rectum; (4) anorectal manometry shows contradictory contraction of the external anal sphincter during forceful evacuation, or the sensory threshold of the rectal wall is abnormal. 3, mixed constipation: with the characteristics of 1 and 2 above. The above three categories are suitable for functional constipation types, but also suitable for other causes of chronic constipation. For example, diabetes, scleroderma combined constipation and drug-induced constipation is mostly slow transmission type constipation. Irritable bowel syndrome constipation type is characterized by a small number of bowel movements, defecation is often difficult, defecation, defecation, abdominal pain or abdominal distension slowed down after defecation, there may be exit dysfunction combined with slow-transmission type constipation, such as can be combined with the relevant functional examination, can be further confirmed by its clinical type. (D), the 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 insist on good defecation habits, and increase activities at the same time. 2.Drug therapy: use appropriate laxative drugs. Selection of drugs should be less toxic, side effects and drug dependence for the principle, often used such as bulking agents (such as wheat bran, Ou Che former, etc.) and osmotic laxatives (such as Fosamax, lactulose). Randomized controlled observation of the application of Fosamax in the treatment of functional constipation showed good efficacy in increasing the number of bowel movements and improving stool properties. For slow-transmission constipation, prokinetic agents, such as cisapride or mosapride, can also be added. It should be noted that for patients with chronic constipation, long-term application or abuse of stimulating 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 long-term treatment of chronic constipation, attention should be paid to the ingredients within them and their side effects. For patients with fecal impaction, clean enema once or combined with short-term use of stimulating laxatives to release the impaction. After release, bulking agents or osmotic drugs are then used to keep the bowel movement open. Capsaicin and glycerin suppositories have the effect of softening the stool and stimulating defecation. Compound keratine acid can be effective in the treatment of constipation of hemorrhoidal origin. 3, psychological therapy and biofeedback: moderate and severe constipation patients often have anxiety or 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 after strict non-surgical treatment is still not effective, and a variety of special tests show that there is a clear pathologic anatomy and conclusive functional anomalies, surgical treatment can be considered. Indications for surgery include secondary megacolon, partial colonic redundancy, colonic incompetence, severe anterior rectal dilatation, intrarectal intussusception, and intramucosal prolapse of the rectum. However, attention should be paid to the presence of serious psychological disorders, the presence of digestive tract abnormalities other than the colon, and the need for preoperative prediction of efficacy. International diagnostic criteria and diagnostic and treatment process of chronic constipation In September 1999, the International Rome II Collaborative Committee formulated a series of diagnostic criteria for functional gastrointestinal disorders in Rome II on the basis of Rome I (Gut 1999, 45:Suppl II). Although the understanding of constipation is not consistent among gastroenterologists in different countries, the diagnostic criteria of Rome II are still used as the basis for the diagnosis and treatment of constipation in each country, taking into account the actual situation of each country. The following introduces the diagnostic criteria of chronic constipation, functional constipation, pelvic floor defecation disorder, and IBS constipation type of Rome II, and introduces the main points of the United States Constipation Guidelines, which was recently formulated in the United States on the basis of the Rome II criteria. (I) Rome II diagnostic criteria for constipation: chronic constipation: Rome II diagnostic criteria for chronic constipation is: with at least 12 weeks in the past 12 months, continuous or intermittent occurrence of two or more of the following symptoms: (1) >1/4 of the time there is defecation effort; (2) >1/4 of the time there is feces in the form of fast masses or hard knots; (3) >1/4 of the time there is a sensation of incomplete evacuation; (4) >1/4 of the time there is a sensation of anal obstruction or anorectal obstruction during defecation; (5) >1/4 of the time there is a need for maneuvering to assist in defecation; and (6) >1/4 of the time there are <3 bowel movements per week. No loose stools were present and the diagnostic criteria for IBS were not met. Functional constipation (functional constipation): according to the Rome II diagnostic criteria, functional constipation should meet the above diagnostic criteria, and at the same time, exclude constipation caused by intestinal or systemic organic pathology and drug factors. Pelvic floor dyssynergia (pelvic floor dyssynergia): Rome II diagnostic criteria for pelvic floor dyssynergia means that in addition to meeting the above Rome II diagnostic criteria for functional constipation, the following points must also be met, namely: (1) there must be anorectal manometry, electromyography, or X-ray evidence that, during the repetitive defecation maneuvers, the pelvic floor muscle groups inappropriately contraction or inability to relax; (2) adequate propulsive contraction of the rectum during forceful defecation; (3) and evidence of poor fecal evacuation. Constipation-predominant irritable bowel syndrome (IBS): irritable bowel syndrome is a functional bowel disorder characterized by abdominal discomfort or pain with altered bowel habits and abnormal defecation, with no lesions on X-ray barium enema or colonoscopy and no systemic disease Evidence. Constipated IBS is defined as a condition that first meets the basic points of the criteria for IBS, i.e., the presence of symptoms of abdominal pain or abdominal discomfort for at least 12 weeks (not necessarily consecutively) within the past 12 months, accompanied by two of the following three: (1) disappearance of the above symptoms after a bowel movement, (2) a change in the frequency of bowel movements at the time of the appearance of the above symptoms or (3) a change in the stool consistency. Supported by the presence of at least 1 of the 3 items of (1) less than 3 stools/week; (2) lumpy or hard stools; (3) straining during defecation and a sense of incomplete defecation; and none of the 3 items of (1) more than 3 stools/day; (2) loose stools; (3) a sense of urgency to defecate; or at least 2 of the 3 items must be met, and at the same time, may be met by the presence of (1) more than 3 stools/day; ( 2) loose stools; and (3) a sense of urgency to defecate. (B), the United States on the diagnosis and treatment process of chronic constipation: the United States put forward the process of chronic constipation is based on the history and physical examination, combined with the relevant laboratory examination, and first put forward the experimental treatment of refractory constipation patients, and then barium fecal imaging and related power function examination, according to the type of constipation, the corresponding treatment. And the process was divided into diagnostic steps and proposing appropriate treatment steps according to different types of constipation. According to the preliminary evaluation results, the diagnosis of constipation was categorized into six cases, namely (1) IBS constipation type; (2) slow transmission constipation; (3) rectal outlet obstruction type; (4) coexistence of (2) and (3) above; (5) functional constipation (functional obstruction or drug side effects); and (6) constipation secondary to systemic diseases. Fourth, China's constipation process and its principles Constipation has the degree, type, and etiology and causation of the points, therefore, the constipation patients need to be graded hierarchical diagnosis and treatment triage, such a diagnosis and treatment process is conducive to active and effective diagnosis and treatment of patients, and produce a reasonable cost-effectiveness ratio. (I), the diagnosis and treatment process Clinically, in order to achieve effective stratification (alarm or not), grading (degree) triage for patients with constipation, it is necessary to assess the causes and triggers of constipation, the type of constipation and the degree of constipation. For most patients, through detailed history and physical examination, the etiology and type of constipation can be understood, and empirical treatment can be carried out; for constipation caused by alarm signs or suspected organic diseases, further examination should be carried out to exclude or confirm the presence or absence of organic diseases, especially colonic tumors; for constipated patients with confirmed organic diseases, in addition to etiological treatment, it is necessary to determine the type of constipation according to the characteristics of constipation and carry out treatment accordingly; for constipated patients with confirmed organic diseases, it is necessary to determine the type of constipation according to the characteristics of constipation and carry out treatment accordingly. type and carry out corresponding treatment; for cases that are not confirmed to be organic constipation by empirical treatment or examination, further examination can determine the type of constipation and then carry out corresponding treatment; for a small number of patients with intractable constipation, relevant examination of the type of constipation, or even a more detailed examination is carried out from the beginning, so as to determine the means of treatment. (B), the principles of diagnosis and treatment The principles of diagnosis and treatment of constipation in China include: 1. Detailed history and physical examination is an important basis for choosing the process of constipation. For most patients with constipation, try to use non-invasive methods to determine the type of constipation, based on empirical treatment efficacy, to verify the clinical inference. 2, the type of constipation is an important basis for the choice of treatment. Whether it is empirical treatment or treatment after further examination, it is emphasized that different types of constipation should be treated accordingly. 3. It is proposed to emphasize the investigation of the etiology of constipation in patients with alarm signs, and to emphasize the importance of determining the type of constipation in patients with intractable constipation and lack of alarm signs. 4, the proportion of receiving various means of examination: for most constipation, empirical treatment is the mainstay, while for refractory constipation, further examination should be performed, and a few patients, especially those who require surgery, need more in-depth examination. 5. Several routes in the process can interpenetrate each other. For example, for the poor efficacy of empirical treatment, further examination to understand the cause and type of disease, and at the beginning of the examination did not find organic lesions, can be returned to understand the characteristics of constipation to make the type of constipation, or further constipation type of constipation related to the examination of the treatment after treatment. (C), the basis of empirical treatment chronic constipation common manifestations of the following categories: 1, less intention to stool, stool times are also less: this type of constipation can be seen in the slow through the type of constipation and exit obstruction type constipation. The former is due to the slow passage, so that the frequency and intention of stool are less, but the interval of a certain period of time can still appear intention of stool, feces is often dry and hard, force defecation to help discharge feces. In the latter case, the sensory threshold is often increased, which does not easily cause the urge to defecate, and therefore, the frequency of defecation is low, and the feces are not necessarily dry and hard. For these patients, we can try bulking agents or osmotic agents to increase the water content of the feces, increase the softness and volume, stimulate colonic peristalsis, and also increase the stimulation of the rectal mucosa. At the same time should be regular defecation. 2.Difficult defecation, effort: the prominent manifestation of fecal discharge is abnormally difficult, also seen in two cases, to the outlet obstruction constipation is more common. When the patient force row, the external anal sphincter shows contradictory contraction, so that defecation is difficult. This type of stool is not necessarily less frequent, but time-consuming and laborious. If it is accompanied by weak abdominal muscle contractions, the difficulty of defecation is exacerbated. The second situation is due to the slow passage, too much water in the feces is absorbed, the feces is dry, especially for a long time without defecation, so that the dry and hard feces is unusually difficult to discharge, and fecal incarceration can occur. This type of constipation can also be tried with bulking agents or osmotic agents to soften the feces for easy evacuation, sometimes in combination with enema treatment. If the stool is still difficult to pass after softening, it is suggestive of outlet obstruction constipation. This kind of patients need to guide the way of defecation, if necessary, biofeedback treatment. 3, defecation: often have anorectal obstruction feeling, defecation is not smooth. Although there is a frequent urge to defecate, there are many times, even if the effort is not helpful, it is difficult to have a smooth bowel movement. May be accompanied by anorectal irritation symptoms, such as falling, discomfort. Such patients often have reduced sensory thresholds, hypersensitive rectal sensation, or are accompanied by intra-rectal dissections, such as intra-rectal intussusception as well as internal hemorrhoids. Individuals with elevated rectal sensory thresholds also present with similar symptoms, which may be related to the combination of localized anatomical changes in the anorectum. The treatment of this part of the patient needs to improve the sensory threshold, reduce the number of bowel movements, treatment of local anorectal lesions, such as hemorrhoidal constipation local treatment. 4, constipation with abdominal pain or abdominal discomfort: common in IBS constipation type, often after defecation symptoms. The above types of constipation are not only seen in functional constipation, but also in IBS constipation (may also have the above types of performance). At the same time, for organic diseases such as chronic constipation caused by diabetes mellitus, as well as drug-induced constipation, can have the above types of manifestations. They should be analyzed. In addition, there is often a combination of the above conditions. (C), the relevant etiological examination imaging or endoscopy, if necessary, combined with pathological examination to determine the presence of intestinal organic disease, such as suspected diabetes mellitus, endocrinopathy, connective tissue disease, and neurological diseases, should be the appropriate biochemical and immunological examination. (D), to determine the type of constipation commonly used methods: used to determine the type of constipation commonly used methods of examination are gastrointestinal through the test and anorectal manometry, proposed anorectal fingerprinting can help diagnosis. 1, gastrointestinal through the test: it is recommended that at least 48h after stopping the drug in question to take impermeable X-ray markers after 20, take an abdominal film (normal when most of the markers have arrived in the rectum or have been discharged), the purpose of the choice of 48h film is possible to observe the distribution of markers at this point in time, such as most of the markers have been concentrated in the sigmoid colon and the rectal region within the area or has not yet reached the region, then the end of the tip through, respectively. If another film is taken at 72h, if most of the markers have not yet reached the sigmoid colon and rectum or are still in the sigmoid colon and rectum, then slow passage constipation or outlet obstruction constipation is supported, respectively. The gastrointestinal passage test is an easy method that can be extended. Its accuracy may increase if it is extended to one film per 5-6 days, but it is less feasible because most patients have difficulty adhering to it and self-administer laxatives. The sensitivity of the test is reduced, especially difficult to determine the type of constipation, unless a series of films. 2, anorectal manometry: can provide the presence or absence of constipation-inducing local anorectal mechanisms, for example, in the force of rows of the external anal sphincter paradoxical contraction, suggesting that there is an outlet obstruction constipation; to the rectal balloon after the injection of gas, such as anorectal inhibitory reflex is absent, suggesting that there is Hirschsprung's disease; as well as the mucous membrane of the rectal wall of the air sac after the injection of gas to cause the stool The mucosa of the rectal wall to the sense of stool caused by the gas injection, the maximum tolerance limit of the volume, etc., can provide the rectal wall of defecation threshold is normal or not. 3, Anorectal finger test: It is emphasized here that anorectal finger test is not only an important method to check whether there is rectal cancer, but also a common and simple method to judge whether there is constipation with outlet obstruction. Especially the enhanced sphincter tension, the sphincter can not be relaxed during forceful defecation, but more contracted and tense, suggesting that prolonged and extremely laborious defecation has led to sphincter hypertrophy, and at the same time, it is in a paradoxical contraction when forceful defecation is in progress. (E), about refractory constipation special examination: for example, severe slow through constipation to all kinds of treatment is ineffective, often suggests that the colon is weak, such as 24h colon pressure monitoring lack of specific propagating contraction wave (Specialized propagating pressure wave, SPPW), suggesting that the need for surgical treatment. Defecography provides a dynamic view of the anatomical and functional changes in the anorectum. Anal manometry combined with ultrasound endoscopy shows both mechanical deficiency and anatomical weakness of the anal sphincter. Army provides important clues for anorectal surgery. A few secrets need to distinguish whether the lesion is myogenic or neurogenic, requiring examination of the perineural nerve latency or electromyography. In patients with significant anxiety and depression, relevant investigations should be made.